Surgical Treatment Of Necrotizing Enterocolitis Research Articles

Necrotizing Enterocolitis: The Role of Hypoxia, Gut Microbiome, and Microbial Metabolites.

Necrotizing enterocolitis (NEC) is a life-threatening disease that predominantly affects very low birth weight preterm infants. Development of NEC in preterm infants is accompanied by high mortality. Surgical treatment of NEC can be complicated by short bowel syndrome, intestinal failure, parenteral nutrition-associated liver disease, and neurodevelopmental delay. Issues surrounding pathogenesis, prevention, and treatment of NEC remain unclear. This review summarizes data on prenatal risk factors for NEC, the role of pre-eclampsia, and intrauterine growth retardation in the pathogenesis of NEC. The role of hypoxia in NEC is discussed. Recent data on the role of the intestinal microbiome in the development of NEC, and features of the metabolome that can serve as potential biomarkers, are presented. The Pseudomonadota phylum is known to be associated with NEC in preterm neonates, and the role of other bacteria and their metabolites in NEC pathogenesis is also discussed. The most promising approaches for preventing and treating NEC are summarized.

Clinical and histopathological correlates of intestinal repair in preterm infants following surgical necrotizing enterocolitis

Objective We sought to determine the clinical and histopathological factors linked with intestinal repair and its correlation with clinical outcomes in preterm infants following surgical necrotizing enterocolitis (NEC). Methods A retrospective study has compared clinical and histopathological characteristics between preterm infants with histopathological reparative changes versus non-reparative changes in resected intestinal tissue following surgical treatment of NEC. Reparative changes were defined as microscopic evidence of neovascularization, increased fibroblasts or myofibroblasts, and epithelial regeneration during histopathological examination of the most affected area of resected intestinal tissue. Results The infants with reparative changes (53/148) had significantly lower median birth weight (725 [650−963] vs. 920 [690−1320]; p = .018), higher likelihood of patent ductus arteriosus (38/53 [71.7%] vs. 48/95 [50.5%]; p = .012), longer TPN days (99 [56−147] vs. 76.5 [39−112.5]; p = .034), higher CRP levels (7.3 [3.2−13] vs. 2.6 [1.1−7.8]; p = .011) at NEC onset, and more short bowel syndrome (27/53 [54.0%] vs. 28/95 [32.2%]; p = .012). Those with reparative changes also received more Penrose drain therapy (21/53 [39.6%] vs. 14/95 [14.7%]; p = .011) and had a longer median time to laparotomy (108 h [28−216] vs. 24 [12−96]; p = .003). Epithelial regeneration observed in 6/53 (11.3%) infants lagged fibroblast proliferation and neovascularization changes in the submucosa/muscularis intestinal layers. On a multivariable logistic regression model which included histopathological and clinical factors, inflammation with a percentage <25% area involvement, time from NEC diagnosis to surgery, and Apgar score < 6 at 5 min were independently and significantly associated with higher odds reparative changes. Conclusion In neonates with surgical NEC, the histopathological findings in the resected bowel are significantly associated with clinical characteristics, other histopathological findings, and outcomes. The presence of reparative changes consistent with healing is significantly associated with Apgar score, Penrose drain therapy, longer time from NEC diagnosis to surgery, and lower burden of inflammation in the resected bowel tissue in multivariable analyses. Routine histopathological grading of resected bowel and optimal use of Penrose drain therapy warrant further investigation in the care of neonates with surgical NEC.

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

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.

