Necrotizing enterocolitis (NEC) is a devastating intestinal disease that primarily strikes premature and low-birth-weight infants, often progressing rapidly from inflammation to a life-threatening surgical emergency. A new comprehensive review, published in the World Journal of Pediatric Surgery, synthesizes current evidence to guide surgeons in making difficult decisions about when and how to operate, with the goal of preserving as much functional bowel as possible and improving long-term outcomes.
The review, led by researchers from the Department of Pediatric Surgery at Nationwide Children's Hospital in Columbus, Ohio, addresses the high stakes of surgical NEC. While mortality for medically managed NEC is around 7%, it jumps to 20%–30% when surgery becomes necessary. Survivors often face serious complications, including strictures, nutritional problems, intestinal failure due to short bowel syndrome, and impaired neurodevelopment. These poor outcomes are compounded by the lack of a specific biomarker for NEC, its overlap with spontaneous intestinal perforation, and the difficulty of determining when a deteriorating infant has crossed from medical to surgical disease.
The review compares the two primary surgical approaches: peritoneal drainage (PD) and exploratory laparotomy. PD is less invasive and can be performed at the bedside, making it an option for extremely low-birth-weight infants too unstable for a full laparotomy. However, if the infant does not improve, rescue surgery is often required. Exploratory laparotomy allows direct inspection and removal of necrotic bowel. Earlier randomized trials showed broadly similar survival between the two methods, but a more recent multicenter RCT found that among infants with a preoperative diagnosis of NEC, death or neurodevelopmental impairment occurred in 69% after laparotomy versus 85% after PD, with a 97% Bayesian probability that laparotomy was beneficial in this subgroup.
After bowel resection, surgeons must decide between creating a stoma or performing a primary anastomosis. Primary anastomosis is preferred when the infant is stable and the remaining bowel is clearly viable. For extensive or multifocal disease, the review discusses several bowel-preserving strategies, including damage control surgery, 'clip and drop,' diverting jejunostomy, 'patch, drain and wait,' and intraluminal stenting. These techniques aim to limit unnecessary bowel loss and preserve intestinal length for future growth.
The review also evaluates emerging perioperative tools that may improve surgical decision-making and recovery. Indocyanine green fluorescence angiography (ICG-FA) can help assess intestinal perfusion in real time, potentially guiding resection margins. Direct peritoneal resuscitation (DPR) may improve bowel perfusion and reduce inflammation. Mucous fistula refeeding, where effluent from a stoma is reintroduced into the distal bowel, may enhance nutritional recovery and reduce dependence on total parenteral nutrition (TPN).
The authors emphasize that there is no single 'best' surgical procedure for NEC. The optimal approach depends on the infant's clinical stability, the extent of bowel injury, and the amount of intestine that can be safely preserved. While the immediate goal is survival, long-term intestinal function, growth, and neurodevelopment must also shape surgical decisions. The review calls for more robust, well-controlled studies to validate these emerging adjuncts before they are widely adopted.
This review provides a valuable framework for neonatal and pediatric surgical teams, helping them structure multidisciplinary decisions around timing, operative risk, and bowel preservation rather than treating all cases of surgical NEC uniformly. Risk scores such as the Neonatal Sequential Organ Failure Assessment (nSOFA), combined with imaging, laboratory findings, and clinical trajectory, can support earlier identification of high-risk infants. In the operating room, perfusion imaging and staged bowel-preserving approaches may reduce avoidable resection, while postoperative strategies like mucous fistula refeeding may improve outcomes. However, the authors caution that many advanced techniques still require larger comparative trials and standardized protocols before they become routine care.
