Proximal Jejunostomy Research Articles

Generalized Infantile Myofibromatosis with Extensive Small Bowel Involvement in a Neonate.

Infantile myofibromatosis is a rare benign congenital tumour that often regresses spontaneously but may pose therapeutic challenges in its widespread visceral form. We present the case of a full-term neonate with generalized infantile myofibromatosis including ubiquitous subcutaneous and muscular nodules, a tumour in the mastoid and disseminated intestinal involvement. The intestinal tumours led to a mechanical ileus with intestinal perforation within the first days of life. After partial small bowel resection and necessary proximal jejunostomy the boy was dependent on total parenteral nutrition. Chemotherapy with vinblastine and methotrexate was started and was temporarily supplemented with imatinib. Feeding stayed impossible despite tumour shrinkage. At the age of 4.5 months, restoration of intestinal continuity with further stricturoplasties was performed which - for the first time - allowed complete oral feeding. Chemotherapy was continued for further two months. Currently, the child is in good general condition with growth and further disease regression. This report suggests that massive visceral involvement of infantile myofibromatosis may require extensive intestinal surgery, as conservative therapy cannot resolve the disease and its sequelae.

A CASE OF ACUTE MESENTERIC ISCHEMIA: DIAGNOSTIC DILEMMA AND SURGICAL CHALLENGE

Mesenteric ischemia is an uncommon condition, and we need to have a high index of suspicion to diagnose and manage this condition. Predisposing conditions such as myocardial infarction, portal hypertension, pancreatitis, inflammatory bowel disease, post-operative states, trauma, and hypercoagulable states such as DVT, pregnancy, and neoplasms should always be accounted for before diagnosing this condition. In emergency situations, surgical exploration is warranted. Here, we present a case of 57-year-old male, known case of DVT RT lower limb, on anticoagulants, presented with the complaints of epigastric pain, absolute constipation, and abdominal distention of 3 days duration. He was investigated and managed by exploratory laparotomy with peritoneal lavage and resection of gangrenous bowel with proximal jejunostomy and distal ileostomy.

EP.FRI.616 Novel Technique of Gastrojejunostomy Tube Insertion to Control Retracted Proximal Stoma

Abstract Introduction Extensive small bowel resection for ischaemia can require formation of a proximal jejunostomy. Depending on length of remaining jejunum, a major potential complication is stoma retraction with resultant peritonitis, intra-abdominal sepsis and enterocutaneous fistula formation. We describe a case using a novel technique of inserting a retrograde gastrojejunostomy tube to gain control of an acutely retracted stoma in a 61 year old patient who developed an enterocutaneous fistula shortly after major resection due to ischaemia. Method Under fluoroscopic guidance, the retracted proximal limb of the jejunostomy was cannulated antegradely by guide wire. A gastro-jejunostomy tube was inserted retrograde over the guide wire and the tip placed within the stomach. The proximal tube fenestrations were sited within the duodenum and the balloon was inflated to limit enteric content spilling into the peritoneal cavity. Conclusion This technique enabled drainage of gastroduodenal fluid, minimised spillage into the peritoneal cavity, reduced fistula output and controlled sepsis. This allowed time for nutritional optimisation, better glycaemic control and endovascular revascularisation in preparation for restoration of intestinal continuity at an appropriate time. This method offered a useful alternative to surgery, in a patient for whom emergency re-exploration of the abdomen would carry significant risk of morbidity or mortality.

Delayed primary fascia closure of Bj\xf6rck grade 4 open abdomen with enteroatmospheric fistulas after repeated surgery for adhesive small bowel obstruction: a case report

BackgroundAn open abdomen with frozen adherent bowels is classified as grade 4 in Björck’s open abdomen classification, and skin grafting after wound granulation is a typical closure option. We achieved delayed primary fascia closure for a patient who developed open abdomen with enteroatmospheric fistulas due to severe adherent small bowel obstruction. We present here the details of his management.Case presentationA 52-year-old man suffered acute abdominal pain during a flight and received an emergency laparotomy due to adhesive small bowel obstruction. Repeated laparotomies were required, and later open abdomen and proximal site jejunostomy were selected. After negative pressure wound therapy, he was transferred to our institution. Two enteroatmospheric fistulas emerged on the exposed intestine, and we diagnosed the condition as a Björck grade 4 open abdomen. After 8 months of wound care and parenteral nutrition, we decided to attempt primary wound closure because the patient required permanent oral restriction and total parenteral nutrition due to short bowel syndrome. A circular incision along the circumference of the exposed bowel allowed us to take a safe approach into the abdominal cavity. We removed the intestinal adhesions completely and resected the bowels, including the fistulas and anastomosed parts. Finally, the abdominal wall defect was reconstructed using the component separation technique, and the patient was discharged without an ostomy.ConclusionsPrimary fascia closure for grade 4 open abdomen is hard, but leaving a long interval before radical surgery and applying pertinent wound management may help solve this adverse situation.

