Laparotomy vs peritoneal drainage in the treatment of necrotizing enterocolitis

Perforated necrotizing enterocolitis is a major cause of morbidity and mortality in premature infants, with a very high mortality rate. The common pathway leading to intestinal necrosis and perforation is intestinal ischemia and infection through an immature mucosal barrier. The resulting perforation, peritonitis, and systemic sepsis occur in infants at high risk and therefore demand prompt intervention. The standard approach is surgical resection of the involved bowel but, in premature infants, this entails substantial risks. An alternative can be primary peritoneal drainage, but several doubts still surrounds this practice. At present, there is considerable controversy regarding which procedure is preferable and current clinical approach depends mostly on the treating institution.

A multicenter, randomized clinical trial was conducted in order to shed new lights over this debate. In total, 117 preterm infants with birth weights less than 1500 g and perforated necrotizing enterocolitis were randomized to undergo primary peritoneal drainage or laparotomy. The primary outcome was survival at 90 days postoperatively. Secondary outcomes included dependence on parenteral nutrition 90 days postoperatively and length of hospital stay.

At the end of the study, 34.5% of infants assigned to peritoneal drainage had died, versus 35.5% in the laparotomy group. The percentages of infants who depended on total parenteral nutrition were 47.2% in the peritoneal-drainage group and 40.0% in the laparotomy group. Also the mean length of hospitalization for infants was similar in the two groups. Subgroup analyses stratified according to the presence of extensive necrotizing enterocolitis, gestational age, and serum pH showed no significant advantage of either treatment in any group.

These findings show that, in premature infants with perforated necrotizing enterocolitis, no significant differences in mortality, dependence on parenteral nutrition or duration of hospital stay emerge between babies who underwent laparotomy and bowel resection and those who underwent primary peritoneal drainage. Therefore, the type of operation performed for perforated necrotizing enterocolitis does not seem to influence survival or other clinically important early outcomes in preterm infants, even stratifying babies according to various risk factors. This conclusion has great clinical importance for the proper management of babies with perforated necrotizing enterocolitis.

Results of this study, anyway, should be considered with great care. In fact, some statistical limitations and a too short follow-up may limit the efficacy of this trial. But, considering also all these limitations, the results strongly support that, in premature babies, there is no apparent difference in short term survival, length of hospitalization, or requirement for parenteral nutrition between infants who undergo primary peritoneal drainage and those who undergo laparotomy.

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