SPONTANEOUS LOCALIZED NON-NECROTIZING ENTEROCOLITIS
PERFORATIONS IN EXTREMELY LOW BIRTH WEIGHT INFANTS
By J. E. Uceda, C.A. Laos, H.W. Kolni, and A.M. Klein
Dallas, Texas
Background/ Purpose: Localized non-NEC intestinal perforations have been
commonly observed in premature infants weighing less than 1000 grams during the last
fifteen years. Conservative management with peritoneal lavage and drainage has been
advocated but mortality figures are still high. We wish to present our experience with 56
consecutive cases treated at a single institution.
Methods: The authors reviewed the outcome of extremely low birth weight infants
(ELBWI) undergoing surgery for non-NEC intestinal perforations.
Results: From 1986 to 2001, 56 ELBWI with spontaneous, localized, non-NEC
intestinal perforations were treated. Their birth weight and gestational age averaged 705
grams and 24.8 weeks, respectively. A one inch long laparotomy incision was followed
by saline lavage and enterostomy. After recovery, reanastomosis was done. Our survival
was 91.1%. 88% of 51 survivors were followed for an average of 77 months and 34
children had excellent recovery. 5 patients died, 3 with Candida sepsis at 1, 3 and 8
weeks post operatively, one with severe broncopulmonary dysplasia at 6 weeks and one
with cardiopulmonary failure at 15 months of age.
Conclusions: Early enterostomy with subsequent reanastomosis is a satisfactory
management of spontaneous, localized, non-NEC intestinal perforations in ELBWI.
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INDEX WORDS: Extremely low birth weight infants, intestinal perforations, nonnecrotizing enterocolitis.
Spontaneous, localized, non-NEC intestinal perforations have been commonly observed
in extremely low birth weight infants during the past fifteen years. These patients
typically weigh less than 1000 grams and are 23 to 28 weeks of gestational age. Several
reports have proposed peritoneal lavage and drainage as the initial and even only
treatment for this condition but overall survival has been low or the series have been
small. We wish to report our experience with 56 consecutive infants treated with an
initial exteriorization of the perforation followed by a subsequent reanastomosis.
MATERIAL AND METHODS
During the eleven year period between February 1991 and November 2001, 55
consecutive <1000 gram infants were treated by one surgeon at a single institution. All
patients presented with a typical non-NEC, spontaneous, localized intestinal perforation.
Another patient had been seen in 1986 and was included in the study. Bell’s diagnostic
criteria were used to exclude necrotizing enterocolitis cases managed during the study
period. Post operative examinations by us or the referring pediatricians or telephone
interviews with relatives provided follow up information.
RESULTS
There were 35 males and 21 females. Birth weights and gestational ages averaged 704
grams (range, 460-1000) and 24.5 weeks (range, 23-28), respectively. Perinatal
medications included indomethacin (34 patients), dexamethasone (48 patients) and
inotropics (54 patients). Most infants were on conventional or high frequency
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ventilation at the time their perforations were diagnosed which typically occurred within
fifteen days of life. Bluish abdominal discoloration was seen in 42 infants. Marked
leukocytosis (>20,000 in 45 patients), rare thrombocytopenia (<50,000 in 6 patients)
and positive cultures to S. Epidermidis (26 patients) were observed. Left lateral
decubitus abdominal X rays detected pneumoperitoneum in 40 instances. None of our
patients had pneumatosis intestinalis or portal venous gas on their abdominal
roentgenograms. Nine infants underwent patent ductus closure, 4 before and 5 after their
perforation. All but two patients with duodenal perforations had an initial enterostomy.
After bile stained peritoneal fluid was cultured, saline lavage was done and a typically
single, 5-10 mm perforation became visible. Most of them were in the distal ileum.
Excessive handling of the bowel was purposely avoided, the perforation resected and
the resulting bowel ends carefully attached to the right corner of the incision with 5-0
polypropilene sutures to the peritoneal edge. Wound closure was completed with a few
interrupted 3-0 vicryl to fascia and peritoneum. Skin edges were not reapproximated.
Reanastomosis was initially done when infants reached 2000 grams, or earlier in the
few instances when stomas began to prolapse. Anastomoses were done in two layers
and we had no leaks. With added experience, reanastomoses were accomplished earlier
than before, the smallest infant weighing 765 grams.
51 (91.1%) of our 56 patients survived. Three infants died at 1, 3 and 8 weeks
postoperatively due to severe bronchopulmonary dysplasia (BPD) and candida sepsis.
The other two deaths occurred 6 weeks and 15 months after surgery, due to severe BPD
and cardiopulmonary failure, respectively. 45 (88%) of the survivors were followed up
an average of 77 months. 38 patients had good to excellent results. Bilateral blindness
occurred in 2, unilateral blindness in 2, fundoplication and lysis of adhesions were
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needed in one each and one last patient developed diabetes insipida which was
medically controlled.
DISCUSSION
Ten years ago we published our early experience with laparotomy and enterostomy on
non-NEC intestinal perforations in extremely low weight (<1000 grams) premature
infants. We compared 17 such patients with 16 under-1000 grams NEC patients
operated upon at our institution. Bell’s criteria were followed to differentiate both
groups. 15 patients in the non-NEC group survived (88.2%).1 Our non-NEC patients
were strikingly similar to those reported in the neonatal literature at that time.2-6
Peritoneal drainage (PD) for necrotizing enterocolitis perforation was first reported in
19757 and a 13-year experience by the same group was published in 1990. Of 37
patients drained, 9 died soon thereafter, 16 had to be operated upon and 7 of these died,
but 12 (32%) recovered without other treatment.8 By the end of the 1990’s three studies
of perforated non-NEC infants reported survivals of 67%, 100% and 90%, but these
were small series (9, 8 and 10 patients, respectively).9-11 Two more recent series of 25
and 19 patients, reported 66% and 53% survivals12,13 There is no question than many
ELBWI with non-NEC perforations improve initially with PD and some even recover
without further operations9-13 but our experience with 56 infants and their 91.1% long
term survival supports our earlier judgement that primary laparotomy remains a safe and
consistent approach to treat infants with non-NEC perforation. Two additional recent
reports have expressed similar conclusions.14,15
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