Clinical determinants of postoperative outcomes in surgical necrotizing enterocolitis

Abstract

Objective

Investigate predictors of postoperative morbidity and mortality in surgical NEC.

Study design

We analyzed the clinical outcomes of infants with surgical NEC from the years 2000–2015.

Results

Ninety infants born at gestation (mean ± standard deviation, SD; standard error of mean, SEM) 27.3 ± 6.6 weeks (SEM ± 0.07 weeks) and weighing 1008 ± 456 g (SEM ± 48 g) developed NEC on 25.2 ± 22.4 days (SEM ± 2.4 days). Average bowel resection was 29.2 ± 30.5 cm (SEM ± 3.2 cm). Postoperative Ileus lasted 16.5 ± 12.2 days (SEM ± 1.3 days), and was significantly longer in infants with higher gestation and birth weight, age at onset of NEC, length of intestinal resection, maternal chorioamnionitis, and need for pressors. Thirty-eight (42.2%) infants died. Mortality was higher at gestation <31 weeks.

Conclusion

Gestational age, birth weight, age at NEC onset, and length of resected bowel determined postoperative morbidity and mortality in NEC. Length of hospital stay was affected by above factors, and also the duration of postoperative ileus and parenteral nutrition.

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Fig. 1: Kaplan–Meier curve shows gestational age (weeks) plotted against mortality (percentage).

References

  1. 1.

    Neu J, Modi N, Caplan M. Necrotizing enterocolitis comes in different forms: historical perspectives and defining the disease. Semin Fetal Neonatal Med. 2018;23:370–3.

    CAS  Article  Google Scholar 

  2. 2.

    Jones IH, Hall NJ. Contemporary outcomes for infants with necrotizing enterocolitis—a systematic review. J Pediatr. 2020;220:86–90.e3.

    Article  Google Scholar 

  3. 3.

    Han SM, Hong CR, Knell J, Edwards EM, Morrow KA, Soll RF, et al. Trends in incidence and outcomes of necrotizing enterocolitis over the last 12 years: a multicenter cohort analysis. J Pediatr Surg. 2020;55:998–1001.

    Article  Google Scholar 

  4. 4.

    Sjoberg Bexelius T, Ahle M, Elfvin A, Bjorling O, Ludvigsson JF, Andersson RE. Intestinal failure after necrotising enterocolitis: incidence and risk factors in a Swedish population-based longitudinal study. BMJ Paediatr Open. 2018;2:e000316.

    Article  Google Scholar 

  5. 5.

    Allin BSR, Long AM, Gupta A, Lakhoo K, Knight M. One-year outcomes following surgery for necrotising enterocolitis: a UK-wide cohort study. Arch Dis Child Fetal Neonatal Ed. 2018;103:F461–6.

    Article  Google Scholar 

  6. 6.

    Knell J, Han SM, Jaksic T, Modi BP. Current status of necrotizing enterocolitis. Curr Probl Surg. 2019;56:11–38.

    Article  Google Scholar 

  7. 7.

    Stoll BJ, Hansen NI, Bell EF, Walsh MC, Carlo WA, Shankaran S, et al. Trends in care practices, morbidity, and mortality of extremely preterm neonates, 1993–2012. JAMA 2015;314:1039–51.

    CAS  Article  Google Scholar 

  8. 8.

    Nair R, Kahlenberg CA, Patel RM, Knesek M, Terry MA. All-arthroscopic suprapectoral biceps tenodesis. Arthrosc Technol. 2015;4:e855–61.

    Article  Google Scholar 

  9. 9.

    Santulli TV, Schullinger JN, Heird WC, Gongaware RD, Wigger J, Barlow B, et al. Acute necrotizing enterocolitis in infancy: a review of 64 cases. Pediatrics. 1975;55:376–87.

    CAS  PubMed  Google Scholar 

  10. 10.

    Mowitz ME, Dukhovny D, Zupancic JAF. The cost of necrotizing enterocolitis in premature infants. Semin Fetal Neonatal Med. 2018;23:416–9.

    Article  Google Scholar 

  11. 11.

    Ganapathy V, Hay JW, Kim JH, Lee ML, Rechtman DJ. Long term healthcare costs of infants who survived neonatal necrotizing enterocolitis: a retrospective longitudinal study among infants enrolled in Texas Medicaid. BMC Pediatr. 2013;13:127.

    Article  Google Scholar 

  12. 12.

    Kurscheid T, Holschneider AM. Necrotizing enterocolitis (NEC)-mortality and long-term results. Eur J Pediatr Surg. 1993;3:139–43.

    CAS  Article  Google Scholar 

  13. 13.

    Thakkar HS, Lakhoo K. The surgical management of necrotising enterocolitis (NEC). Early Hum Dev. 2016;97:25–8.

