Modern possibilities of diagnostic and surgical treatment of neonatal necrotizing enterocolitis. (Review article)

Abstract

In recent years there has been an increase in the number of infants with low birth weight and preterm infants undergoing antenatal and intrapartum hypoxia, which leads to an increase in the number of severe diseases of the gastrointestinal tract, such as necrotizing enterocolitis (NEC) of newborns. NEC is known to be one of the most common acquired diseases of the gastrointestinal tract of newborns in neonatal departments and intensive care units, which in some cases require urgent surgical intervention. From a clinical point of view, NEC occurs as mild and severe complications in the form of necrosis of the intestinal wall, peritonitis, sepsis causing high mortality. As to understanding of NEC pathophysiology, it is considered to be of a multifactorial nature of damage with the development of excessive intestinal wall inflammation of a relative immaturity of the intestine in response to intestinal ischemia. The final result is a cascade of immune system activation and release of proinflammatory cytokines, which leads to spread determined inflammatory response. In the world practice, Walsh M., Kleigman R. classification (1986) is the most common, taking into account stage changes of clinical, radiographic, and gastrointestinal symptoms. However, the diagnosis is complicated by NEC nonspecific clinical picture and the lack of accuracy of additional methods of examination, the absence of specific markers. Diagnostic criteria are based on NEC clinical, laboratory and instrumental methods of research. Many serological markers for the diagnosis of necrotizing enterocolitis are suggested, including: C-reactive protein, platelet activating factor, binding protein intestinal fatty acid, fecal calprotectin, matrix metalloproteinase inhibitors of matrix metalloproteinases, Claudin-3, endogenous antimicrobial peptide cathelicidin, citrulline, but there is no consensus as to their use in terms of clinical benefit. The most valuable objective diagnostic methods used to examine newborns during the active phase of NEC are plain radiography of the abdomen and ultrasound examination of the abdomen. Application of X-ray contrast examinations of the gastrointestinal tract, computed tomography and magnetic resonance imaging is not considered useful in clinical practice to diagnose NEC. In their studies, the authors have shown great benefit using color Doppler ultrasound to assess the thickness of the intestinal wall, echogenicity, motility and perfusion in healthy infants and children with NEC. Recently, there have been reports concerning the use of non-invasive methods to diagnose cerebral and visceral blood flow using near-infrared spectroscopy. Among invasive methods of NEC diagnosis, which are used in case of serious condition of the patient and a significant increase in abdominal circumference, abdominocentesis is applied. The treatment of therapeutic stages of NEC is standard almost in all hospitals and it includes: enteral pause, parenteral nutrition, infusion, antibiotic therapy, administration of inotropic drugs, blood products, correction of electrolyte and acid - base balance of the blood, dynamic monitoring. The most common method of surgical treatment of perforated NEC is laparotomy, bowel resection, or removal enterostoma, application of primary anastomosis, the use of peritoneal drainage as a preoperative preparation, or as an independent method of surgical treatment. There is currently no convincing prospective controlled studies of the effect of application of specific surgical approach to the results of survival. Among the alternatives to laparotomy the authors propose to use laparoscopy, which can be a useful tool in the arsenal of diagnostics and surgical treatment of NEC, it can be used in infants with suspected NEC, to avoid unnecessary laparotomy when there is no confidence in the need for surgery and to minimize surgical trauma. Surgical treatment for NEC is not standardized. There are no clear indications for surgical treatment, type of the surgery, and technical aspects. Keeping babies with NEC is a common problem of neonatologists, pediatric surgeons and intensive care specialists. Nowadays, there is no uniform standard of care for patients with this disease, and the suggested methods of surgical treatment have confused results. Despite a large number of methods to diagnose NEC, the issues of early pre-clinical diagnosis as well as the extensive use of laboratory-instrumental predictors of NEC, the course and progression of complications of the disease remain unsolved. Despite a large number of proposed methods of surgery surgical treatment of NEC remains complicated, there are certain problems concerning the use of these methods at each surgical stage of NEC. Early diagnosis, unified and at the same time an individual choice of surgical tactics on every step of surgery of NEC will reduce mortality, complications and disability in this group of patients. The objective of this article is to review current capabilities of diagnosis and surgical treatment of infants with NEC.