Surgical Necrotizing Enterocolitis: Early Surgery - The Key to Live Bowel and Quality Life

  • Adrian Bianchi


Premature babies <30 weeks’ gestation with surgical necrotizing enterocolitis (SNEC) and presenting late with bowel perforation, septicaemia, bone marrow depression, and multiorgan failure, carry 30–50% mortality even following ‘last-ditch surgery’ guided by Bell’s criteria, that were designed for staging the disease and not for timing of surgery. Surgeons have sacrificed well-proven criteria for management of the ‘acute abdomen’, driving neonatologists to inappropriately prolonged complex conservative care and delaying surgery until ‘all else has failed’. Lucky survivors frequently suffer from functionally damaged bowel or the short bowel state requiring long-term parenteral nutrition, complex bowel reconstruction, and possibly transplant with life-long immunosuppression.

Prevention of SNEC commences with parenteral nutrition supplemented with small volumes of residue-free enteral feeds rendered immunologically active by the addition of Whey from chymotrypsin-treated freshly expressed breast milk. Frequent joint assessment by a specialist neonatal team (neonatologist, surgeon, anaesthetist), proven management of the ‘acute abdomen’ supported by Doppler ultrasound for bowel loop perfusion, and early surgery for a child in good condition (Bell Stage Ia–c) should lead to better survival and live bowel. Aggressive-but-conservative surgery drains the peritoneal space and collapses and cleans distended bowel rapidly returning perfusion and avoiding bowel loss.

Modern neonatal anaesthesia and surgery ensure that premature infants in good condition, presenting with SNEC, do not die from early surgery (Bell Stage I), but rather from a failure to offer adequate surgery until late in the disease. Early surgery and live bowel are the keys to lower mortality, fewer children with short or damaged bowel, and quality of life.


NEC Necrotizing enterocolitis Short bowel state Bowel ischaemia Doppler bowel perfusion sonogram 


  1. 1.
    Gordon PV, Swanson JR, Attridge JT, Clark R. Emerging trends in acquired neonatal intestinal disease: is it time to abandon Bell’s criteria? J Perinatol. 2007;27(11):661–71.CrossRefGoogle Scholar
  2. 2.
    Bell MJ, Ternberg JL, Feigin RD, Keating JP, Marshall R, Barton L, Brotherton T. Neonatal necrotizing enterocolitis. Therapeutic decisions based upon clinical staging. Ann Surg. 1978;187(1):1–7.CrossRefGoogle Scholar
  3. 3.
    Kliegman RM, Walsh MC. Neonatal necrotizing enterocolitis: pathogenesis, classification, and spectrum of disease. Curr Probl Pediatr. 1987;17(4):213–88.PubMedGoogle Scholar
  4. 4.
    Bianchi A. From the cradle to enteral autonomy: the role of autologous gastrointestinal reconstruction. Gastroenterology. 2006;130(2 Suppl 1):S138–46.CrossRefGoogle Scholar
  5. 5.
    Nowicki PT. Ischemia and necrotizing enterocolitis: where, when, and how. Semin Pediatr Surg. 2005;14(3):152–8.CrossRefGoogle Scholar
  6. 6.
    Caplan MS, MacKendrick W. Inflammatory mediators and intestinal injury. Clin Perinatol. 1994;21(2):235–46.CrossRefGoogle Scholar
  7. 7.
    Vieten D, Corfield A, Carroll D, Ramani P, Spicer R. Impaired mucosal regeneration in neonatal necrotising enterocolitis. Pediatr Surg Int. 2005;21(3):153–60.CrossRefGoogle Scholar
  8. 8.
    Epelman M, Daneman A, Navarro OM, Morag I, Moore AM, Kim JH, Faingold R, Taylor G, Gerstle JT. Necrotizing enterocolitis: review of state-of-the-art imaging findings with pathologic correlation. Radiographics. 2007;27(2):285–305.CrossRefGoogle Scholar
  9. 9.
    Aliev MM, Dekhqonboev AA, Yuldashev RZ. Advantages of abdominal ultrasound in the management of infants with necrotizing enterocolitis. Pediatr Surg Int. 2017;33(2):213–6.CrossRefGoogle Scholar
  10. 10.
    Faingold R, Daneman A, Tomlinson G, Babyn PS, Manson DE, Mohanta A, Moore AM, Hellmann J, Smith C, Gerstle T, Kim JH. Necrotizing enterocolitis: assessment of bowel viability with color Doppler US. Radiology. 2005;235(2):587–94.CrossRefGoogle Scholar
  11. 11.
    Urboniene A, Palepsaitis A, Uktveris R, Barauskas V. Doppler flowmetry of the superior mesenteric artery and portal vein: impact for the early prediction of necrotizing enterocolitis in neonates. Pediatr Surg Int. 2015;31(11):1061–6.CrossRefGoogle Scholar
  12. 12.
    Kim WY, Kim WS, Kim IO, Kwon TH, Chang W, Lee EK. Sonographic evaluation of neonates with early-stage necrotizing enterocolitis. Pediatr Radiol. 2005;35(11):1056–61.CrossRefGoogle Scholar
  13. 13.
    Daneman A, Woodward S, de Silva M. The radiology of neonatal necrotizing enterocolitis (NEC). A review of 47 cases and the literature. Pediatr Radiol. 1978;7(2):70–7.CrossRefGoogle Scholar

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© Springer Nature Switzerland AG 2019

Authors and Affiliations

  • Adrian Bianchi
    • 1
  1. 1.Royal Manchester Children’s HospitalManchesterUK

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