Necrotizing Enterocolitis: Detection, Management, and Outcomes
NEC
NEC
Disease of premature & low birth weight infant.
Disease of premature & low birth weight infant.
Difficult to define.
Difficult to define.
Unclear risk factors.
Unclear risk factors.
What are the best treatment strategies ?
What are the best treatment strategies ?
What are the optimal prevention ?
What are the optimal prevention ?
Considerable mortality & morbidity.
Considerable mortality & morbidity.
Overlooked long term sequelae.
Overlooked long term sequelae.
Epidemiology
Epidemiology
2.3-11% of infant with less than 1500kg.
2.3-11% of infant with less than 1500kg.
Incidence & fatality inversely associated with B.W.
Incidence & fatality inversely associated with B.W.
BLACK race.
BLACK race.
Male infant.
Male infant.
Mortality of 15-30%.
Mortality of 15-30%.
Mortality increased to 50% when surgery is necessary.
Mortality increased to 50% when surgery is necessary.
Worse long-term outcomes.
Worse long-term outcomes.
90% of cases are preterm. Occasional cases in full-term.
90% of cases are preterm. Occasional cases in full-term.
Term have the same clinical & patho. Findings but
Term have the same clinical & patho. Findings but
different initiating factors.
different initiating factors.
considerable economic burden.
considerable economic burden.
Pathophysiologic factors
Pathophysiologic factors
1- intestinal motility.
1- intestinal motility.
2- intestinal digestion.
2- intestinal digestion.
3- mucous coat.
3- mucous coat.
4- tight junctions.
4- tight junctions.
5- intestinal regeneration.
5- intestinal regeneration.
6- NO.
6- NO.
7- endotoxin (LPS).
7- endotoxin (LPS).
8- PAF-AH.
8- PAF-AH.
9- EGF (HB-EGF).
9- EGF (HB-EGF).
10- balance between constrictor ET-1 & dilator NO.
10- balance between constrictor ET-1 & dilator NO.
11- balance between commensal & pathologic Bactria.
11- balance between commensal & pathologic Bactria.
nNOS
eNOS
iNOS
Symptoms &
signs.
Exclude
extra-abd.
Problems
Feeding
regimen.
Medications
Abd. Wall
discoloration.
Abd.
distention.
Pain,
tenderness.
Palpable
mass.
Scrotum.
WBC.
Platelet.
Hb.
ABG.
Lactic acid.
Erect abd film.
Lat. decubitus
film.
Serial X-rays.
Finding ?
•
Ileus.
•
Fixed loop.
•
Pneumatosis.
•
Portal V. gas.
•
pneumoperit.
Q/ For how long to continue on medical treatment ?
Q/ For how long to continue on medical treatment ?
•
7 – 10 days.
7 – 10 days.
Q/ If patient shows clinical improvement ?
Q/ If patient shows clinical improvement ?
•
Start slowly advancing feeds.
Start slowly advancing feeds.
Q /If patient not tolerate feeds ?
Q /If patient not tolerate feeds ?
•
Repeat episode of NEC.
Repeat episode of NEC.
•
Post-NEC stricture.
Post-NEC stricture.
Post-NEC stricture
Post-NEC stricture
Most commonly occur in :
Most commonly occur in :
the left colon near splenic flexure.
the left colon near splenic flexure.
But may occur anywhere.
But may occur anywhere.
What investigation you should consider ?
What investigation you should consider ?
Contrast enema & UGI study.
Contrast enema & UGI study.
Which is first to perform? & why ?
Which is first to perform? & why ?
I- Absolute indications:
I- Absolute indications:
Free air.
Free air.
II- Relative indications:
II- Relative indications:
Do not decide to operate after one assessment
Do not decide to operate after one assessment
but after serial examinations.
but after serial examinations.
When to operate on NEC ?
When to operate on NEC ?
Peritoneal drain Vs laparotomy !
Peritoneal drain Vs laparotomy !
Mortality ?
Mortality ?
Early results ?
Early results ?
Delayed result ?
Delayed result ?
Patients with peritoneal drain may have
Patients with peritoneal drain may have
worse neurological outcomes 1-2 years after
worse neurological outcomes 1-2 years after
NEC recovery compared to laparotomy patients.
NEC recovery compared to laparotomy patients.
Why ???
Why ???
NEST (necrotizing enterocolitis surgery trial)
NEST (necrotizing enterocolitis surgery trial)
•
RCT study.
RCT study.
•
300 patients.
300 patients.
