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Initial surgical treatment of necrotizing enterocolitis: a meta-analysis of peritoneal drainage versus laparotomy

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Abstract

Necrotizing enterocolitis (NEC) in premature infants is associated with high morbidity and mortality, and the optimal intervention remains uncertain. To compare the mortality of primary peritoneal drainage versus primary peritoneal laparotomy as initial surgical intervention for NEC. All data were extracted from PubMed, Embase, and the Cochrane Library. Studies published up to December 2021. Patients with NEC. Studies centered on primary peritoneal drainage and primary peritoneal laparotomy as the initial surgical treatment. Mortality outcomes were available for both interventions. Randomized controlled trials, retrospective cohort studies, and case series in peer-reviewed journals. Language limited to English. Odds ratio (OR) with 95% confidence intervals (CIs) was used to evaluate mortality outcome. Subgroup analyses and linear regression were performed to ascertain the association between mortality pre-specified factors. Data of 1062 patients received peritoneal drainage and 2185 patients received peritoneal laparotomy from five case series, five retrospective cohort studies, and three randomized controlled trials. Peritoneal drainage caused similar mortality (OR 1.49, 95% CI 0.99–2.26) compared with peritoneal laparotomy as initial surgical management for NEC infants. The subgroup analysis of study design, sample size, birth weight, and sex showed similar findings, but inconsistent results were found for country (USA: 1.47, 95% CI 0.90–2.41; Canada: 2.53, 95% CI 0.30–21.48; Australia: 10.29, 95% CI 1.03–102.75; Turkey: 0.09, 95% CI 0.01–0.63) and gestational age (age mean difference < 3: 1.23, 95% CI 0.72–2.11; age mean difference ≥ 3: 2.29, 95% CI 1.04–5.05). No statistically significance was found for the linear regression between mortality and sample size (P = 0.842), gestational age (P = 0.287), birth weight (P = 0.257), sex (P = 0.6). Small sample size, high heterogeneity, NEC, and spontaneous intestinal perforation (SIP) had to be analyzed together, lack of selection criteria for the future selection of an intervention, and no clear, standardized procedures.

   Conclusion: There was no significant difference in mortality between peritoneal drainage and laparotomy as initial surgical intervention. The results suggest that either intervention could be used in selected patients.

What is Known:

• Necrotizing enterocolitis (NEC) in premature infants is associated with high morbidity and mortality, and the optimal intervention remains uncertain.

What is New:

• No significant difference of mortality between peritoneal drainage and laparotomy as initial surgical intervention.

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Data availability

Since it is a meta-analysis, all data were extracted from public database, then all data were available.

Abbreviations

CIs:

Confidence intervals

NEC:

Necrotizing enterocolitis

OR:

Odds ratio

SIP:

Spontaneous intestinal perforation

References

  1. Lawrence G, Bates J, Gaul A (1982) Pathogenesis of neonatal necrotising enterocolitis. Lancet 1:137–139

    Article  CAS  Google Scholar 

  2. Henry MC, Moss RL (2009) Necrotizing enterocolitis. Annu Rev Med 60:111–124

    Article  CAS  Google Scholar 

  3. Rich BS, Dolgin SE (2017) Necrotizing enterocolitis. Pediatr Rev 38:552–559

    Article  Google Scholar 

  4. Jones IH, Hall NJ (2020) Contemporary outcomes for infants with necrotizing enterocolitis-a systematic review. J Pediatr 220:86–92 e83

  5. Braun D, Braun E, Chiu V, Burgos AE, Gupta M, Volodarskiy M, Getahun D (2020) Trends in neonatal intensive care unit utilization in a large integrated health care system. JAMA Netw Open 3:e205239

  6. Cuttini M, Forcella E, Rodrigues C, Draper ES, Martins AF, Laine A, Willars J, Hasselager A, Maier RF, Croci I, Bonet M, Zeitlin J (2020) What drives change in neonatal intensive care units? A qualitative study with physicians and nurses in six European countries. Pediatr Res 88:257–264

    Article  Google Scholar 

  7. Nino DF, Sodhi CP, Hackam DJ (2016) Necrotizing enterocolitis: new insights into pathogenesis and mechanisms. Nat Rev Gastroenterol Hepatol 13:590–600

