Conservative Management of Necrotizing Enterocolitis in Newborns: Incidence and Management of Intestinal Strictures

Abstract

Background Necrotizing enterocolitis (NEC) is one of the main causes of acute abdomen in neonates. Surgical treatment entails important morbidity and mortality and conservative management, when possible, offers better outcomes. Post-NEC intestinal strictures are one of the main complications.

Methods Retrospective analysis from June 2011 to November 2022 of post-NEC strictures (PNS) after conservative management of neonates diagnosed with NEC (modified Bell stage IIA or higher) at a tertiary neonatal surgery center.

Results Out of 219 NEC, 126 received initial conservative management (57.5%), 24 (19%) of which eventually underwent surgery for PNS. Average gestational age and weight at birth of our cohort were 31.3 ± 4.9 weeks and 1,694 ± 1,009 g.

PNS diagnosis was made 38.4 ± 16.5 days after the NEC episode. 6/24 (25%) were asymptomatic and diagnosed by screening enema, 11 (46%) presented signs of intestinal obstruction before the enema could be performed and 7 (29%) after a normal previous protocol study.

Median age at PNS surgery was 56 ± 17.9 days. A total of 2/3 strictures were found in cecum, ascendent, and transverse colon. Primary resection and anastomosis were performed in all cases. Feeds were restarted on postoperative day 4.3 ± 2.9. Two cases presented anastomotic complications (1 dehiscence and 1 stenosis), and no deaths were recorded.

Conclusions PNS is a frequent complication after conservative management. Deffered surgical treatment after the acute NEC episode is resolved allows for safer surgeries (since patients have reached hemodynamical stability and overcome septic shock), shorter resections, and favorable postoperative outcomes.

Keywords

necrotizing enterocolitis - stricture - conservative management - newborn - premature

Note

All images come from real patients treated by the authors' surgical team and are original files. All figures have been combined and put together by the authors, created in their whole by the coauthors except for the icons (arrows and asterisks), that are those provided by Microsoft Word. No third party holds any rights of use for these images.

Publication History

Received: 29 March 2024

Accepted: 26 September 2024

Accepted Manuscript online:
30 September 2024

Article published online:
18 October 2024

• References

• 1 Jones IH, Hall NJ. Contemporary outcomes for infants with necrotizing enterocolitis-a systematic review. J Pediatr 2020; 220: 86-92.e3
• 2 Liu W, Wang Y, Zhu J. et al. Clinical features and management of post-necrotizing enterocolitis strictures in infants: a multicentre retrospective study. Medicine (Baltimore) 2020; 99 (19) e20209
• 3 Zhang H, Chen J, Wang Y, Deng C, Li L, Guo C. Predictive factors and clinical practice profile for strictures post-necrotising enterocolitis. Medicine (Baltimore) 2017; 96 (10) e6273
• 4 Garg PM, Bernieh A, Hitt MM. et al. Incomplete resection of necrotic bowel may increase mortality in infants with necrotizing enterocolitis. Pediatr Res 2021; 89 (01) 163-170
• 5 Zani A, Eaton S, Puri P. et al; EUPSA Network. International survey on the management of necrotizing enterocolitis. Eur J Pediatr Surg 2015; 25 (01) 27-33
• 6 Rao H, Xie Y, Zhou Y, Liao Z. Application of comprehensive score of risk factors to determine the best time for surgical intervention in neonatal necrotizing enterocolitis. J Paediatr Child Health 2023; 59 (02) 267-281
• 7 Bethell GS, Knight M, Hall NJ. BAPS-CASS NEC Investigator Group on behalf of BAPS-CASS. Surgical necrotizing enterocolitis: association between surgical indication, timing, and outcomes. J Pediatr Surg 2021; 56 (10) 1785-1790
• 8 Montalva L, Incerti F, Qoshe L. et al. Early laparoscopic-assisted surgery is associated with decreased post-operative inflammation and intestinal strictures in infants with necrotizing enterocolitis. J Pediatr Surg 2023; 58 (04) 708-714
• 9 Neu J. Necrotizing enterocolitis: the future. Neonatology 2020; 117 (02) 240-244
• 10 Feng W, Hou J, Xiang C. et al. Correlation of systemic immune-inflammation Index with surgical necrotizing enterocolitis. Front Pediatr 2022; 10: 1044449
• 11 Duric B, Gray C, Alexander A, Naik S, Haffenden V, Yardley I. Effect of time of diagnosis to surgery on outcome, including long-term neurodevelopmental outcome, in necrotizing enterocolitis. Pediatr Surg Int 2022; 39 (01) 2
• 12 Gaudin A, Farnoux C, Bonnard A. et al. Necrotizing enterocolitis (NEC) and the risk of intestinal stricture: the value of C-reactive protein. PLoS One 2013; 8 (10) e76858
• 13 Heida FH, Loos MHJ, Stolwijk L. et al. Risk factors associated with postnecrotizing enterocolitis strictures in infants. J Pediatr Surg 2016; 51 (07) 1126-1130
• 14 Evrard J, Khamis J, Rausin L. et al. A scoring system in predicting the risk of intestinal stricture in necrotizing enterocolitis. Eur J Pediatr 1991; 150 (11) 757-760
• 15 Phad N, Trivedi A, Todd D, Lakkundi A. Intestinal strictures post-necrotising enterocolitis: clinical profile and risk factors. J Neonatal Surg 2014; 3 (04) 44
• 16 Born M, Holgersen LO, Shahrivar F, Stanley-Brown E, Hilfer C. Routine contrast enemas for diagnosing and managing strictures following nonoperative treatment of necrotizing enterocolitis. J Pediatr Surg 1985; 20 (04) 461-463
• 17 Chen J, Mu F, Gao K, Yan C, Chen G, Guo C. Value of abdominal ultrasonography in predicting intestinal resection for premature infants with necrotizing enterocolitis. BMC Gastroenterol 2022; 22 (01) 524
• 18 Kosloske AM, Burstein J, Bartow SA. Intestinal obstruction due to colonic stricture following neonatal necrotizing enterocolitis. Ann Surg 1980; 192 (02) 202-207
• 19 Ou J, Courtney CM, Steinberger AE, Tecos ME, Warner BW. Nutrition in necrotizing enterocolitis and following intestinal resection. Nutrients 2020; 12 (02) 520
• 20 Garg PM, Hitt MM, Blackshear C, Maheshwari A. Clinical determinants of postoperative outcomes in surgical necrotizing enterocolitis. J Perinatol 2020; 40 (11) 1671-1678
• 21 Chong C, van Druten J, Briars G. et al. Neonates living with enterostomy following necrotising enterocolitis are at high risk of becoming severely underweight. Eur J Pediatr 2019; 178 (12) 1875-1881