•
Follow up 18 -22 months after NEC recovery
Follow up 18 -22 months after NEC recovery
•
Results are expected in 2016.
Results are expected in 2016.
How to decide between drain & laparotomy ?
How to decide between drain & laparotomy ?
•
Currently unknown which is better.
Currently unknown which is better.
•
Neurological outcomes.
Neurological outcomes.
•
Focal area of perforation.(drain , laparotomy).
Focal area of perforation.(drain , laparotomy).
•
Discuss with family.
Discuss with family.
Peritoneal drain
Peritoneal drain
Technique:
Technique:
Drain management:
Drain management:
When to feed ?
When to feed ?
1- bed side.
1- bed side.
2- L.A
2- L.A
3- transverse incision.
3- transverse incision.
4- RIF.
4- RIF.
5- penrose drain.
5- penrose drain.
6- avoid too large incision.
6- avoid too large incision.
7- enter abdominal cavity with hemostate.
7- enter abdominal cavity with hemostate.
8- place the drain carefully.
8- place the drain carefully.
9- install normal saline to wash abd. Cavity.
9- install normal saline to wash abd. Cavity.
9- secure the drain in place.
9- secure the drain in place.
•
Irrigate the drain regularly to keep it patent.
Irrigate the drain regularly to keep it patent.
•
Start to remove it after 7-10 days.
Start to remove it after 7-10 days.
•
If continued leakage of stool ?
If continued leakage of stool ?
If patient doing well, start feeds.
If patient doing well, start feeds.
If there is feeding intolerance, contrast study
If there is feeding intolerance, contrast study
Operative management
Operative management
Pre-operative:
Pre-operative:
1- resuscitate the patient & correct any coagulopathy.
1- resuscitate the patient & correct any coagulopathy.
2- set up packed RBC, FFP, platelets for OR.
2- set up packed RBC, FFP, platelets for OR.
Surgical technique:
Surgical technique:
In the OR or bedside in NICU.
In the OR or bedside in NICU.
Supra-umbilical transverse incision.
Supra-umbilical transverse incision.
Abd. Wall is very thin
Abd. Wall is very thin
Assess the integrity of intestine, ischemia, necrosis, perforation.
Assess the integrity of intestine, ischemia, necrosis, perforation.
Segmental necrosis
Segmental necrosis
bowel, liver, spleen injury.
bowel, liver, spleen injury.
resection & primary anastomosis.
resection & primary anastomosis.
proximal stoma & mucous fistula.
proximal stoma & mucous fistula.
stoma creation:
stoma creation:
Bring the stoma out through the same incision.
Bring the stoma out through the same incision.
Bring out the functional stoma & mucous fistula next to each other.
Bring out the functional stoma & mucous fistula next to each other.
Proper fixation of both ends to the fascia.
Proper fixation of both ends to the fascia.
Leave more length of the distal end.
Leave more length of the distal end.
It is not necessary to mature the stoma.
It is not necessary to mature the stoma.
Management of diffuse NEC
Management of diffuse NEC
Usually see diffuse pneumatosis, unhealthy bowel but not necrotic.
Usually see diffuse pneumatosis, unhealthy bowel but not necrotic.
This is usually occur if you go to OR too early.
This is usually occur if you go to OR too early.
Need to decide if there is something to resect.
Need to decide if there is something to resect.
If you are unsure, it is better to leave intestine for second look.
If you are unsure, it is better to leave intestine for second look.
Consider leaving the abdomen open if there are dilated bowel.
Consider leaving the abdomen open if there are dilated bowel.
Management of skip lesions
Management of skip lesions
Consider resecting all lesions together with one anastomosis.
Consider resecting all lesions together with one anastomosis.
If not, resect individual lesions, multiple anastomosis, proximal
If not, resect individual lesions, multiple anastomosis, proximal
diverting stoma.
diverting stoma.
Clipping & dropping:
Clipping & dropping:
Usually for unstable patient with no time for multiple anastomosis.
Usually for unstable patient with no time for multiple anastomosis.
Only resect the necrotic bowel & return another day to complete
Only resect the necrotic bowel & return another day to complete
the anastomosis when the patient is more stable.
the anastomosis when the patient is more stable.
Management of NEC totalis
Management of NEC totalis
Currently no technique can manage such problem.
Currently no technique can manage such problem.
Likelhood of survival through years of TPN to reach liver & intestine
Likelhood of survival through years of TPN to reach liver & intestine
transplant is zero %.
transplant is zero %.
Just close the abdomen & pursue comfort care for the patient.