    Article  CAS  Google Scholar 

  8. Neu J, Walker WA (2011) Necrotizing enterocolitis. N Engl J Med 364:255–264

    Article  CAS  Google Scholar 

  9. Denning TL, Bhatia AM, Kane AF, Patel RM, Denning PW (2017) Pathogenesis of NEC: role of the innate and adaptive immune response. Semin Perinatol 41:15–28

    Article  Google Scholar 

  10. Neu J, Pammi M (2017) Pathogenesis of NEC: Impact of an altered intestinal microbiome. Semin Perinatol 41:29–35

    Article  Google Scholar 

  11. Tanner SM, Berryhill TF, Ellenburg JL, Jilling T, Cleveland DS, Lorenz RG, Martin CA (2015) Pathogenesis of necrotizing enterocolitis: modeling the innate immune response. Am J Pathol 185:4–16

    Article  CAS  Google Scholar 

  12. Rose AT, Patel RM (2018) A critical analysis of risk factors for necrotizing enterocolitis. Semin Fetal Neonatal Med 23:374–379

    Article  Google Scholar 

  13. Samuels N, van de Graaf RA, de Jonge RCJ, Reiss IKM, Vermeulen MJ (2017) Risk factors for necrotizing enterocolitis in neonates: a systematic review of prognostic studies. BMC Pediatr 17:105

    Article  Google Scholar 

  14. Cotten CM (2019) Modifiable risk factors in necrotizing enterocolitis. Clin Perinatol 46:129–143

    Article  Google Scholar 

  15. Hintz SR, Kendrick DE, Stoll BJ, Vohr BR, Fanaroff AA, Donovan EF, Poole WK, Blakely ML, Wright L, Higgins R, Network NNR (2005) Neurodevelopmental and growth outcomes of extremely low birth weight infants after necrotizing enterocolitis. Pediatrics 115:696–703

    Article  Google Scholar 

  16. Zhou Q, Nino DF, Yamaguchi Y, Wang S, Fulton WB, Jia H, Lu P, Prindle T, Jr., Pamies D, Morris M, Chen LL, Sodhi CP, Hackam DJ (2021) Necrotizing enterocolitis induces T lymphocyte-mediated injury in the developing mammalian brain. Sci Transl Med 13

  17. Moschopoulos C, Kratimenos P, Koutroulis I, Shah BV, Mowes A, Bhandari V (2018) The neurodevelopmental perspective of surgical necrotizing enterocolitis: the role of the gut-brain axis. Mediators Inflamm 2018:7456857

    Article  Google Scholar 

  18. Hong CR, Han SM, Jaksic T (2018) Surgical considerations for neonates with necrotizing enterocolitis. Semin Fetal Neonatal Med 23:420–425

    Article  Google Scholar 

  19. Ahle S, Badru F, Damle R, Osei H, Munoz-Abraham AS, Bajinting A, Barbian ME, Bhatia AM, Gingalewski C, Greenspon J, Hamilton N, Stitelman D, Strand M, Warner BW, Villalona GA (2020) Multicenter retrospective comparison of spontaneous intestinal perforation outcomes between primary peritoneal drain and primary laparotomy. J Pediatr Surg 55:1270–1275

    Article  Google Scholar 

  20. Rao SC, Basani L, Simmer K, Samnakay N, Deshpande G (2011) Peritoneal drainage versus laparotomy as initial surgical treatment for perforated necrotizing enterocolitis or spontaneous intestinal perforation in preterm low birth weight infants. Cochrane Database Syst Rev CD006182

  21. Rakshasbhuvankar A, Rao S, Minutillo C, Gollow I, Kolar S (2012) Peritoneal drainage versus laparotomy for perforated necrotising enterocolitis or spontaneous intestinal perforation: a retrospective cohort study. J Paediatr Child Health 48:228–234

