New Review Guides Surgical Choices for Necrotizing Enterocolitis in Preemies

Necrotizing enterocolitis (NEC) is a devastating intestinal disease that primarily strikes premature and low-birth-weight infants, rapidly progressing from inflammation to a life-threatening surgical emergency. A comprehensive review published in the World Journal of Pediatric Surgery provides a much-needed clinical framework for surgical decision-making, comparing peritoneal drainage (PD) with exploratory laparotomy, examining reconstruction options after bowel resection, and outlining bowel-preserving strategies for extensive disease. The review, from researchers at Nationwide Children's Hospital in Columbus, Ohio, emphasizes that surgery must do more than control immediate disease; it should preserve as much functional bowel as possible, reduce long-term complications, and improve quality of life for these vulnerable patients.

The stakes are high: mortality in surgical NEC ranges from 20%–30%, and survivors often face strictures, short bowel syndrome, nutritional problems, and neurodevelopmental impairment. The review highlights that choosing between PD and laparotomy depends on the infant's stability. PD is less invasive and useful for extremely low-birth-weight infants, but a recent multicenter randomized controlled trial found that among infants with a preoperative diagnosis of NEC, laparotomy resulted in better outcomes—death or neurodevelopmental impairment occurred in 69% after laparotomy versus 85% after PD, with a 97% Bayesian probability that laparotomy was beneficial. After resection, surgeons may opt for stoma creation or primary anastomosis, and for extensive disease, damage control techniques like "clip and drop" or "patch, drain and wait" aim to limit bowel loss. The review also evaluates emerging adjuncts like indocyanine green fluorescence angiography (ICG-FA), direct peritoneal resuscitation, and mucous fistula refeeding.

The authors stress that operative care cannot be reduced to a single preferred procedure; it must be individualized based on how sick the infant is, bowel viability, and the extent of disease. While emerging tools are promising, they require stronger evidence before broad adoption. This review provides a roadmap for neonatal and pediatric surgical teams to structure multidisciplinary decisions, potentially improving outcomes through better timing, operative selection, and bowel preservation. It underscores the need for continued research to refine risk stratification and perioperative care, ultimately aiming to improve survival and long-term quality of life for the most fragile patients.