    Article  Google Scholar 

  14. 14.

    Raval MV, Moss RL. Current concepts in the surgical approach to necrotizing enterocolitis. Pathophysiology. 2014;21:105–10.

    Article  Google Scholar 

  15. 15.

    Rees CM, Hall NJ, Eaton S, Pierro A. Surgical strategies for necrotising enterocolitis: a survey of practice in the United Kingdom. Arch Dis Child Fetal Neonatal Ed. 2005;90:F152–5.

    CAS  Article  Google Scholar 

  16. 16.

    Robinson JR, Rellinger EJ, Hatch LD, Weitkamp JH, Speck KE, Danko M, et al. Surgical necrotizing enterocolitis. Semin Perinatol. 2017;41:70–9.

    Article  Google Scholar 

  17. 17.

    Fenton TR, Kim JH. A systematic review and meta-analysis to revise the Fenton growth chart for preterm infants. BMC Pediatr. 2013;13:59.

    Article  Google Scholar 

  18. 18.

    Davies HT. Describing and estimating: use and abuse of standard deviations and standard errors. Hosp Med. 1998;59:327–8.

    CAS  PubMed  Google Scholar 

  19. 19.

    Manuck TA, Rice MM, Bailit JL, Grobman WA, Reddy UM, Wapner RJ, et al. Preterm neonatal morbidity and mortality by gestational age: a contemporary cohort. Am J Obstet Gynecol. 2016;215:103 e1–14.

    Article  Google Scholar 

  20. 20.

    Sheng Q, Lv Z, Xu W, Liu J, Wu Y, Shi J, et al. Short-term surgical outcomes of preterm infants with necrotizing enterocolitis: a single-center experience. Medicine. 2016;95:e4379.

    Article  Google Scholar 

  21. 21.

    Wright NJ, Thyoka M, Kiely EM, Pierro A, De Coppi P, Cross KM, et al. The outcome of critically ill neonates undergoing laparotomy for necrotising enterocolitis in the neonatal intensive care unit: a 10-year review. J Pediatr Surg. 2014;49:1210–4.

    Article  Google Scholar 

  22. 22.

    Li X, Li L, Wang Y, Deng C, Guo C. Postoperative characteristics of infants who developed necrotizing enterocolitis with different postnatal ages. Medicine. 2017;96:e7774.

    Article  Google Scholar 

  23. 23.

    Hau EM, Meyer SC, Berger S, Goutaki M, Kordasz M, Kessler U. Gastrointestinal sequelae after surgery for necrotising enterocolitis: a systematic review and meta-analysis. Arch Dis Child Fetal Neonatal Ed. 2019;104:F265–73.

    Article  Google Scholar 

  24. 24.

    Geng Q, Wang Y, Li L, Guo C. Early postoperative outcomes of surgery for intestinal perforation in NEC based on intestinal location of disease. Medicine. 2018;97:e12234.

    Article  Google Scholar 

  25. 25.

    Cole CR, Hansen NI, Higgins RD, Ziegler TR, Stoll BJ. Eunice Kennedy Shriver NNRN. Very low birth weight preterm infants with surgical short bowel syndrome: incidence, morbidity and mortality, and growth outcomes at 18 to 22 months. Pediatrics. 2008;122:e573–82.

    Article  Google Scholar 

  26. 26.

    Blakely ML, Lally KP, McDonald S, Brown RL, Barnhart DC, Ricketts RR, et al. Postoperative outcomes of extremely low birth-weight infants with necrotizing enterocolitis or isolated intestinal perforation: a prospective cohort study by the NICHD Neonatal Research Network. Ann Surg. 2005;241:984–9; discussion 9–94.

  27. 27.

    Bhatt D, Travers C, Patel RM, Shinnick J, Arps K, Keene S, et al. Predicting mortality or intestinal failure in infants with surgical necrotizing enterocolitis. J Pediatr. 2017;191:22–7 e3.

    Article  Google Scholar 

  28. 28.

    Jammeh ML, Adibe OO, Tracy ET, Rice HE, Clark RH, Smith PB, et al. Racial/ethnic differences in necrotizing enterocolitis incidence and outcomes in premature very low birth weight infants. J Perinatol. 2018;38:1386–90.

    Article  Google Scholar 

  29. 29.

    Horbar JD, Badger GJ, Carpenter JH, Fanaroff AA, Kilpatrick S, LaCorte M, et al. Trends in mortality and morbidity for very low birth weight infants, 1991-1999. Pediatrics. 2002;110(1 Pt 1):143–51.

    Article  Google Scholar 

  30. 30.

    Janevic T, Zeitlin J, Auger N, Egorova NN, Hebert P, Balbierz A, et al. Association of race/ethnicity with very preterm neonatal morbidities. JAMA Pediatr. 2018;172:1061–9.