The Neonate With Major Malformations: Experiences in a University Children's Hospital in The Netherlands

Advancements in medical technology over the last decades have greatly benefited perioperative care of newborns undergoing major surgical interventions. Yet, a proportion of these babies will not survive, and doctors are forced to face the difficult ethical question of whether, in cases of severe congenital malformations or acquired diseases, the expected quality of life justifies the decision to continue, withhold, or withdraw treatment. In a tripartite approach, the authors present their relevant experiences with these newborns in the pediatric surgical department of the Sophia Children's Hospital (SCH). First the authors evaluated the mortality pattern and causes of death in surgical neonates over 2 periods (1986 through 1990 and 1996 through 2000). The mortality rate was the same, 10%. Pattern of mortality was classified into 3 groups: nonpreventable, permissible, and preventable death. The most striking difference between both mortality groups existed between the percentage of preventable deaths, 14.5% in the earlier period, versus 5% in the most recent period. Half of the preventable deaths in the former period occurred in relation to postoperative, infectious treatment complications, such as inadequate sepsis management. These errors were not seen anymore in our recent evaluation. Second, the authors studied the physical and psychosocial adjustment of former patients, particularly those operated on for digestive tract anomalies. The follow-up period encompasses from 8 to 12 years showing that the physical functioning of these children was relatively good. With respect to their cognitive and psychosocial functioning it seems justified to conclude that they are at risk for lower cognitive functioning, learning problems, and possibly lower educational levels. Third, the authors decided that ethical questions related to surgical treatment of necrotizing enterocolitis (NEC) actually fits within the scope of this article. They hypothesized that a particular minimum birth weight could be a decisive factor for refraining from surgery on ethical grounds in the treatment of this particular disease. A total of 116 patients with NEC were identified over a 5-year study period. Seventy-five fell into the lowest birth weight group (< 1,500 g). The operative mortality rate (21 patients) increased with decreasing birth weight: group A, 29% (A1, 31%; A2,26%); group B, 23%; and group C, 0%. The authors were particularly interested in the long-term follow-up of the A1 group (BW < 1,000 g), and 18 of the 30 survivors of this group were available for follow-up. There were 2 survivors with short bowel syndrome. Early assessment and neurodevelopmental outcome, at least 2 years after surgery, showed that in 14 of these 18 (78%) there were no major handicaps. The other 4 patients had one or more major handicaps (cerebral palsy, mental and/or visual handicap, and hearing loss). NEC-related mortality after surgery is highest for patients with birth weight less than 1,000 g (31%). However, in view of the overall good 2-year follow-up results of the survivors, we feel unable to define a minimum birth weight that, as such, could serve as a cutoff point for deciding to forbear, on ethical grounds, surgical treatment for NEC. The picture represented by our tripartite investigation of life and death in and after the intensive care unit period serves as a mirror and truthfully reflects ethical questions of our medical practices.

Surgical Treatment of Necrotizing Enterocolitis and the Short Bowel Syndrome

Necrotizing enterocolitis (NEC) is the most common surgical emergency of newborns and the most common cause of short bowel syndrome in infancy. The surgical treatment of NEC is reviewed, including indications for operation, surgical procedures, postoperative management and complications, and survival. The causes, pathophysiology, and treatment of short bowel syndrome are also discussed.

Intestinal obstruction due to colonic stricture following neonatal necrotizing enterocolitis.

After resolution of acute necrotizing enterocolitis (NEC), six of 31 surviving infants (19%) developed late ischemic stricture of the colon. Stricture occurred after both medical and surgical treatment for NEC, and in both functional and defunctionalized bowel. In medically-treated infants, the symptoms of intestinal obstruction usually began six to eight weeks after NEC. Surgically-treated infants developed asymptomatic strictures distal to an enterostomy. Barium enema was the appropriate diagnostic study for both groups. Operative management consisted of segmental colonic resection with frequent use of enterostomy. On histopathologic examination, resected strictures showed a spectrum of the reparative process after intestinal ischemia, ranging from obliterative scar to near-normal colon. Because delayed diagnosis led to the death of one of our infants, we recommend a barium enema for early diagnosis of stricture about six weeks after NEC, whether initial treatment was medical or surgical. In a recent infant, two colonic strictures were thus diagnosed and resected prior to development of symptoms of intestinal obstruction.