**9.3 Comparison of laparotomy and PPD**

There are limited data about the superiority of one procedure over other. In a multicenter controlled study, 117 infants who were <34 weeks of gestation with perforated NEC were randomized to PPD or laparotomy. No differences were noted in mortality (34.5 versus 35.5%), TPN dependence on postoperative day 90 (47.2 versus 40%), and length of hospital stay (126 ± 58 versus 116 ± 56 days) [49]. A subgroup analysis of cases with extensive pneumatosis intestinalis, GA less than 25 weeks, and serum pH less than 7.30 at presentation showed no significant advantage of one procedure over the other. In another randomized multicenter trial of 69 extremely low birth weight (ELBW) infants with NEC or SIP, no difference in the survival rates was noted between the two interventions, while 74% treated with PPD subsequently required laparotomy [50]. A cohort study from the NICHD neonatal research group reported no difference in mortality rate, and 24% treated with PPD required subsequent laparotomy. Blakely et al. reported that PPD is more likely to result in a composite outcome of death or neurodevelopmental impairment at 18–22 months postmenstrual age [51]. However in their study, PPD was performed in infants who were more premature (gestational age 24.7 versus 25.7 weeks), were more likely to be hypotensive, required higher respiratory support, and were more likely to have a preoperative diagnosis of SIP. Most of these studies are compromised by a lack pf power.