Concurrent intestinal malrotation and Meckel's diverticulum presenting as acute intestinal obstruction in an adult

Intestinal malrotation is the partial or complete failure of rotation of midgut around the superior mesenteric artery, while Meckel’s diverticulum is the remnant of vitellointestinal duct and concurrence of these congenital abnormalities in an adult is considered a rarity. Till date only 3 cases of concurrent intestinal malrotation and Meckel's diverticulum have been reported. We report a 18 years male who presented with a 3 day history of abdominal pain, bilious vomiting, obstipation and chronic abdominal pain on and off since 3 years of age. During the last episode which occurred 1 year back, he was diagnosed with intestinal malrotation with subacute intestinal obstruction and was treated conservatively. Examination revealed the presence of signs of peritonitis. After resuscitation, CECT abdomen was taken which showed dilated small bowel loops in the subhepatic region associated with malrotation. Emergency laparotomy revealed a Ladd's band below which the gangrenous small bowel loops 150 cm from the duodenojejunal (flexure until 5 cm proximal to the ileocecal junction) were found herniating into the subhepatic region with a Meckel’s diverticulum and a right sided DJ flexure. We proceeded with the band release and resection of gangrenous bowel followed by proximal jejunostomy with distal ileostomy. HPE was consistent with Meckel’s diverticulitis without any ectopic gastric or pancreatic mucosa. Ostomy reversal was done after 8 weeks. Patient had an uneventful postoperative recovery during both the admissions and he is on regular follow-up now.

30 Novel Technique of Gastrojejunostomy Tube Insertion to Control Retracted Proximal Stoma

Abstract Introduction Extensive small bowel resection for ischaemia can require formation of a proximal jejunostomy. Depending on length of remaining jejunum, a major potential complication is stoma retraction with resultant peritonitis, intra-abdominal sepsis and enterocutaneous fistula formation. We describe a case using a novel technique of inserting a retrograde gastrojejunostomy tube to gain control of an acutely retracted stoma in a 61-year-old patient who developed an enterocutaneous fistula shortly after major resection due to ischaemia. Method Under fluoroscopic guidance, the retracted proximal limb of the jejunostomy was cannulated antegradely by guide wire. A gastro-jejunostomy tube was inserted retrograde over the guide wire and the tip placed within the stomach. The proximal tube fenestrations were sited within the duodenum and the balloon was inflated to limit enteric content spilling into the peritoneal cavity. Conclusions This technique enabled drainage of gastroduodenal fluid, minimised spillage into the peritoneal cavity, reduced fistula output and controlled sepsis. This allowed time for nutritional optimisation, better glycaemic control, and endovascular revascularisation in preparation for restoration of intestinal continuity at an appropriate time. This method offered a useful alternative to surgery, in a patient for whom emergency re-exploration of the abdomen would carry significant risk of morbidity or mortality.

New simple low-cost surgical approach to complex jejuno-ileal atresia.

We report our experience of staged operations in the surgical treatment of complex jejuno-ileal atresia. Our study examined transgastric deflation of the proximal segment and feeding jejunostomy through the distal segment as a first stage followed by a definitive restoration of continuity secondarily at a tertiary centre over a period of three years. A cohort of 21 cases were studied. None suffered with intestinal perforation or volvulus. Tube plugging was seen in three patients who were relieved by flushing. Tube replacement was not required. One patient developed necrotising enterocolitis and died. Sepsis was seen in three. The age at the second operation was 56.2 ± 6.6 days. There was no complication after this second procedure. We therefore recommend this staged management for complex jejuno-ileal atresia, but suggest further studies.

