Abstract
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.
Keywords
necrotizing enterocolitis - newborn - surgical treatment - mortality - short bowel
syndrome
