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Management of necrotising enterocolitis

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Necrotising enterocolitis (NEC) and focal intestinal perforation (FIP) in preterm babies are both associated with hypoxia, indomethicin treatment, and hypertonic feeds and may be different manifestations of the same disease. Laparotomy has been regarded as standard practice but recently peritoneal drainage has been proposed, particularly for infants with FIP, in an attempt to avoid laparotomy in sick infants. Surgeons in Los Angeles (Alda L Tam and colleagues.

; Alfonso Camberos and colleagues. Ibid: 1692–5) continue to favour laparotomy and have reviewed the value of preoperative plain abdominal x rays and the results of laparotomy.

The radiological series, over the 11 years 1990–2000, included 80 infants (mean gestational age 28 weeks, mean birthweight 1170g), 61 with NEC diagnosed at surgery or autopsy, and 19 with FIP without NEC. They found that positive signs on x ray were of great diagnostic significance but the absence of these signs was of little value. For NEC, radiological pneumatosis intestinalis was 100% specific but only 44% sensitive and portal venous gas was 100% specific but 13% sensitive. For FIP free air was 92% specific and 52% sensitive and a gasless abdomen 92% specific and 32% sensitive. Others have argued that the absence of pneumatosis intestinalis on x ray suggests a diagnosis of FIP and favours treatment with peritoneal drainage.

A second review included 35 infants with birthweights under 1500 g who had undergone laparotomy for NEC (23) or FIP (12) between 1994 and 2000. Postoperative mortality by 7 days was 7/35 (20%) and by 30 days 9/35 (26%). For NEC the corresponding figures were 26% at both 7 and 30 days and for FIP 8% and 25%. Excluding five infants with pan-intestinal necrosis, who all died, reduced the overall 7 and 30 day mortalities to 6% and 11%. The authors of this paper conclude that their mortality with laparotomy was similar to the 21% to 43% reported for peritoneal drainage. They favour laparotomy because it allows direct inspection of the type and extent of disease, removal of gangrenous bowel, and diversion of the faecal stream. They point out that many (26% to 83%) infants treated with peritoneal drainage need subsequent laparotomy.