Saudi Journal of Gastroenterology
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Year : 1997  |  Volume : 3  |  Issue : 1  |  Page : 41-45
Necrotizing enterocolitis, surgical experience


1 Department of Surgery, Security Forces Hospital, Riyadh, Saudi Arabia
2 Department of Pediatrics, Security Forces Hospital, Riyadh, Saudi Arabia

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Date of Submission12-Sep-1995
Date of Acceptance22-Sep-1996
 

   Abstract 

Between January 1988 and December 1994, 29 cases of necrotizing enterocolitis (NEC) required surgical management. There were 15 males and 14 females. The gestational age range was 24-38, average 32.7 weeks and body weight range was 565-4500 grams, average 1,680 grams. Necrotizing enterocolitis developed within two weeks of age in 55% of the cases, between two and four weeks in 34% and beyond four weeks in four cases (14%). Pneumoperitoneum was the commonest indication for surgery (55%) of cases, followed by failure of response to medical treatment. The commonest surgical procedure was resection of the gangrenous bowel with creation of an enterostomy for the segmental disease in 15 cases (50%) and resection with primary anastomosis in six cases (20%). Four cases (14%) had NEC totalis for which drainage alone was done, and two cases had external drainage alone. Survival rate was 72%.

How to cite this article:
Saleem MM, Skef Z, Bashir O, Shaheed M, Ahmed ZS, Al-Qasabi Q. Necrotizing enterocolitis, surgical experience. Saudi J Gastroenterol 1997;3:41-5

How to cite this URL:
Saleem MM, Skef Z, Bashir O, Shaheed M, Ahmed ZS, Al-Qasabi Q. Necrotizing enterocolitis, surgical experience. Saudi J Gastroenterol [serial online] 1997 [cited 2020 Feb 23];3:41-5. Available from: http://www.saudijgastro.com/text.asp?1997/3/1/41/33944


Necrotizing enterocolitis (NEC) is an acquired disease of the gastrointestinal tract that affects premature neonates in 90 percent of cases. With improvement of perinatal and neonatal care in the past two decades, more and more premature and critically-ill neonates are surviving; therefore, the number of cases of NEC is increasing [1],[2],[3],[4] . It is becoming the commonest neonatal surgical emergency. The etiology and pathogenesis are still unknown. The risk factors are prematurity and low birth weight with their inherent immaturity of body systems including the pulmonary, gastrointestinal, and immune systems [5],[6] . Secondary risk factors are infection and early feeding of these neonates, especially feeding with hyperosmolar formulas. The diagnosis of NEC has become an easy task with the awareness of the disease and its commonly used triad of abdominal distention, intolerance to feedings, and increased gastric aspirate with or without bloody stools and with or without pneumatosis intestinalis. Surgical intervention is only indicated in about 40 to 50 percent of cases, depending upon the criteria used [1],[2],[7] . Complications of the disease are those of the underlying associated illnesses with particular gastrointestinal complications including fistula fonnation, strictures, malabsorption, and short­gut syndrome.

These complications develop in about 10 to 40 percent of cases. The overall survival has improved dramatically in the past two decades, both short-term and long-term, mainly due to better preoperative and postoperative intensive care management. The impact of NEC per se on survival and outcome is minimal. This report describes our experience in the diagnosis and management of NEC at the Security Forces Hospital in Riyadh, Saudi Arabia.


   Patients and Methods Top


Between January 1988 and December 1994, the medical records of neonates with the diagnosis of NEC, who required surgical interventions at the Security Forces Hospital were reviewed. Data extracted from the files included the birth weight, gender, gestational age, and associated conditions. The diagnosis, medical and surgical procedure, complications, and outcome were also noted.

Twenty-nine out of 90 cases ofNEC (32%) required surgical intervention in our hospital. They were 24 preterm (83%)(gestational age < 37 weeks) and five term babies (17%). Three cases developed NEC in the postoperative period of surgical patients and three were referred to us from outside at different stages of their disease. The male to female ratio was 15 to 14.


