**9.2 Surgical management**

The only definite indication for surgery is intestinal perforation. Other relative indications, which are highly suggestive of bowel perforation or necrosis, are abdominal mass, fixed dilated bowel loop, positive paracentesis, and severe metabolic acidosis that is unresponsive to treatment (**Figures 5** and **6**) [46]. Signs that indicate peritonitis or bowel necrosis are unremitting clinical deterioration, worsening or unrelenting metabolic acidosis, and DIC or thrombocytopenia. Signs of ascites and intestinal obstruction may be present. Perforation can occur without evidence of free air on the radiograph as the timing of study may not coincide with the occurrence of perforation and the free air may get absorbed. Likewise, pneumatosis may not be always caught on serial X-rays. Under such conditions other signs and clinical judgment should be used to assess the severity and need for surgery. As clinical parameters may not be reliable to assess progression to surgical from medical NEC, abnormalities in biochemical markers, such as platelet count, CRP, WBC count, blood lactate, fecal calprotectin, and serum IL-6 and IL-8 may be used. Surgical procedures performed in cases of NEC are exploratory laparotomy with resection of the affected intestinal region or primary peritoneal drainage (PPD). PPD is preferred as the initial procedure in ELBW infants and is performed in the NICU at bedside with analgesia and local anesthesia. Laparotomy is done in an operating room under general anesthesia and may require a second surgical procedure for reanastomosis.

In primary peritoneal drainage abdomen is prepped with iodine solution, and local anesthesia is administered. Small transverse incision is made at McBurney's point and abdominal wall layers bluntly dissected to enter the peritoneal cavity. A rush of air and the presence of meconium are generally encountered. Cultures are obtained, and then peritoneal cavity is copiously irrigated with warm saline solution. Following this Penrose drain is gently threaded into the abdomen and secured. The drain site is observed over the subsequent days. When there is no intestinal or meconium drainage, the drain is backed out daily until removed. After the return of bowel function, a trial of feeding can be started, or the patency of the gastrointestinal tract may be determined with a contrast study. In laparotomy the procedure includes resection of the affected bowel segment and placement of a proximal enterostomy (usually an ileostomy) and distal mucous fistula. Primary reanastomosis, if required, usually is performed 8–12 weeks after the initial procedure, depending

**37**

**Figure 6.**

*Necrotizing Enterocolitis*

*DOI: http://dx.doi.org/10.5772/intechopen.85784*

upon the infant's clinical condition. A contrast enema usually is performed before the reanastomosis to detect intestinal strictures. If NEC affects only a short segment of bowel, and the resection is limited, some surgeons perform a primary anastomosis. Complications associated with ileostomies are fluid and electrolyte abnormalities, delayed resumption of oral feedings, poor growth, and stenosis of the enterostomy site. An alternative approach is placement of an intestinal patch and peritoneal drain instead of resection and enterostomy. Preservation of ileocecal valve is a favorable prognostic sign. When a substantial length of bowel is affected, resection is restricted to segments of definite necrosis or perforation to avoid the risk of short bowel syndrome. If the potential viability of some segments is uncertain, one approach is to place peritoneal drains and plan a second operation in 2–3 days to

Recently, standard and fluorescein laparoscopy has been used in cases of NEC when there is no evidence of perforation, but clinical deterioration with maximum support continues, and a diagnosis for the presence and extent of bowel necrosis needs to be made in order to decide against, or in favor of, surgical exploration and its type [47]. Laparoscopy can also identify infants who do not need surgical intervention as it can visualize the viability and perfusion status of the bowel. According to a Cochrane review by Smith and Thyoka, which included eight reports and 44 patients, laparoscopy was able to diagnose NEC in 91% of the cases and exclude in 9% [48]. Moreover, additional surgical intervention was avoided in eight (18%) infants. Among those who did not require surgery, NEC was excluded in four (9%), while two (5%) had no perforation or intestinal gangrene, and two (5%) had NEC totalis which contraindicated surgery. Thirty-six infants out of 44 required surgery following laparoscopy, which included placement of a peritoneal drain (9) or a stoma (20) and intestinal resection and anastomosis (7). Perforation was detected in 25 out of 44 (57%) infants and was missed in one case which subsequently

reexamine the bowel and excise necrotic segments.

*Flow chart outlining management principles in NEC.*

*Pediatric Surgery, Flowcharts and Clinical Algorithms*

resolves and bowel gas pattern normalizes.

