Yikilmaz Ali, Hall Nigel J, Daneman Alan, Gerstle J Ted, Navarro Oscar M, Moineddin Rahim, Pleasants Hazel, Pierro Agostino
Department of Diagnostic Imaging, The Hospital for Sick Children, Toronto, Canada.
Pediatr Surg Int. 2014 Dec;30(12):1231-40. doi: 10.1007/s00383-014-3613-8. Epub 2014 Oct 20.
BACKGROUND/AIM: Established indications for surgery in necrotizing enterocolitis (NEC) are pneumoperitoneum and failure to improve or clinical deterioration with medical treatment alone. It has been proposed that infants with intestinal necrosis may benefit from surgery in the absence of one of these indications yet the diagnosis of definitive intestinal necrosis is challenging. Recent data suggest that abdominal ultrasound (US) examination focused on the gastrointestinal tract and the peritoneal cavity may be of utility in this regard. The aim of this study was to evaluate the ability of abdominal US to detect intestinal necrosis in infants with radiographically confirmed NEC.
Twenty-six consecutive infants with Bell stage II or III NEC were prospectively included in the study between September 2013 and July 2014. Infants with a pre-existing indication for surgery were excluded. At least one abdominal US examination was performed in each patient using a standardized previously described method. Surgery was performed at the discretion of the attending surgeon based on clinical and imaging findings. Clinical, radiographic, US, and intra-operative data were recorded to allow comparison between US findings, surgical findings and outcome.
US demonstrated signs of intestinal necrosis in 5 of the 26 patients. All of these five had laparotomy. Intestinal necrosis requiring resection was confirmed in four and the other was found to have NEC but no necrosis was identified. In 21 patients US did not suggest intestinal necrosis. Of these, only one had surgery in whom NEC but no necrosis was identified. The remaining 20 responded to medical treatment for NEC and were assumed not to have had intestinal necrosis based on improvement without surgical intervention. The sensitivity, specificity, positive predictive value and negative predictive values of US for the detection of bowel necrosis were calculated as 100, 95.4, 80.0, and 100%, respectively.
Our prospective findings suggest that abdominal US can identify those infants with NEC who may need surgery by detecting bowel necrosis (prior to the development of perforation or medical deterioration) with high sensitivity and specificity. Early surgical intervention in the clinical pathway of NEC may lead to improved outcomes.
背景/目的：坏死性小肠结肠炎（NEC）的既定手术指征是气腹以及单纯药物治疗后病情未改善或临床恶化。有人提出，肠道坏死的婴儿在缺乏这些指征之一的情况下可能从手术中获益，但明确肠道坏死的诊断具有挑战性。最近的数据表明，专注于胃肠道和腹腔的腹部超声（US）检查在这方面可能有用。本研究的目的是评估腹部超声检测经影像学证实为NEC的婴儿肠道坏死的能力。
2013年9月至2014年7月期间，前瞻性纳入了26例连续的Bell II期或III期NEC婴儿。排除先前有手术指征的婴儿。使用标准化的先前描述的方法对每位患者至少进行一次腹部超声检查。主治外科医生根据临床和影像学检查结果自行决定是否进行手术。记录临床、影像学、超声和术中数据，以便比较超声检查结果、手术结果和预后。
26例患者中有5例超声显示肠道坏死迹象。这5例均接受了剖腹手术。4例被证实需要切除坏死肠段，另1例被发现患有NEC但未发现坏死。21例患者超声未提示肠道坏死。其中，只有1例接受了手术，术中发现患有NEC但未发现坏死。其余20例对NEC药物治疗有反应，基于未进行手术干预而病情改善，推测未发生肠道坏死。超声检测肠坏死的敏感性、特异性、阳性预测值和阴性预测值分别计算为100%、95.4%、80.0%和100%。
我们的前瞻性研究结果表明，腹部超声可以通过高敏感性和特异性检测肠道坏死（在穿孔或病情恶化之前）来识别那些可能需要手术的NEC婴儿。在NEC的临床治疗过程中尽早进行手术干预可能会改善预后。