    Article  Google Scholar 

  31. 31.

    Cuna A, George L, Sampath V. Genetic predisposition to necrotizing enterocolitis in premature infants: current knowledge, challenges, and future directions. Semin Fetal Neonatal Med. 2018;23:387–93.

    Article  Google Scholar 

  32. 32.

    Cuna A, Yu W, Menden HL, Feng L, Srinivasan P, Chavez-Bueno S, et al. NEC-like intestinal injury is ameliorated by Lactobacillus rhamnosus GG in parallel with SIGIRR and A20 induction in neonatal mice. Pediatr Res. 2020. https://doi.org/10.1038/s41390-020-0797-6. [Epub ahead of print]

  33. 33.

    Sampath V, Helbling D, Menden H, Dimmock D, Mulrooney NP, Murray JC, et al. Necrotizing enterocolitis is not associated with sequence variants in antioxidant response genes in premature infants. J Pediatr Gastroenterol Nutr. 2016;62:420–3.

    CAS  Article  Google Scholar 

  34. 34.

    Sampath V, Le M, Lane L, Patel AL, Cohen JD, Simpson PM, et al. The NFKB1 (g.-24519delATTG) variant is associated with necrotizing enterocolitis (NEC) in premature infants. J Surg Res. 2011;169:e51–7.

    CAS  Article  Google Scholar 

  35. 35.

    Sampath V, Menden H, Helbling D, Li K, Gastonguay A, Ramchandran R, et al. SIGIRR genetic variants in premature infants with necrotizing enterocolitis. Pediatrics. 2015;135:e1530–4.

    Article  Google Scholar 

  36. 36.

    Necrotizing enterocolitis in the premature infant. Br Med J. 1966;2:1089–90.

  37. 37.

    Remon JI, Amin SC, Mehendale SR, Rao R, Luciano AA, Garzon SA, et al. Depth of bacterial invasion in resected intestinal tissue predicts mortality in surgical necrotizing enterocolitis. J Perinatol. 2015;35:755–62.

    CAS  Article  Google Scholar 

  38. 38.

    Bell MJ, Feigin RD, Ternberg JL, Brotherton T. Evaluation of gastrointestinal microflora in necrotizing enterocolitis. J Pediatr. 1978;92:589–92.

    CAS  Article  Google Scholar 

  39. 39.

    Gewolb IH, Schwalbe RS, Taciak VL, Harrison TS, Panigrahi P. Stool microflora in extremely low birthweight infants. Arch Dis Child Fetal Neonatal Ed. 1999;80:F167–73.

    CAS  Article  Google Scholar 

  40. 40.

    Smith B, Bode S, Skov TH, Mirsepasi H, Greisen G, Krogfelt KA. Investigation of the early intestinal microflora in premature infants with/without necrotizing enterocolitis using two different methods. Pediatr Res. 2012;71:115–20.

    CAS  Article  Google Scholar 

  41. 41.

    Andrews WW, Goldenberg RL, Faye-Petersen O, Cliver S, Goepfert AR, Hauth JC. The Alabama Preterm Birth study: polymorphonuclear and mononuclear cell placental infiltrations, other markers of inflammation, and outcomes in 23- to 32-week preterm newborn infants. Am J Obstet Gynecol. 2006;195:803–8.

    CAS  Article  Google Scholar 

  42. 42.

    Dorling J, Kempley S, Leaf A. Feeding growth restricted preterm infants with abnormal antenatal Doppler results. Arch Dis Child Fetal Neonatal Ed. 2005;90:F359–63.

    CAS  Article  Google Scholar 

  43. 43.

    Venkatesh KK, Jackson W, Hughes BL, Laughon MM, Thorp JM, Stamilio DM. Association of chorioamnionitis and its duration with neonatal morbidity and mortality. J Perinatol. 2019.

  44. 44.

    Peterslund P, Rasmussen L, Qvist N, Hansen TP, Husby S, Detlefsen S. Frequencies of immune cells in the human small bowel during normal gestation and in necrotizing enterocolitis. Fetal Pediatr Pathol. 2019:1–14.

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Funding

National Institutes of Health awards HL124078 and HL133022 to AM Category of study: Clinical science.

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PMG and AM designed the study and wrote the manuscript, MH and CB collected data and did data analysis. All the authors contributed to and approved the manuscript.

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Correspondence to Parvesh M. Garg or Akhil Maheshwari.

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Garg, P.M., Hitt, M.M., Blackshear, C. et al. Clinical determinants of postoperative outcomes in surgical necrotizing enterocolitis. J Perinatol (2020). https://doi.org/10.1038/s41372-020-0728-8

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