    Article  Google Scholar 

  22. Yanowitz TD, Sullivan KM, Piazza AJ, Brozanski B, Zaniletti I, Sharma J, DiGeronimo R, Nayak SP, Wadhawan R, Reber KM, Murthy K, Group CSNF (2019) Does the initial surgery for necrotizing enterocolitis matter? Comparative outcomes for laparotomy vs. peritoneal drain as initial surgery for necrotizing enterocolitis in infants <1000g birth weight. J Pediatr Surg 54:712–717

    Article  Google Scholar 

  23. van Heesewijk AE, Rush ML, Schmidt B, Kirpalani H, DeMauro SB (2020) Agreement between study designs: a systematic review comparing observational studies and randomized trials of surgical treatments for necrotizing enterocolitis. J Matern Fetal Neonatal Med 33:1965–1973

    Article  Google Scholar 

  24. Moss RL, Dimmitt RA, Barnhart DC, Sylvester KG, Brown RL, Powell DM, Islam S, Langer JC, Sato TT, Brandt ML, Lee H, Blakely ML, Lazar EL, Hirschl RB, Kenney BD, Hackam DJ, Zelterman D, Silverman BL (2006) Laparotomy versus peritoneal drainage for necrotizing enterocolitis and perforation. N Engl J Med 354:2225–2234

    Article  CAS  Google Scholar 

  25. Rees CM, Eaton S, Kiely EM, Wade AM, McHugh K, Pierro A (2008) Peritoneal drainage or laparotomy for neonatal bowel perforation? A randomized controlled trial. Ann Surg 248:44–51

    Article  Google Scholar 

  26. Grave GD, Nelson SA, Walker WA, Moss RL, Dvorak B, Hamilton FA, Higgins R, Raju TN (2007) New therapies and preventive approaches for necrotizing enterocolitis: report of a research planning workshop. Pediatr Res 62:510–514

    Article  Google Scholar 

  27. Rees CM, Eaton S, Khoo AK, Kiely EM, Members of NETTG, Pierro A (2010) Peritoneal drainage does not stabilize extremely low birth weight infants with perforated bowel: data from the NET Trial. J Pediatr Surg 45:324–328; discussion 328–329

  28. Sola JE, Tepas JJ 3rd, Koniaris LG (2010) Peritoneal drainage versus laparotomy for necrotizing enterocolitis and intestinal perforation: a meta-analysis. J Surg Res 161:95–100

    Article  Google Scholar 

  29. Blakely ML, Tyson JE, Lally KP, McDonald S, Stoll BJ, Stevenson DK, Poole WK, Jobe AH, Wright LL, Higgins RD, Network NNR (2006) Laparotomy versus peritoneal drainage for necrotizing enterocolitis or isolated intestinal perforation in extremely low birth weight infants: outcomes through 18 months adjusted age. Pediatrics 117:e680-687

    Article  Google Scholar 

  30. Ma LL, Wang YY, Yang ZH, Huang D, Weng H, Zeng XT (2020) Methodological quality (risk of bias) assessment tools for primary and secondary medical studies: what are they and which is better? Mil Med Res 7:7

    PubMed  PubMed Central  Google Scholar 

  31. Ahmed T, Ein S, Moore A (1998) The role of peritoneal drains in treatment of perforated necrotizing enterocolitis: recommendations from recent experience. J Pediatr Surg 33:1468–1470

    Article  CAS  Google Scholar 

  32. Azarow KS, Ein SH, Shandling B, Wesson D, Superina R, Filler RM (1997) Laparotomy or drain for perforated necrotizing enterocolitis: who gets what and why? Pediatr Surg Int 12:137–139

    Article  Google Scholar 

  33. Dimmitt RA, Meier AH, Skarsgard ED, Halamek LP, Smith BM, Moss RL (2000) Salvage laparotomy for failure of peritoneal drainage in necrotizing enterocolitis in infants with extremely low birth weight. J Pediatr Surg 35:856–859

    Article  CAS  Google Scholar 

  34. Morgan LJ, Shochat SJ, Hartman GE (1994) Peritoneal drainage as primary management of perforated NEC in the very low birth weight infant. J Pediatr Surg 29:310–314; discussion 314–315

  35. Zenciroglu A, Cakmak O, Demirel N, Bas AY, Yilmaz D, Karaman I, Erdogan D (2005) Outcome of primary peritoneal drainage for perforated necrotizing enterocolitis: comparison between laparotomy and drainage. Eur J Pediatr Surg 15:243–247