Cascade of Surgical Complications: A Case of Necrotizing Fasciitis

A 60 year old female presented with abdominal distension and non-specific abdominal pain and describes herself to have a ‘lazy bowel’, with a complicated surgery history. Patient subsequently underwent an emergency laparotomy for multiple small bowel perforations, requiring small bowel resection. The patient developed necrotizing fasciitis (NF) due to an increased use of inotropes during surgery which causes excessive vasoconstriction, and she had a major portion of the abdominal flab removed. This followed by a 33 day ITU admission (level 3) due to septic shock and poor pulmonary compliance. During the ITU stay, the patient was taken back into theatre 14 times for vac dressing changes to reduce the pressure from 150 mmHg down to 25 mmHg. Back in the surgery ward, the patient developed a fistula due to the vac dressing eroding the small bowel, leading to a proximal jejunostomy in situ which effectively worked as a high output stoma. The patient later suffered from re-feeding syndrome as the feed was primarily through the jejunostomy. Eventually absorbable mesh was added behind the vac dressing to protect the soft tissue underneath and the final stage was referral to plastic surgeons that would a joint reconstruction of the abdominal wall with the general surgeons at St Marks (tertiary centre for intestinal feeding and the combined reconstruction).

Distal Bowel Re-feeding in Patients with Proximal Jejunostomy

BackgroundPatients who have a proximal jejunostomy are difficult to manage because of their high stoma output which results in fluid and electrolyte imbalance with repeated hospital admissions and the necessity for expensive parenteral nutrition (PN). There are few reports on the use of re-feeding of the proximal effluents in this situation. MethodsWe here relate our experience with this manoeuvre in 35 patients between Jan 2010 and Feb 2016 who had stomas less than 120 cm away from the duodenojejunal flexure. ResultsThere were 26 males and 9 females, whose median age was 47 (19–74) years. The most common indications for massive bowel resection were gangrene in 25 (71%) and intestinal perforation in 7 (20%). The median proximal and distal small bowel lengths were 45 (15–120) cm and 90 (0–240) cm respectively. The ileocaecal (IC) valve was preserved in 33 (94%) and there was only colon distally (without the ileocaecal valve) in 2 (6%) patients. Twenty-five (71%) patients required post-operative ICU care. Additional PN was required in 6 (17%) patients during their index admission with the average extra cost of treatment being 20,000 rupees. Their median hospital stay was 13 (6–60) days. Patients were discharged without intravenous (IV) lines. Eight (26%) patients required re-admission for acute renal failure which was managed conservatively. No major problems were associated with re-feeding. None of the patients required PN after discharge from hospital. Thirty (86%) patients had their stomas closed at 65 (14–224) days. Both the patients with colon only as their distal bowel remnant died. Sepsis was the cause of mortality in 4 (11%) during index admission and 3 after their discharge. On follow-up after bowel re-connection, 2 patients died after 1 and 12 months, both due to intracranial bleeding, and the overall survival was 74%. ConclusionsPatients with proximal jejunostomies can be managed with distal re-feeding. It is a cost-effective and effective substitute for PN, is associated with few problems, and has a fairly good long-term outcome.

Is jejunostomy output nutrient or waste in short bowel syndrome? Experience from six cases.

Certain patients who undergo proximal jejunum resection are unable to undergo primary anastomosis and require exteriorization of the proximal jejunum. These patients usually have major problems with short bowel due to the high output of the stoma. The output of a proximal jejunostomy contains abundant amounts of enzymes and electrolytes. Therefore, it is a feasible approach to re-infuse jejunostomy output to regain homeostasis. To evaluate the effects of proximal jejunostomy output reinfusion into the distal small bowel for patients with short bowel syndrome, and to determine whether reinfusion could avoid long-term parenteral nutrition (PN). PN was initiated immediately after surgery. When patients started enteral nutrition, we started the proximal jejunostomy output reinfusion protocol. Proximal jejunostomy output reinfusion was performed by the patients, and continued by them after discharge. When proximal jejunostomy output reinfusion could be performed stably, PN was stopped. The median length of the proximal jejunum was 20 cm and of the distal small bowel was 77.5 cm in patients who could stably receive proximal jejunostomy output reinfusion alone. Three patients did not require home PN; they only required PN during hospitalization. Four patients successfully underwent stoma takedown with intestinal anastomosis after 6-7 months without any nutritional or metabolic complications. Short bowel syndrome patients with an adequate length of small bowel and functional colon could avoid long-term PN by receiving reinfusion of proximal jejunostomy output into the distal small bowel.

