Dantes Goeto, Keane Olivia A, Raikot Swathi, Do Louis, Rumbika Savanah, He Zhulin, Bhatia Amina M
Department of Surgery, Emory University, Atlanta, GA, USA.
Division of Pediatric Surgery, Department of Surgery, Emory University School of Medicine, Children's Healthcare of Atlanta, Atlanta, GA, USA.
J Perinatol. 2024 Oct 24. doi: 10.1038/s41372-024-02155-3.
Necrotizing enterocolitis (NEC) and spontaneous intestinal perforation (SIP) are severe gastrointestinal complications of prematurity. The clinical presentation and treatment of NEC and SIP (peritoneal drain vs laparotomy) can overlap; however, the pathogenesis is distinct. Therefore, a patient initially treated for SIP can subsequently develop NEC. This phenomenon has only been described in case reports, and no risk factor evaluation exists. We evaluate clinical characteristics, risk factors, and outcomes of patients treated for a distinct episode of NEC after SIP.
We performed a retrospective review of very low birth weight (<1500 g) neonates who presented with pneumoperitoneum between 07/2004 and 09/2022. Data was obtained from two separate neonatal intensive care units that were part of the same institution. Patients with an initial preoperative, intraoperative, or pathological diagnosis of NEC were excluded. Patients with an intraoperative diagnosis of SIP or preoperative diagnosis of SIP successfully treated with a peritoneal drain (PD) were evaluated. Patients subsequently treated (medically or surgically) for NEC after SIP were then compared to SIP-alone patients. Clinical characteristics included demographics, gestational age (GA), birth weight (BW), perinatal risk factors (chorioamnionitis, steroids, indomethacin), postoperative feeding regimen, and length of stay (LOS) were compared.
Of the 278 patients included, 31 (11.2%) patients had NEC after SIP. There was no difference in GA (25 weeks vs 25 weeks, p = 0.933) or BW (760 g vs 735 g, p = 0.370) between NEC after SIP vs SIP alone cohorts, respectively. Twenty (64%) of NEC after-SIP patients were previously treated with LP. NEC after SIP occurred with a median onset of 56 days. Pneumatosis was the most frequent (81%) presenting symptom and 12 (39%) patients had hematochezia. Four (12.9%) patients required LP for NEC and all had NEC intraoperatively and on pathology. A majority (77.4%) of patients were on breast milk (BM) at time of NEC diagnosis. NEC after SIP patients had lower maternal age at delivery (29.0 vs 25.0, p = 0.055) and the incidence of NEC after LP (primary or failed drain) was higher than PD alone (16.7% vs 6.2%, p = 0.007). NEC after SIP patients had longer LOS (135 vs 81, p < 0.001).
We report an 11.2% incidence of NEC at a median of 56 days following successful treatment of SIP, resulting in increased LOS. SIP patients are a high-risk cohort and protocols to prevent this phenomenon should be investigated.
坏死性小肠结肠炎（NEC）和自发性肠穿孔（SIP）是早产严重的胃肠道并发症。NEC和SIP的临床表现及治疗（腹腔引流与剖腹手术）可能重叠；然而，其发病机制不同。因此，最初接受SIP治疗的患者随后可能发展为NEC。这种现象仅在病例报告中有所描述，且尚无危险因素评估。我们评估了SIP后接受不同NEC发作治疗的患者的临床特征、危险因素及结局。
我们对2004年7月至2022年9月间出现气腹的极低出生体重（<1500 g）新生儿进行了回顾性研究。数据来自同一机构的两个独立新生儿重症监护病房。排除术前、术中或病理诊断为NEC的患者。评估术中诊断为SIP或经腹腔引流（PD）成功治疗的术前诊断为SIP的患者。然后将SIP后随后接受NEC治疗（药物或手术）的患者与单纯SIP患者进行比较。比较临床特征，包括人口统计学、胎龄（GA）、出生体重（BW）、围产期危险因素（绒毛膜羊膜炎、类固醇、吲哚美辛）、术后喂养方案及住院时间（LOS）。
在纳入的278例患者中，31例（11.2%）患者在SIP后发生NEC。SIP后发生NEC与单纯SIP队列之间的GA（25周 vs 25周，p = 0.933）或BW（760 g vs 735 g，p = 0.370）无差异。20例（64%）SIP后发生NEC的患者先前接受过腹腔镜探查（LP）。SIP后发生NEC的中位发病时间为56天。气肿是最常见的（81%）表现症状，12例（39%）患者有便血。4例（12.9%）患者因NEC需要进行LP，且所有患者术中及病理均诊断为NEC。大多数（77.4%）患者在NEC诊断时正在接受母乳喂养（BM）。SIP后发生NEC的患者分娩时母亲年龄较低（29.0 vs 25.0，p = 0.055），LP（初次或引流失败）后NEC的发生率高于单纯PD（16.7% vs 6.2%，p = 0.007）。SIP后发生NEC的患者住院时间更长（135天 vs 81天，p < 0.001）。
我们报告了SIP成功治疗后中位时间56天NEC的发生率为11.2%，导致住院时间延长。SIP患者是高危人群，应研究预防这种现象的方案。