    Article  CAS  Google Scholar 

  36. Kelleher J, Mallick H, Soltau TD, Harmon CM, Dimmitt RA (2013) Mortality and intestinal failure in surgical necrotizing enterocolitis. J Pediatr Surg 48:568–572

    Article  Google Scholar 

  37. Stey A, Barnert ES, Tseng CH, Keeler E, Needleman J, Leng M, Kelley-Quon LI, Shew SB (2015) Outcomes and costs of surgical treatments of necrotizing enterocolitis. Pediatrics 135:e1190-1197

    Article  Google Scholar 

  38. Tashiro J, Wagenaar AE, Perez EA, Sola JE (2017) Peritoneal drainage is associated with higher survival rates for necrotizing enterocolitis in premature, extremely low birth weight infants. J Surg Res 218:132–138

    Article  Google Scholar 

  39. Blakely ML, Tyson JE, Lally KP, Hintz SR, Eggleston B, Stevenson DK, Besner GE et al (2021) Initial laparotomy versus peritoneal drainage in extremely low birthweight infants with surgical necrotizing enterocolitis or isolated intestinal perforation: a multicenter randomized clinical trial. Ann Surg 274:e370–e380

    PubMed  Google Scholar 

  40. Patel RM, Kandefer S, Walsh MC, Bell EF, Carlo WA, Laptook AR, Sanchez PJ, Shankaran S, Van Meurs KP, Ball MB, Hale EC, Newman NS, Das A, Higgins RD, Stoll BJ, Eunice Kennedy Shriver National Institute of Child H, Human Development Neonatal Research N (2015) Causes and timing of death in extremely premature infants from 2000 through 2011. N Engl J Med 372:331–340

    Article  Google Scholar 

  41. Ahle M, Drott P, Andersson RE (2013) Epidemiology and trends of necrotizing enterocolitis in Sweden: 1987–2009. Pediatrics 132:e443-451

    Article  Google Scholar 

  42. Frost BL, Modi BP, Jaksic T, Caplan MS (2017) New medical and surgical insights into neonatal necrotizing enterocolitis: a review. JAMA Pediatr 171:83–88

    Article  Google Scholar 

  43. Stoll BJ (1994) Epidemiology of necrotizing enterocolitis. Clin Perinatol 21:205–218

    Article  CAS  Google Scholar 

  44. Mintz AC, Applebaum H (1993) Focal gastrointestinal perforations not associated with necrotizing enterocolitis in very low birth weight neonates. J Pediatr Surg 28:857–860

    Article  CAS  Google Scholar 

  45. Han SM, Hong CR, Knell J, Edwards EM, Morrow KA, Soll RF, Modi BP, Horbar JD, Jaksic T (2020) Trends in incidence and outcomes of necrotizing enterocolitis over the last 12years: a multicenter cohort analysis. J Pediatr Surg 55:998–1001

    Article  Google Scholar 

  46. Loepke AW, Soriano SG (2008) An assessment of the effects of general anesthetics on developing brain structure and neurocognitive function. Anesth Analg 106:1681–1707

    Article  Google Scholar 

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Authors and Affiliations

  1. Department of Neonatal Surgery, Children’s Hospital of Nanjing Medical University, Nanjing, China

    Wei Li, Jie Tang, Zhongxian Zhu & Weibing Tang

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  1. Wei Li
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  2. Jie Tang
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Contributions

Wei Li and Jie Tang carried out the studies, participated in collecting data, and drafted the manuscript. Wei Li and Zhongxian Zhu performed the statistical analysis and participated in its design. Jie Tang and Zhongxian Zhu helped to draft the manuscript. All authors read and approved the final manuscript.

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Correspondence to Weibing Tang.

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Communicated by Daniele De Luca

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Li, W., Tang, J., Zhu, Z. et al. Initial surgical treatment of necrotizing enterocolitis: a meta-analysis of peritoneal drainage versus laparotomy. Eur J Pediatr 181, 2593–2601 (2022). https://doi.org/10.1007/s00431-022-04454-3

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