SHORT BOWEL SYNDROME AND NUTRITIONAL ENTERAL

The particularity of this case is the nutritional management that has managed to avoid the use of prolonged parenteral nutrition and possible complications by placing jejunal tube at the distal end in patients with short bowel. It is a 34-year-old colecistectomizado complicated with postoperative peritonitis and dehiscence; two years he studied with small bowel obstruction, he was made de-volvulus and was complicated with two leak at different times after the second escape took place jejunostomy side double barreled shotgun level dehiscence, presented high debits by afferent loop of the terminal jejunostomy; during admission, polyurethane probe enteral feeding was inserted by the efferent loop jejunostomy. He received jejunal tube feeding laundry in the efferent loop terminal with decreased weight gain and subsequent reconstruction of intestinal transit debit proximal jejunostomy.

Necrotizing Enterocolitis in a Neonate

Necrotizing enterocolitis (NEC) is a disease of the intestine detrimental that occurs in approximately 10% of neonates who weigh 1500 g or less; it is associated with a 25% mortality rate. Additional abdominal wall defects and disturbance of environmental surroundings further compromise the likelihood of mortality. Early intervention and aggressive surgical treatment have been shown to decrease the mortality rate of this disease process. This case study describes wound and ostomy management on a neonate with NEC who, after bowel perforation, required a distal and proximal jejunostomy and a colostomy. Frequent dressing changes were disrupting the neonates' environmental factors that affect growth. Management began with an alginate dressing, but it was unsuccessful in containing the drainage. Negative pressure wound therapy was then applied to eliminate exudate and infectious material, control odor, and decrease environmental factors affecting growth, as well as to assist in wound closure. Necrotizing enterocolitis and potential complications such as perforation and dehiscence can be devastating for hospitalized neonates. In this case, negative pressure wound therapy promoted tissue growth and managed exudate and odor, while decreasing intervals between dressing changes. The abdominal wound healed, allowing for a better plane for stoma pouching. The neonate's ostomies were successfully reversed and he continues to thrive to date.

Tacrolimus trough levels before, during and after jejunostomy in a liver transplant patient: A case report

SummaryAlthough the feasibility of oral tacrolimus administration in the presence of jejunostomy has already been reported, few studies monitoring tacrolimus trough blood levels have been analyzed in detail, either during or after a jejunostomy closure. We report on our experience with a 34-year-old patient who underwent liver transplantations, with a proximal jejunostomy constructed a few days prior to the second transplantation. He was administered tacrolimus by a predominantly oral route, and less frequently received it by jejunostomy. The aim of this paper is to discuss this administration strategy and whether a different method could have been more suitable. This case report highlights that during the jejunostomy period, the tacrolimus doses that were required to maintain trough concentrations within the therapeutic range were four times higher than those administered after the closure of the jejunostomy. We observed an increase in the Dose-Normalized Trough Concentration (DNTC) values when tacrolimus was administered for 4 consecutive days by jejunostomy as compared to oral administration, indicating that the relative bioavailability of tacrolimus increased. Moreover, when returning to oral administration, the subsequent DNTC value was halved, highlighting a reduction in the tacrolimus bioavailability. Thus, in such a case, administration by jejunostomy could be more appropriate.

Risk Factors for Parenteral Nutrition–associated Liver Disease Following Surgical Therapy for Necrotizing Enterocolitis

The aim of the study was to prospectively determine risk factors for the development of parenteral nutrition-associated liver disease (PNALD) in infants who underwent surgery for necrotizing enterocolitis (NEC), the most common cause of intestinal failure in children. : From February 2004 to February 2007, we diagnosed 464 infants with NEC, of whom 180 had surgery. One hundred twenty-seven patients were available for full analysis. PNALD was defined as serum direct bilirubin ≥ 2 mg/dL or ALT ≥ 2 × the upper limit of normal in the absence of sepsis after ≥ 14 days of exposure to PN. Median gestational age was 26 weeks and 68% were boys. Seventy percent of the cohort developed PNALD and the incidence of PNALD varied significantly across the 6 study sites, ranging from 56% to 85% (P = 0.05). Multivariable logistic regression analysis identified small-bowel resection or creation of jejunostomy (odds ratio [OR] 4.96, 95% confidence interval [CI] 1.97-12.51, P = 0.0007) and duration of PN in weeks (OR 2.37, 95% CI 1.56-3.60, P < 0.0001) as independent risk factors for PNALD. Preoperative exposure to PN was also associated with the development of PNALD; the risk of PNALD was 2.6 (95% CI 1.5-4.7; P = 0.001) times greater in patients with ≥ 4 weeks of preoperative PN compared with those with less preoperative PN use. Breast milk feedings, episodes of infection, and gestational age were not related to the development of PNALD. The incidence of PNALD is high in infants with NEC undergoing surgical treatment. Risk factors for PNALD are related to signs of NEC severity, including the need for small-bowel resection or proximal jejunostomy, as well as longer exposure to PN. Identification of these and other risk factors can help in the design of clinical trials for the prevention and treatment of PNALD and for clinical assessment of patients with NEC and prolonged PN dependence.

