Surgical Procedure Effectively Treats Severe Necrotizing Enterocolitis in Neonates

Jim Kling

October 12, 2010

October 12, 2010 (San Francisco, California) — Diverting jejunostomy is an effective surgical procedure in the treatment of severe necrotizing enterocolitis (NEC) in neonates, according to research presented here at the American Academy of Pediatrics 2010 National Conference and Exhibition.

There are several surgical methods available to treat NEC, but there is no consensus on which option is best. One choice is a high diverting jejunostomy without resection of the diseased bowel. Researchers led by Mandela Thyoka, MRCS(Ed), MCS(ECSA), a clinical research associate at the Institute of Child Health in London, United Kingdom, conducted a prospective study to determine outcomes in infants who underwent this procedure.

The study included 188 consecutive neonates with NEC in the researchers' center who required surgical intervention. The team evaluated infants with severe and extensive NEC who underwent a primary laparotomy with diverting jejunostomy and no bowel resection. They collected and analyzed data on gestational age, birth weight and weight on admission, age at diagnosis, operative findings, outcome of stoma, total parenteral nutrition (TPN) dependency, and mortality.

A total of 17 neonates (9%) underwent a diverting jejunostomy as a primary procedure for treatment of severe NEC (mean birth weight, 1.03 kg, standard error of the mean ±0.44 kg; mean weight on admission, 1.28 ± 0.55 kg; mean gestational age at birth, 27.6 ± 3.0 weeks). Of these, 11 patients (65%) had multifocal disease and 6 patients (35%) had pan-intestinal involvement.

There were 7 cases (41%) with perforation, all with multifocal disease. The surgeon placed the stoma at a median distance of 12 cm from the duodenojejunal flexure (range, 8 - 45 cm). Six infants (35%) died — 4 within a day — as a result of persisting instability.

Survivors achieved intestinal continuity (median time, 52 days; range, 17 - 83 days); 1 infant (9%) had a colonic stricture, and 8 infants (73%) recovered with no further need for resection.

Survivors required TPN for 60 days (range, 29 - 548 days). One patient developed short bowel syndrome, which required TPN for 18 months (548 days). Median follow-up was 1.9 years (range, 0.5 - 11 years).

"This series indicates that using this technique, enteral autonomy and a high survival (65%) can be achieved even in most critically ill neonates with NEC. The majority of survivors do not require resection of diseased bowel indicating a high capacity for recovery of defunctioned bowel," the authors write in the abstract.

"We propose that jejunostomy is a useful tool in such challenging circumstances and should be used often," Dr. Thyoka said during his presentation.

"These are some very impressive results for a very sick group of children. It's a technique that's been around for a while, which other surgeons and institutions have used. It's not entirely clear how they achieved such great results, but it's interesting, and it's provocative," said Larry Moss, MD, chief of surgery at Yale–New Haven Children's Hospital in Connecticut.

Dr. Moss noted that debate has gone on for years about which operation should be used with NEC, and some randomized trials suggest that the choice of operation may have little influence on outcome.

"This study looked at a very specific subset of patients, and perhaps (the type of operation) did matter in these patients, but it's a small series from one institution. It raises more questions than it answers, but it raises some pretty interesting questions," Dr. Moss observed.

Dr. Thyoka and Dr. Moss have disclosed no relevant financial relationships.

American Academy of Pediatrics 2010 National Conference and Exhibition: Abstract 9438. Presented October 2, 2010.

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