**9.2 Surgical management**

dure for reanastomosis.

if needed. In addition, arterial blood gas values are measured and repeated every 4–6–12 h as per the severity of respiratory decompensation. Serial lactate levels are helpful in monitoring progression of the necrotic process and assessing systemic status. Worsening or persistent metabolic acidosis and persistent hyperglycemia or thrombocytopenia are poor prognostic signs. Improvement in metabolic acidosis is a positive prognostic sign but may be misleading if blood circulation to the necrotic bowel is completely severed and the generated lactic acid cannot enter the circulation. Blood in stools is not predictive of resolution or outcome. Radiographic monitoring is done with abdominal radiograph performed in supine position during the initial phase of illness. A lateral decubitus view is simultaneously obtained with the infant's left side down to visualize the presence of free air over the liver. It should be repeated q 6–12 h as per the severity and progression of the disease and when improvement is obtained less frequently. In the initial stages q 4–6 h may be appropriate and advisable. Supine cross-table lateral view may be done to visualize layering of free air under umbilical area if patient is too sick to move or put in a decubitus position (**Figure 2**). Radiography is discontinued when pneumatosis

The only definite indication for surgery is intestinal perforation. Other relative indications, which are highly suggestive of bowel perforation or necrosis, are abdominal mass, fixed dilated bowel loop, positive paracentesis, and severe metabolic acidosis that is unresponsive to treatment (**Figures 5** and **6**) [46]. Signs that indicate peritonitis or bowel necrosis are unremitting clinical deterioration, worsening or unrelenting metabolic acidosis, and DIC or thrombocytopenia. Signs of ascites and intestinal obstruction may be present. Perforation can occur without evidence of free air on the radiograph as the timing of study may not coincide with the occurrence of perforation and the free air may get absorbed. Likewise, pneumatosis may not be always caught on serial X-rays. Under such conditions other signs and clinical judgment should be used to assess the severity and need for surgery. As clinical parameters may not be reliable to assess progression to surgical from medical NEC, abnormalities in biochemical markers, such as platelet count, CRP, WBC count, blood lactate, fecal calprotectin, and serum IL-6 and IL-8 may be used. Surgical procedures performed in cases of NEC are exploratory laparotomy with resection of the affected intestinal region or primary peritoneal drainage (PPD). PPD is preferred as the initial procedure in ELBW infants and is performed in the NICU at bedside with analgesia and local anesthesia. Laparotomy is done in an operating room under general anesthesia and may require a second surgical proce-

In primary peritoneal drainage abdomen is prepped with iodine solution, and local anesthesia is administered. Small transverse incision is made at McBurney's point and abdominal wall layers bluntly dissected to enter the peritoneal cavity. A rush of air and the presence of meconium are generally encountered. Cultures are obtained, and then peritoneal cavity is copiously irrigated with warm saline solution. Following this Penrose drain is gently threaded into the abdomen and secured. The drain site is observed over the subsequent days. When there is no intestinal or meconium drainage, the drain is backed out daily until removed. After the return of bowel function, a trial of feeding can be started, or the patency of the gastrointestinal tract may be determined with a contrast study. In laparotomy the procedure includes resection of the affected bowel segment and placement of a proximal enterostomy (usually an ileostomy) and distal mucous fistula. Primary reanastomosis, if required, usually is performed 8–12 weeks after the initial procedure, depending

**36**

**Figure 6.** *Flow chart outlining management principles in NEC.*

upon the infant's clinical condition. A contrast enema usually is performed before the reanastomosis to detect intestinal strictures. If NEC affects only a short segment of bowel, and the resection is limited, some surgeons perform a primary anastomosis. Complications associated with ileostomies are fluid and electrolyte abnormalities, delayed resumption of oral feedings, poor growth, and stenosis of the enterostomy site. An alternative approach is placement of an intestinal patch and peritoneal drain instead of resection and enterostomy. Preservation of ileocecal valve is a favorable prognostic sign. When a substantial length of bowel is affected, resection is restricted to segments of definite necrosis or perforation to avoid the risk of short bowel syndrome. If the potential viability of some segments is uncertain, one approach is to place peritoneal drains and plan a second operation in 2–3 days to reexamine the bowel and excise necrotic segments.

Recently, standard and fluorescein laparoscopy has been used in cases of NEC when there is no evidence of perforation, but clinical deterioration with maximum support continues, and a diagnosis for the presence and extent of bowel necrosis needs to be made in order to decide against, or in favor of, surgical exploration and its type [47]. Laparoscopy can also identify infants who do not need surgical intervention as it can visualize the viability and perfusion status of the bowel. According to a Cochrane review by Smith and Thyoka, which included eight reports and 44 patients, laparoscopy was able to diagnose NEC in 91% of the cases and exclude in 9% [48]. Moreover, additional surgical intervention was avoided in eight (18%) infants. Among those who did not require surgery, NEC was excluded in four (9%), while two (5%) had no perforation or intestinal gangrene, and two (5%) had NEC totalis which contraindicated surgery. Thirty-six infants out of 44 required surgery following laparoscopy, which included placement of a peritoneal drain (9) or a stoma (20) and intestinal resection and anastomosis (7). Perforation was detected in 25 out of 44 (57%) infants and was missed in one case which subsequently

required laparotomy. Six (14%) infants died due to NEC totalis and two of ongoing and recurrent NEC following recovery from the acute episode of each. The authors concluded that laparoscopy is a useful procedure in the management of NEC, with one-fifth of patients not requiring further surgery. However, due to the lack of enough evidence about its utility and benefits, the procedure is generally not undertaken in the routine management of NEC.
