Slovenská chirurgia 3/2014

Surgical treatment of necrotizing enterocolitis of newborn

Introduction:Necrotizing enterocolitis of newborn is one of the most common and most serious diseases affecting predominantly preterm neonates with very low birth weight. Mortality of necrotising enterocolitis remains high, especially in patients whose clinical condition requires surgical intervention. Surgical intervention is indicated in 30 – 50 % of cases. A clear indication for surgical intervention is confirmed intestinal perforation. Other appropriate indications for surgical treatment itself are currently not clearly defined and vary depending on the workplace. The basic and most frequently used surgical interventions include primary peritoneal drainage, resection of the affected bowel segment with creation of diverting enterostomy with or without mucous fistula, resection of the affected bowel segment with primary anastomosis, high jejunostomy. In patients with panintestinal disease, there are described several surgical techniques. Aim of study:The aim of our study was to analyze the surgical treatment and its results in patients affected with necrotizing enterocolitis hospitalized in the University Hospital Martin. Methodology:In the article we present the retrospective study of patients with so-called „surgical necrotising enterocolitis” stage III, IV according to Bell, who were hospitalized at Neonatology Clinic University Hospital in Martin and were operated by surgeons of the Department of Pediatric Surgery University Hospital in Martin during the period of January 2002 to May 2013. The analyzed group consisted of the 24 patients (n = 24), 23 babies were born prematurely – before 37th weeks of gestation, only one newborn baby was born in term. The mean gestational age was 29 weeks (24 – 40 weeks of gestational age). The average birth weight was 1 223,75 g (660 – 2900 g), there were 17 newborns with birth weight < 1500 g in the analyzed group. Average number of days from birth to undergoing surgery was 17,33 days (5 – 46 days). The study included all newborns who met the criteria for the indication of surgical intervention. We evaluated the indications for surgical intervention, postnatal age at the time of surgical intervention, intraoperative findings, surgical procedure that we used, complications relating to the used surgical technique and overall mortality of patients in group. Results:The patients underwent surgery on the basis of meeting the indicator criteria, the presence of pneumoperitoneum (13 patients), positive paracentesis (1 patient), clinical deterioration, persistent high inflammatory activity (7 patients), ileus (2 patients), fixed intestinal loop on the radiograph (1 patient). Average number of days from birth to undergoing surgery was 17,33 (5 – 46 days). Intraoperatively, there was found unifocal bowel perforation in 13 cases. Multifocal perforations were found in 6 cases. In 2 patients no perforation was found intraoperatively, there were found some gangrenous changes in the area of the ileum. Stricture of the intestine as a result of necrotizing enterocolitis previous managed conservatively was found in 3 patients. If surgical intervention was indicated, there have been used several procedures. Primary peritoneal drainage was performed in 3 patients in poor clinical condition, followed by a delayed laparotomy after stabilization of the clinical condition. Bowel resection with creation of the diverting stoma was used in 17 patients. Primary anastomosis after resection of the damaged intestine was used in 6 patients. In one patient with intraoperative finding of panintestinal disease, there was realized only lavage and drainage of the abdominal cavity. Postoperative complications occurred in 12 cases. In the group of patients dealt with bowel resection technique with creation of diverting enterostomy, stoma complications occured in 3 patients, 1 x was established enterocutaneous fistula, 1 x wound dehiscence, 3 patients developed a mechanical ileus of adhesions. Bowel stricture occurred in 2 cases. In the group of patients dealt with resection of the affected bowel with primary anastomosis complications occurred in 2 patients, 1x mechanical ileus of adhesions, 2x bowel stricture. The patient’s death occurred in 14 cases. Conclusion:Necrotizing enterocolitis in neonates despite advances in conservative and surgical treatment as well as advanced post--operative care remains a serious disease. Clear recommendations for surgical management of necrotizing enterocolitis are not yet established. The laparotomy with resection of the affected bowel segments with creation of diverting enterostomy remains the gold standard of surgical treatment of necrotizing enterocolitis. Necrotizing enterocolitis still remains a „surgical dilemma” with relatively high morbidity and mortality.

Keywords: necrotising enterocolitis, surgical treatment, indications, complications.