Evaluation systems of surgical exploration for necrotizing enterocolitis

Abstract

Objective To explore the appropriate surgical exploration for necrotizing enterocolitis with Duke abdominal assessment scale (DASS) and seven clinical metrics of metabolic derangement (MD7) and discuss the best operative opportunity. Methods Retrospective analyses were performed for the clinical data of 38 confirmed cases NEC from June 2012 to October 2014. There were 26 males and 12 females with an age range of 233 days. According to revised Bell staging scheme, there were Ⅰ(n=8), Ⅱ(n=16) and Ⅲ (n=14). And there were 15 fullterm newborns and 23 preterms. Their weights were >2 500 g (n=16), 2 000-2 500 g (n=12); 1 500-2 000 g (n=9) and <1 500 g (n=1). Results Among them, 15 cases were conservatively cured within 7-22 days while the remainder underwent surgery for DAAS ≥7 or MD7 ≥3 within 113 days. The procedure included laparotomy (n=8), laparoscopy (n=15) and conversion into laparotomy (n=5). Intestinal necrosis was found in 10 cases. Among 9 cases of, perforation, there was multiple perforation (n=1). The perforation sites included ileum (n=3), ileocecus (n=1), ascending colon (n=3), transverse colon (n=2) and descending colon (n=1). Intestine had focal dark purple and became swollen and stiff with abdominal purulent exudates (n=4). There were intestinal perforation repair & enterostomy (n=1), intestinal resection & anastomosis (w=3), intestinal resection anastomosis & enterostomy (n=9), 2 cases to intestinal resection & enterostomy (n=2), enterostomy (n=5), abdominal cavity drainage (n=3) and enterostomy with transverse colostomy stricture healed by intestinal resection anastomosis (n=1). The curative rate of surgery was 82.6% (19/23). Three cases died while another gave up treatment. For 20 cases with DAAS ≥7, the numbers of bowel perforation and necrosis were 9 and 9 cases respectively. For 17 cases with MD7≥3, the numbers of bowel perforation and necrosis were 9 and 6 cases respectively. And 1/18 cases with DAAS<7 and 4/21 cases with MD7<3 had intestinal necrosis. The true positive rate of DAAS scores was 94.7% (18/19) and true negative rate 89.5%(17/19); the true positive rate of MD7 was 78.9%(15/19) and true negative rate 89.5%(17/19). But for both DAAS ≥7 and MD7 ≥3, the true positive rate was 100% (14/14) and this group included 9 cases with intestinal perforation. The receiver operating characteristic (ROC) curve indicated that DAAS and MD7 had higher diagnostic accuracies of identifying intestinal necrosis and perforation of NEC cases. Conclusions DAAS and MD7 are relatively objective and convenient in clinical practices. It is necessary to reach a consultation consensus between internal medicine and surgery. These two evaluation methods may be used as an important supplement of NEC surgical indications for other than pneumoperitoneum. It guides surgical intervention to reduce the incidence of preoperative perforation and achieve a better longterm prognosis. Key words: Enterocolitis, necrotizing; Surgical procedures, operative; Neonate