Just close the abdomen & pursue comfort care for the patient.
Discuss with family & give them realistic explanations.
Discuss with family & give them realistic explanations.
Management of extremely friable bowel
Management of extremely friable bowel
Result from being forced to operate when the inflammatory
Result from being forced to operate when the inflammatory
process in the abdomen is at the peak.
process in the abdomen is at the peak.
The smartest decision a surgeon can make is know when to stop
The smartest decision a surgeon can make is know when to stop
the operation & return another day.
the operation & return another day.
Continuing the operation will result in more serosal tears & bowel
Continuing the operation will result in more serosal tears & bowel
injuries & worse outcome to patient.
injuries & worse outcome to patient.
If possible, identify the proximal bowel & create a diverting stoma.
If possible, identify the proximal bowel & create a diverting stoma.
Management of tension pneumoperitoneum
Management of tension pneumoperitoneum
Abdominal compartement syndrome may occure from free air.
Abdominal compartement syndrome may occure from free air.
Decompress using angiocath as a temporizing maneuvuer as
Decompress using angiocath as a temporizing maneuvuer as
patient may not be stable enough to go to OR.
patient may not be stable enough to go to OR.
Post - operative management
Post - operative management
Reversing the stoma:
Reversing the stoma:
Consider after the patient is stable & tolerating feeds.
Consider after the patient is stable & tolerating feeds.
Wait until the patient is at least 2 kg.
Wait until the patient is at least 2 kg.
Consider re-feeding through mucous fistula if the
Consider re-feeding through mucous fistula if the
patient has high output stoma.
patient has high output stoma.
If there are signs of TPN- induced cholestasis or you
If there are signs of TPN- induced cholestasis or you
cannot nourish the patient because of high output
cannot nourish the patient because of high output
stoma, then consider closing the stoma sooner.
stoma, then consider closing the stoma sooner.
Re-feeding through mucous fistula:
Re-feeding through mucous fistula:
Recent article shows a substantial decrease in TPN use.
Recent article shows a substantial decrease in TPN use.
Be careful when creating the mucous fistula as they
Be careful when creating the mucous fistula as they
often retracted or get stenosis.
often retracted or get stenosis.
Consider leaving a soft catheter in the fistula post-
Consider leaving a soft catheter in the fistula post-
operatively to keep it open.
operatively to keep it open.
Necrotizing enterocolitis (NEC) is a severe condition affecting premature and low birth weight infants, characterized by high mortality rates and long-term complications. The disease poses challenges in defining risk factors and treatment strategies, with considerable emphasis on prevention. Diagnosis involves a comprehensive work-up, including abdominal examination, laboratory tests, and imaging studies, with medical management focusing on gradual feeding advancement and antibiotic therapy. Post-NEC strictures may require investigations such as contrast enema and upper gastrointestinal studies. Surgical intervention is considered based on absolute and relative indications, emphasizing serial assessments for optimal decision-making.
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Presentation Transcript
NECROTIZING ENTEROCOLITIS NECROTIZING ENTEROCOLITIS
NEC Disease of premature & low birth weight infant. Difficult to define. Unclear risk factors. What are the best treatment strategies ? What are the optimal prevention ? Considerable mortality & morbidity. Overlooked long term sequelae. Mortality of 15-30%. Mortality increased to 50% when surgery is necessary. Worse long-term outcomes. 90% of cases are preterm. Occasional cases in full-term. Term have the same clinical & patho. Findings but different initiating factors. considerable economic burden. 9- EGF (HB-EGF). 10- balance between constrictor ET-1 & dilator NO. 11- balance between commensal & pathologic Bactria. Epidemiology 2.3-11% of infant with less than 1500kg. Incidence & fatality inversely associated with B.W. BLACK race. Male infant. 2- intestinal digestion. 3- mucous coat. 4- tight junctions. 5- intestinal regeneration. 6- NO. 7- endotoxin (LPS). 8- PAF-AH. Pathophysiologic factors 1- intestinal motility. nNOS eNOS iNOS
Work-up for NEC Abdominal examination History Lab. Test Imaging Abd. Wall discoloration. Abd. distention. Pain, tenderness. Palpable mass. Scrotum. WBC. Platelet. Hb. ABG. Lactic acid. Erect abd film. Lat. decubitus film. Serial X-rays. Finding ? Ileus. Fixed loop. Pneumatosis. Portal V. gas. pneumoperit. Symptoms & signs. Exclude extra-abd. Problems Feeding regimen. Medications
Medical management for NEC Q/ For how long to continue on medical treatment ? 7 10 days. Stop all feeds. Insert NG Gastric decompression Q/ If patient shows clinical improvement ? Start slowly advancing feeds. Specific AB Anti-fungal ? Broad spectrum AB Q /If patient not tolerate feeds ? Repeat episode of NEC. Serial abd. exam, lab. Test & imaging Post-NEC stricture. Clinical deterioration Frequency of serial tests & imaging.