   The preterm local group Top


The weight of the preterm group ranged from 565 to 2450 gms, (average 1.170 gms). The gestational age ranged from 24 to 36 week (average 30.1 weeks). The distribution of weight and gestational age are shown in [Table - 1]. Other associated conditions either in the pregnancy, delivery or in the infant which may directly or indirectly be related to the development of NEC are depicted in [Table - 2].


   The term group Top


This includes the term babies, postoperative babies, and referral cases. The body weight, gestational age, primary and secondary risk factors and outcome of this group of patients is summarised in [Table - 3].

The diagnosis and medical treatment were based on high index of suspicion and the development of the triad of abdominal distension, intolerance to feed and high gastric aspirate, with or without blood in stools. The NEC regime included stopping of feeding, gastric decompression, septic workup, fluid resuscitation, total parenteral nutrition, and broad spectrum antibiotics. In three to five days if the condition of the patient is stable and the septic work-up is negative, feeding is re-started and antibiotics are discontinued. If the condition progresses to obvious NEC with pneumatosis intestinalis, the regime is continued for 14-21 days. If perforation ensues or the general condition of the patient deteriorates, surgery is undertaken. The indications for surgery were pneumoperitoneum in (55%) of cases and failure to respond to medical treatment. The surgical procedure consisted of resection of the gangrenous bowel with creation of enterostomy for segmental disease, or resection and primary anastomosis, if the disease is localised and the perforation is single, or resulted in a stricture formation and the contamination is minimal. Other procedures were; drainage done for segmental disease with sealed perforation or massive involvement with proximal decompression. We encountered NEC totalis in four cases (14%), where only drainage was performed with the intention of performing a second­look procedure. Unfortunately, all of the patients with massive involvement died before they had a chance to have second-look procedure. Two (7%) of our patients were very critical and very small; they were drained under local anesthesia in the NICU and felt to be unsuitable for performing major surgical procedures. We did not believe that the type of surgical procedure was in any way related to the death of these patients or those who died as in the group with massive bowel involvement where death occurred within 48 hours after surgery. Our complication rate was 20% (six patients). All of our patients survived, but two developed strictures, two had fistulas; and two developed short-gut syndrome (7%). Overall survival rate was (72%) but when it is limited to only pretenn infants, it was (78%). There were two late deaths (7%) both were more than 30 days after surgery, but in the same hospital stay.

Of the term infants, one had Down Syndrome, developed NEC with perforation in the first 24 hours and survived. One case of biliary atresia, who was investigated and awaiting surgery, suddenly developed massive NEC and died shortly after exploration and drainage only. The third case was a six-month-old infant who suffered recurrent septic episodes while being investigated for failure to thrive and developed massive NEC, who also died shortly after exploration and decompression. In the last two patients, sepsis was the underlying risk factor (Klebsiella Pneumonia, Staph. Epidermis).

In the postoperative group, two cases developed NEC after successful repair of diaphragmatic hernia, both of them survived. The third one, three weeks following Kasai procedure for biliary atresia, died with massive disease, thought to be sepsis.

The referral group, consists of two preterm infants referred several weeks following their primary and multiple surgeries and the third, a term infant referred with abdominal mass following an episode of what looked like gastroenteritis. All of this group survived. The latter one developed short gut syndrome.


   Discussion Top


With the present knowledge and awareness ofNEC and increased number of surviving critical neonates, the number of reports on treatment of NEC is on the increase [3],[4],[7],[16] . The etiology is still unknown with prematurity and low birth weight being the only predisposing factors that are agreed upon. Even so, they also occur with equal frequency in matched controls thus minimizing their role as primary etiology factors [5],[6],[7] . Since there are so many variables involved in these patients, it is difficult to pinpoint the actual risk factors.

