Peritoneal drainage versus laparotomy as an initial treatment in complicated necrotizing enterocolitis: a single institution experience
Objective To determine whether initial peritoneal drainage (PD) or primary laparotomy is the most effective intervention in very-low-birth-weight and extremely lowbirth- weight infants who are diagnosed with necrotizing enterocolitis (NEC, Bell’s stage II and stage III).
Patients and methods It is a retrospective chart review study. Demographic data, clinical characteristics, and outcome were reviewed from records of neonates with severe NEC requiring surgical intervention (Bell’s stage II and stage III) at our institution from 2003 to 2009.
Results Thirty-two patients were included in our study. Seventeen patients (53.1%) underwent PD and 15 patients (46.8%) underwent laparotomy. Out of 17 patients in the drainage group, 11 patients (64.7%) underwent laparotomy and six patients (35.2%) did not undergo laparotomy because they were sick and died within few days. Difference in gestational age, sex, and birth weights between two groups was not statistically significant. Similarly, difference in variables as mode of delivery and days of enteral feeding was not statistically significant. Mean age at diagnosis was 31.5 days for the laparotomy group and 18.4 days for the drainage group. P value was 0.026 in the univariate analysis, but P value in the final model of analysis was found to be statistically not significant. It was found from our study that patients with many associated diseases were more in the PD group (P value was 0.008). Almost all patients were mechanically ventilated. Mean pH was 7.29 in the laparotomy group and 7.25 in the drainage group, which was statistically not significant. In the PD group, 13 patients required vasopressors; however, only four patients in the laparotomy group were on vasopressors (P value was 0.017). Difference in variables such as indomethacin, white blood cell count, and platelet count was found to be statistically not significant between the two groups. Six patients were on steroids in the PD group and only one patient was on steroid in the laparotomy group (P value is 0.007). In addition, outcome at 90 days was analyzed; nine patients died in the PD group, whereas four patients died in the laparotomy group (P value is 0.081). Data were also analyzed for complications such as stricture, short bowel syndrome, and cholestasis and the difference was not significant. Finally, total parenteral nutrition dependency difference was found to be statistically not significant between two groups.
Conclusion Patients were very sick in the PD group and they were on vasopressors and steroids. Moreover, it was found that diagnosis of NEC early in life signifies a higher mortality. Insertion of a PD is still useful in resuscitating small critically ill infants with NEC; however, the majority of these infants will require subsequent laparotomy. Early diagnosis and early intervention are necessary to decrease the inflammatory insults to the body systems and this reflects on survival.
Keywords: drainage versus laparotomy, less than 1500 g, necrotizing enterocolitis