Management strategies for infants with total intestinal aganglionosis

Purpose This study investigated appropriate management strategies for infants with total intestinal aganglionosis(TIA), focusing on surgical and medical managements. Methods Six infants with TIA or near TIA treated in our institution between 1980 and 2007 were reviewed retrospectively. Surgery was performed as a simple jejunostomy, 65 to 70 cm below the ligament of Treitz (LOT) in 2 infants, and 30 cm below LOT in 1 without extended myectomy-myotomy(EMM). Jejunostomy with EMM 30 to 35 cm below LOT were performed in 3. Results Two infants with jejunostomy 65 cm or 70 cm distal from LOT died of sepsis at 7 months and 8 months of age, respectively. One infant with jejunostomy 30 cm from LOT without EMM died of cholestatic liver failure at the age of 1 year and 8 months. To date, the remaining 3 infants with jejunostomy 30 cm or 35 cm distal from LOT in addition to EMM have survived 10 years, 3 years and 10 months, and 2 years of age, respectively. Nutritional managements such as parenteral nutrition with 80 to 100 kcal/kg/day and oral feeding with elemental diet(ED) were preferable to reduce the occurrence of enteritis, sepsis, and cholestatic liver dysfunction. Conclusion A good combination of cyclic parenteral nutrition and oral intake with elemental diet after short proximal jejunostomy with EMM may be a key for the survival of infants with TIA. In addition, in infants whose absorptive function was not ameliorated by EMM, medical management such as GH administration might be worth trying.

Intestinal stenting in preterm, very-low-birth-weight infants with necrotizing enterocolitis and multiple perforations

We present 2 cases of necrotizing enterocolitis with multiple intestinal perforations or areas of segmental bowel necrosis in preterm, very-low-birth-weight infants. We reviewed their charts and researched the related literature. We used SILASTIC (Silmag, Argentina) intestinal stents to avoid multiple formal bowel anastomosis or stomas and longer resections, and to reduce operative time. In the first case, we externalized the stent through the first and last perforation; and in the second, through a proximal jejunostomy and the orifice left after an appendectomy. This method was useful in avoiding short bowel syndrome in both infants, and they were discharged successfully. They are currently 31/2 and 2 years old, respectively, eating without any restriction and with mild developmental delays. Treatment of preterm infants with multiple bowel perforations or areas of bowel necrosis requires a maximal effort to preserve as much intestinal length as possible. Use of the SILASTIC stent technique provides a good treatment variant in selected cases to preserve bowel length, reduce operative time, and avoid short bowel syndrome.

Clonidine Reduces Diarrhea and Sodium Loss in Patients With Proximal Jejunostomy: A Controlled Study

