Necrotizing Enterocolitis: Does Perforation Matter?

Varun Bhalla, Childrens National Medical Center; Gezzer Ortega, Howard University; Gillian Abrams, Childrens National Medical Center; Margaret McGuire, All Childrens Hospital; Seth Goldstein, Johns Hopkins University; Vanessa Pinard, Howard University; Mariam Said, Childrens National Medical Center; Faisal Qureshi, Childrens National Medical Center

Necrotizing enterocolitis (NEC) continues to cause significant mortality and morbidity in neonates despite evolving surgical management over the last decade. The aim of our study was to evaluate the early (<30 days) outcomes of management strategies at a single referral institution.

We hypothesized that premature newborns with intestinal perforation had a higher mortality rate than those without perforation.

We performed a 3-year retrospective review (2011-2014). Inclusion criteria were neonates diagnosed with NEC > stage I or perforation. Patients were grouped by peritoneal drainage (PD), exploratory laparotomy (EXLAP), and non-operative (NOP) management. Demographic data, birth weight, age, and age at perforation were extracted. The primary outcome was mortality.

163 patients were evaluated (58.9% male) with an average age at admission of 16.9 days, birth weight of 1139.9 g, and gestational age of 27.8 weeks. 53.4%(n=87) presented with perforation. These were smaller, more premature, and presented earlier than non-perforated (p<0.02). 54%(n=47) underwent PD, 40%(n=35) EXLAP, and 6%(n=5) had no intervention. Of the non-perforated patients (n=76,46.6%), 75%(n=57) required no surgical intervention and 25%(n=19) had an ex-lap. Overall early mortality was 20.2%(n=33) with 27.6%(n=24) in the perforated group and 12%(n=9) in those non-perforated (p=0.001). Patient characteristics and outcomes based on management are seen in Table 1. Neonates without perforation but requiring laparotomy had the highest mortality rate (p=0.002). On adjusted analysis, neonates with perforation had a higher likelihood of death (OR 2.81, 95%CI 1.16-6.84).

Smaller and more premature neonates presented with perforation and had a higher mortality. Exploratory laparotomy was preferred in the older, larger newborns that presented later with perforation but had no difference in mortality. Neonates without perforation failing medical management presented late and may be reflective of delayed referral.