Post-NEC stricture Most commonly occur in : the left colon near splenic flexure. But may occur anywhere. What investigation you should consider ? Contrast enema & UGI study. Which is first to perform? & why ?
When to operate on NEC ? I- Absolute indications: Free air. II- Relative indications: best good fair 1- Portal venous gas. 2- positive paracentesis. 3- clinical deterioration. 1- fixed loop. 2- erythema. 3- palpable mass. Severe pneumatosis. Do not decide to operate after one assessment but after serial examinations.
Surgical management Surgical management Peritoneal drain Vs laparotomy ! Mortality ? Early results ? Delayed result ? Patients with peritoneal drain may have worse neurological outcomes 1-2 years after NEC recovery compared to laparotomy patients. Why ??? Neurological outcomes. Focal area of perforation.(drain , laparotomy). Discuss with family. How to decide between drain & laparotomy ? Currently unknown which is better. NEST (necrotizing enterocolitis surgery trial) RCT study. 300 patients. Follow up 18 -22 months after NEC recovery Results are expected in 2016.
Peritoneal drain Technique: Drain management: When to feed ? 3- transverse incision. 4- RIF. 5- penrose drain. 6- avoid too large incision. 7- enter abdominal cavity with hemostate. 8- place the drain carefully. 9- install normal saline to wash abd. Cavity. 9- secure the drain in place. 1- bed side. 2- L.A Irrigate the drain regularly to keep it patent. Start to remove it after 7-10 days. If continued leakage of stool ? If there is feeding intolerance, contrast study If patient doing well, start feeds. Hernia.
Operative management Pre-operative: 1- resuscitate the patient & correct any coagulopathy. 2- set up packed RBC, FFP, platelets for OR. Surgical technique: In the OR or bedside in NICU. Supra-umbilical transverse incision. Abd. Wall is very thin Assess the integrity of intestine, ischemia, necrosis, perforation. Segmental necrosis resection & primary anastomosis. proximal stoma & mucous fistula. stoma creation: Bring the stoma out through the same incision. Bring out the functional stoma & mucous fistula next to each other. Proper fixation of both ends to the fascia. Leave more length of the distal end. It is not necessary to mature the stoma. bowel, liver, spleen injury.
Management of diffuse NEC Usually see diffuse pneumatosis, unhealthy bowel but not necrotic. This is usually occur if you go to OR too early. Need to decide if there is something to resect. If you are unsure, it is better to leave intestine for second look. Consider leaving the abdomen open if there are dilated bowel. diverting stoma. Clipping & dropping: Usually for unstable patient with no time for multiple anastomosis. Only resect the necrotic bowel & return another day to complete the anastomosis when the patient is more stable. the operation & return another day. Continuing the operation will result in more serosal tears & bowel injuries & worse outcome to patient. If possible, identify the proximal bowel & create a diverting stoma. Management of skip lesions Consider resecting all lesions together with one anastomosis. If not, resect individual lesions, multiple anastomosis, proximal Currently no technique can manage such problem. Likelhood of survival through years of TPN to reach liver & intestine transplant is zero %. Just close the abdomen & pursue comfort care for the patient. Discuss with family & give them realistic explanations. The smartest decision a surgeon can make is know when to stop Decompress using angiocath as a temporizing maneuvuer as patient may not be stable enough to go to OR. Management of NEC totalis Management of extremely friable bowel Result from being forced to operate when the inflammatory process in the abdomen is at the peak. Abdominal compartement syndrome may occure from free air. Management of tension pneumoperitoneum
Post - operative management Reversing the stoma: Consider after the patient is stable & tolerating feeds. Wait until the patient is at least 2 kg. Consider re-feeding through mucous fistula if the patient has high output stoma. If there are signs of TPN- induced cholestasis or you cannot nourish the patient because of high output stoma, then consider closing the stoma sooner. Re-feeding through mucous fistula: Recent article shows a substantial decrease in TPN use. Be careful when creating the mucous fistula as they often retracted or get stenosis. Consider leaving a soft catheter in the fistula post- operatively to keep it open. Thank you