Patients with short bowel syndrome have significant fluid losses. This represents a significant management problem, especially in patients with minimal residual intestine. We determined whether clonidine, an alpha2-adrenergic agonist, is effective in decreasing fecal water and sodium (Na) losses in patients with proximal jejunostomy. Eight parenteral nutrition (PN)-dependent subjects (3 men, 5 women), aged 49.9+/-10.2 years, with a residual small bowel length of 71.8+/-152.0 cm that ended in a jejunostomy, were studied. Subjects were admitted to the North-western General Clinical Research Center (GCRC) for a 2-day equilibrium period while receiving a self-selected 100 g fat diet with protein 1.5 g/kg/d and 30 kcal/kg/d and 1 L/d of oral rehydration solution. A D-xylose test was performed after an overnight fast. On days 3-5, all stool and urine were collected for volume, weight, fat, nitrogen, energy, sodium, magnesium, potassium, and calcium. Meals were provided in duplicate and the equivalent portions consumed by each patient were analyzed for fluid volume, fat, nitrogen, energy, sodium, magnesium, calcium, and potassium in order to calculate nutrient balances. At the conclusion of the stool and urine collections (day 6), a clonidine (0.3 mg) patch was applied to the shoulder. Subjects were restudied after 1 week. Daily fecal volume and weight were 4.514+/-1.769 L/d and 4394+/-1727 g/d, respectively, at baseline. Five subjects were net "secretors" in that excreted fecal volume exceeded oral intake. Fecal volume decreased by 427+/-562 mL/d (8.9%, p=.07). Fecal weight decreased by 438+/-527 g/d (9.4%, p=.05). Urine volume correspondingly increased by 747+/-1934 mL (18.9%, p=not significant [NS]). The increase in urine output was weakly and negatively correlated with the decrease in fecal volume and weight (r=-0.37 and -0.41, respectively, p=NS). Oral fluid intake decreased slightly from 3.328+/-1.246 L/d baseline to 3.203+/-1.119 L/d with clonidine therapy (-3.8%, p=NS). Fecal Na loss was significantly decreased from baseline (887+/-996 mg/d, 11.2+/-12.3%; p=.036). This was not related to decreased oral Na intake, which actually increased from baseline (3.799+/-2.271 g/d) to 3.933+/-1.314 g/d after clonidine therapy (p=NS). No patient developed hypotension. Our results show the transdermal administration of clonidine is associated with a modest but clinically significant decrease in fecal output in patients with short bowel syndrome and high-output proximal jejunostomy that require chronic parenteral fluid infusion. This is accompanied by decreased fecal Na loss.

Metabolic Response to Stress in the Neonate Who Has Surgery

After completing this article, readers should be able to: 1. Describe the basic metabolic pathways involved in neonatal nutrition. 2. Describe the effect of stress on nutrition and metabolism in the neonate undergoing surgery. 3. Describe the differences in the metabolic response to stress between an adult and a neonate. Over the past 4 decades, there have been remarkable improvements in our ability to care for critically ill infants. Progress in surgical and critical care of neonates has led to improved survival rates. Our understanding of the nutritional requirements of infants continues to advance. In contrast to years past, practitioners caring for critically ill infants undergoing surgery today have various nutritional options, including specialized parenteral and enteral formulations. Although our understanding of host defense and nutritional support continues to evolve, the interplay between the immune system and metabolism is being investigated. Hence, we are improving the match between the infant’s energy expenditure and nutritional requirements. Critical to further progress is additional understanding of the metabolic response of a neonate to surgical stress. All living organisms require energy to survive. Fuel sources enter into complex metabolic cascades to form the ultimate energy substrate, adenosine triphosphate (ATP), a fuel needed to drive and maintain all physiologic systems. Under stressful conditions, intrinsic substrate mobilizes to synthesize additional energy substrate. In essence, host substrate is mobilized for the promotion of healing after injury. Cytokines, released in response to injury, drive the catabolic response to stress, but in abundance, as with the systemic inflammatory response syndrome (SIRS), cytokines are detrimental to the organism. The nutritional requirements of a neonate are significantly greater than those of an adult because not only are there requirements for substrate intake to fulfill basic metabolic needs, but there are metabolic needs to maintain rapid and continued growth and development. Furthermore, the metabolic response …

Pumping device for re-infusion excretions derived from a proximal jejunostomy or high output fistula.

Pumping device for re-infusion excretions derived from a proximal jejunostomy or high output fistula.

The surgical management of necrotising enterocolitis

Necrotizing enterocolitis (NEC) is the most common gastrointestinal emergency in neonates. The disease affects mainly premature neonates. The pathogenesis is still unknown but predisposing factors are prematurity, formula feeding and sepsis. The disease can lead to gangrene and intestinal perforation requiring surgery. The options for surgery are between primary peritoneal drainage or laparotomy. However, the optimum choice between peritoneal drainage and laparotomy remains controversial, particularly in low-birth-weight infants (<1000 g). Peritoneal drainage offers temporary decompression, drainage and stabilization of patients whilst awaiting surgery, or in patients too unstable to be able to tolerate surgery or anaesthesia. Those weighing >1000 g who have no associated morbidities and are clinically stable are preferentially treated by primary laparotomy. The principal surgical objectives of laparotomy in acute NEC are to control sepsis and removal of gangrenous bowel preserving as much bowel length as possible. The surgical options at laparotomy include resection with enterostomy, resection with primary anastomosis, proximal jejunostomy and “clip and drop” technique. The option exercised is influenced by the clinical status of the patient and the extent of the disease.