A number of authors have suggested that, for preterm infants, prematurity is the only perinatal factor that is related to an increased risk of NEC [5],[6],[7] . However, other risk factors for NEC were identified, but differed from study to study. For example, hyaline membrane disease was reportedly more common in patients with NEC, in some studies and in others it was more common in controls. Similarly, in some reports, asphyxia and umbilical artery catherization were associated with NEC, but not in other studies [5],[6],[7] . The likely explanation for this lack of agreement lies in the differences in patient population in these studies. Our patient population had the same variation among risk factors in agreement with the average reported series. Various schemes have been proposed for predicting the occurrence of NEC, staging the disease, and outcome [8],[9],[10],[11] . Most are based on subjected clinical and imaging assessments and are observer dependent. They are of limited value when considering an individual patient. There is agreement as to the diagnosis and medical treatment once NEC is suspected in any infant using the triad of abdominal distension, high gastric residual, and intolerance to feedings with or without bleeding or pneumatosis.

The principles of medical therapy of NEC are: 1) Adequate decompression of the gastrointestinal tract, 2) Control of sepsis, 3) Fluid resuscitation, and 4) Frequent clinical and radiologic assessment of the patient for the development of gangrene or perforation [1],[2],[3],[4],[5],[6],[7],[8],[9] .

Forty to 50 percent of NEC patient require surgical intervention [2],[3],[4],[5],[6],[7],[8] . The only universally accepted indication for surgery is pneumoperitoneurn demonstrated on radiographs. Other indications are positive paracentesis [10],[11],[12] , fixed dilated loops on serial radiographs [10],[12],[13] , erythema of the abdominal wall [10],[12],[13] and portal vein gas [10],[12] . Our medical treatment of the suspected or highly suspected NEC is within the average reported series. Our surgical indication policy is to individualize the cases for their merits. The type of surgical procedures are also controversial. With the common segmental or localized disease, the consensus is to either exteriorize or resect the gangrenous bowel with creation of an enterostomy. Resection and primary anastomosis has been debated for a long time and has shown no difference in either morbidity or mortality in those patients who were treated with this procedure [14],[15] . Drainage alone was also proposed by several investigators and, again, demonstrated no significant difference in morbidity or mortality in those so-treated, especially in the extremely low birth weight infants [16],[17] . External drainage as the primary treatment of NEC is appealing as a simple, minimally invasive procedure, but the main disadvantages are the inability to evaluate the status of the diseased bowel and the extent of the disease, as well as the number and site of drains, notwithstanding, that drains never drain the entire peritoneal cavity but rather drain their vacinity.

Recent series of surgical experience with NEC report survival rates from 50 to 73% [16],[18],[19] . Long­term follow-up on neonates weighing under 1,000 grams or having gestational age less than 31 weeks indicates a high (24%) late mortality rate. These neonates have also late morbidity resulting from complications of sepsis, total parenteral nutrition, short-gut, bronchopulmonary dysplasia; however, the incidence of these complications was no higher than for those resulting from prematurity, respiratory distress syndrome, or other problems present before the onset of NEC and they should not discourage one from treating these infants aggressively [11],[12],[13],[14],[15],[16],[17],[18],[19] . Our survival rate as well as complication rate are within the average reported series and we believe that complications are non-fatal except for the short bowel syndrome which is the long term fatal complications. Success has been achieved mainly by progress in preoperative and postoperative intensive care medicine which has had the influence on the changing indications for surgery. Today, operative intervention can be easily postponed until free perforation becomes evident on radiographs.


   Conclusion Top


It is concluded that NEC is a common condition at our hospital and a high percentage of these patients required surgery. Our patient characteristics including treatment complications and survival rates are comparable to those in most reported series. Since this report describes one hospital experience, data from other centers in the Kingdom are needed. While awaiting the results of that studies, it seems that prevention is the key and prophylactic NEC protocol should be adopted in patients at high-risk who are yet to be clearly identified.

