The Clip and Drop Back Technique in the Management of Multifocal Necrotizing Enterocolitis: a Single Centre Experience
15 May 2011
21 September 2011
07 December 2011 (online)
Aim The surgical management of multifocal necrotizing enterocolitis (NEC) remains a major challenge. The “clip-and-drop” strategy with a second-look laparotomy permits re-assessment of bowel viability after optimization, thus offering the potential of both improving survival and conserving bowel length. This study reviews the outcome of this strategy in a single regional center.
Methods Since 2000, NEC patients undergoing emergency laparotomy selectively underwent a “clip-and-drop” operation if there was peri-operative instability and/or multifocal disease with uncertain bowel viability. Bowel with full thickness gangrene was resected and bowel-ends were temporarily tied-off; a second-look definitive procedure was performed when the patient had stabilized. For this review, in-hospital and follow-up records were studied retrospectively for demographics, 30-day mortality and long-term outcome.
Main results Between 2000 and 2010, 16 patients underwent a “clip-and-drop” operation. The mean post-conception age was 32.8 weeks (27.7–41.7 weeks) with a median body weight of 1.4 kg (0.76–4.4 kg) at first operation. Preoperative radiograph showed free gas in 43.8% and portal venous gas in 37.5% of patients. 2 patients did not survive to the second laparotomy. 14 patients received a second laparotomy, after a mean of 51 h (35–74 h). 2 patients were found to suffer from NEC totalis on the second laparotomy and died without further procedures. All other patients (n = 12) had stoma formation. 1 patient died 4 days after stoma formation. The 30-day mortality for NEC with the “clip-and-drop” strategy was 31.6% (5/16). Among the 11 survivors, 1 died from liver failure complicated by short bowel syndrome at 5 months post operation, 2 others died from respiratory complications of prematurity despite adequate gastrointestinal function. The median follow-up time for the 8 long-term survivors was 45 months (7–129 months). Their median time to achieving full feeds was 41 days (range 21–105 days) after the second operation.
Conclusion The “clip-and-drop” strategy, when used in selected patients with multifocal NEC, may help bowel conservation in survivors.
- 1 Fitzgibbons SC, Ching Y, Yu D , et al. Mortality of necrotizing enterocolitis expressed by birth weight categories. J Pediatr Surg 2009; 44: 1072-1076
- 2 Grosfeld JL, Cheu H, Schlatter M , et al. Changing trends in necrotizing enterocolitis. Ann Surg 1991; 214: 300-306
- 3 Lin PW, Stoll BJ. Necrotising enterocolitis. Lancet 2006; 368: 1271-1283
- 4 Bell MJ, Grossman H, Baker DH , et al. Necrotizing enterocolitis: therapeutic decisions based upon clinical staging. Ann Surg 1978; 187: 1-7
- 5 Walsh MC, Kliegman RM. Necrotizing enterocolitis: treatment based on staging criteria. Pediatr Clin North Am 1986; 33: 179-201
- 6 Pierro A, Hall N. Surgical treatment of infants with necrotizing enterocolitis. Semin Neonatol 2003; 8: 223-232
- 7 Vaughan WG, Grosfeld JL, West K , et al. Avoidance of stomas and delayed anastomosis for bowel necrosis: the ‘clip and drop back' technique. J Pediatr Surg 1996; 31: 542-545
- 8 Weber TR, Tracy TF, Silen ML. Enterostomy and its closure in newborns. Arch Surg 1995; 130: 534-537
- 9 O'Connor A, Sawin RS. High morbidity of enterostomy and its closure in premature infants with necrotizing enterocolitis. Arch Surg 1998; 133: 875-880
- 10 Griffiths DM, Forbes DA, Pemberton PJ. Primary anastomosis for necrotizing enterocolitis: a 12-year experience. J Pediatr Surg 1989; 24: 515-518
- 11 Ade-Ajayi N, Edward K, Drake D , et al. Resection and primary anastomosis in necrotizing enterocolitis. J R Soc Med 1996; 89: 385-388
- 12 Chwals WJ, Blakely ML, Cheng A , et al. Surgery-associated complications in necrotizing enterocolitis: a multiinstituitional study. J Pediatr Surg 2001; 36: 1722-1724
- 13 Molik KA, West K, Rescorla FJ , et al. Portal venous air: the poor prognosis persists. J Pediatr Surg 2001; 36: 1143-1145
- 14 Ron O, Davenport M, Patel S , et al. Outcomes of the “clip and drop” technique for multifocal necrotizing enterocolitis. J Pediatr Surg 2009; 44: 749-754
- 15 Fasoli L, Turi A, Spitz L , et al. Necrotizing enterocolitis: extent of disease and surgical treatment. J Pediatr Surg 1999; 34: 1096-1099
- 16 Arnold M, Moore SW, Sidler D , et al. Long-term outcome of surgically managed necrotizing enterocolitis in a developing country. Pediatr Surg Int 2010; 26: 355-360
- 17 Ladd AP, Rescorla FJ, West K , et al. Long-term follow-up after bowel resection for necrotizing enterocolitis: factors affecting outcome. J Pediatr Surg 1998; 33: 967-972