Making decisions for surgical intervention in neonates with necrotizing enterocolitis and the selection of appropriate surgical intervention

Abstract

Objective: Necrotizing enterocolitis (NEC) is one of the mostcommon conditions requiring surgical intervention in the neonatalperiod. The decision for surgical intervention in NEC is difficultand the surgical procedures differ according to the condition of thepatient. This study assesses the decision for surgical intervention inpatients being followed with a preliminary diagnosis of NEC andthe appropriate surgical procedure.

Material and Method: The files of patients undergoingsurgery with a diagnosis of NEC at the Marmara UniversityHospital Neonatal Intensive Care Unit between 15.07.2013-

15.07.2015 were studied retrospectively. Patients were evaluatedfor the following: gestational age, birth weight, gender, time ofonset of symptoms, abdominal distention, tenderness, presence ofabdominal erythema, hypotension, acidosis, thrombocytopenia,

radiological findings, surgical timing and post-operative follow up.

Results: A total of 10 neonates (7 boys, 3 girls) were treatedsurgically with an NEC diagnosis. The average gestational age ofthe patients was 27.6 weeks (22-37 weeks), and the median birthweight was 710 grams (400-3750). Average onset of symptomswas found to be 8.1 days (2-30) postnatal. Abdominal distentionand tenderness (10), hypotension (4), and abdominal erythema(3) were observed in patients upon physical examination.

Acidosis (7), thrombocytopenia (6) was observed in patients inlaboratory findings. Free fluid (4), thickening of the intestinalwall ans (3), pneumatosis intestinalis (1), portal venous gas (1)

was observed in patients during the assessment of the abdominalultrasonography (US). 3 patients whose direct x-ray evaluationswere grade III underwent peritoneal drainage. The drain site ofone of these patients closed by itself, and there was no need forfurther surgery for the patient. Laparotomy was carried out a dayafter clinical stabilization was achieved. Our third patient, thelowest birth weight in our series, was lost immediately followingthe peritoneal drainage process. Peritoneal drainage was plannedin two other grade III patients based on the radiological findings.

However, due to the appearance of necrotic bowel segments fromthe incision site, they underwent bowel resection and ileostomyduring a bedside laparotomy. One of these patients improvedclinically, but the other patient was lost in the early stages. Dueto the deterioration seen in the clinical findings of 5 patients whowere radiologically grade II, the decision for laparotomy was madeinitially. All of these 5 patients were discharged after an uneventfulpostoperative period.

Conclusion: In patients who are grade II radiologically, thedecision for surgical intervention in an operating room can be madeaccording to clinical deterioration. In infants who are grade III, andwhose clinical condition is poor, bedside surgical intervention inthe neonatal intensive care unit is preferable..