 
   References Top

1.Touloukian RJ, Berdon WE, Amoury RA et al. Surgical experience with necrotizing enterocolitis in the infant. J Pediatr Surg 1967;2:389-401.  Back to cited text no. 1    
2.Grosfeld JL, Cheu II, Schlatter M, West K, Rescoria FJ. Changing trends in necrotizing enterocolitis. Ann Surg 1991;214:300-7.  Back to cited text no. 2    
3.Kliegman RM, Hack M, Jones P, Fanaroff AA. Epidemiologic study of necrotizing enterocolitis among low birth­weight infants. J Pediatr 1982;100:440-4.  Back to cited text no. 3  [PUBMED]  
4.Cheu HW, Sukarochana K, Lloyd DA. Peritoneal drainage for necrotizing enterocolitis. J Pediatr Surg 1988;23:557-61.  Back to cited text no. 4  [PUBMED]  [FULLTEXT]
5.Kosloske AM, Musemeche CA, Ball WS Jr et al. Necrotizing enterocolitis: value of radiographic findings to predict outcome. Am J Radiol 1988;151:771-4.  Back to cited text no. 5    
6.Walsh MC, Kliegman RM. Necrotizing enterocolitis: treatment based on staging criteria. Pediatr Clin North Am 1986;33:17985.  Back to cited text no. 6    
7.Kosloske AM, papile LA, Burstein J. Indications for operation in acute necrotizing enterocolitis of the neonate. Surgery 1980;87:502-8.  Back to cited text no. 7  [PUBMED]  
8.Kosloske AM. Necrotizing enterocolitis in the neonate. Surg Gynecol Obstet 1979;149:259-69.  Back to cited text no. 8    
9.Kliegman RM, FanaroffAA. Necrotizing enterocolitis. N Eng J Med 1984;310:1093-103.  Back to cited text no. 9    
10.Stoll BL Kanto QP Jr, Glass RJ, et al. Epidemiology of necrotizing enterocolitis: a case control study. J Pediatr 1980;96:447-51.  Back to cited text no. 10    
11.Bell MJ, Temberg JL, Feigin RD et al. Neonatal necrotizing enterocolitis: Therapeutic decision based upon clinical staging. Ann Surg 1978;187:1-7.  Back to cited text no. 11    
12.Kanto WP Jr, Wilson R, Breast GL, et al. Perinatal events and necrotizing enterocolitis in premature infants. Am J Dis Child 1987;141:167-9.  Back to cited text no. 12    
13.Cikrit D, Mastandrea J, West KW et al. Necrotizing enterocolitis: Factors affecting mortality in 101 surgical cases. Surgery 1984;648-55.  Back to cited text no. 13    
14.Ein SH, Shandling B, Wesson D, Filler RM. A 13-year experience with peritoneal drainage under local anastomosis for NEC perforation. J Pediatr Surg 1990;25:1034-7.  Back to cited text no. 14  [PUBMED]  [FULLTEXT]
15.Pokorny WJ, Garcia-Prats JA, Barry YN. Necrotizing enterocolitis; incidence, operative care and outcome. J Pediatr Surg 1986;21:1149-54.  Back to cited text no. 15  [PUBMED]  [FULLTEXT]
16.Harberg FJ, McGill CW, Saleem MM, Halbert R. Resection and primary anastomosis necrotizing enterocolitis. J Pediatr Surg 1983;18:743-6.  Back to cited text no. 16    
17.Kosloske AM. Surgery of necrotizing enterocolitis. World J Surg 1985;9:277­  Back to cited text no. 17  [PUBMED]  
18.Kiesewater WB, Taghizadeh F, Bower RJ. Necrotizing enterocolitis: Is there a place to resection and primary anastomosis ? J Pediatr Surg 1979;14:360-3.  Back to cited text no. 18    
19.Wayne ER, Burrington JD, Hutter J. Neonatal necrotizing enterocolitis: evaluation of new principles in management. Arch Surg 1975;110:476-80.  Back to cited text no. 19  [PUBMED]  

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Correspondence Address:
Mohammad M Saleem
Security Forces Hospital, P.O. Box 3643, Riyadh 11481
Saudi Arabia
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Source of Support: None, Conflict of Interest: None


PMID: 19864812

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