Protocol-Driven Surgical Care of Necrotizing Enterocolitis and Spontaneous Intestinal Perforation

Hallie J. Quiroz; Krishnamurti Rao; Ann Christina Brady; Anthony R. Hogan; Chad M. Thorson; Eduardo A. Perez; Holly L. Neville; Juan E. Sola

doi:10.1016/j.jss.2020.05.079

Protocol-Driven Surgical Care of Necrotizing Enterocolitis and Spontaneous Intestinal Perforation

Hallie J. Quiroz, Krishnamurti Rao, Ann Christina Brady, Anthony R. Hogan, Chad M. Thorson, Eduardo A. Perez, Holly L. Neville, Juan E. Sola

Surgery

Research output: Contribution to journal › Article › peer-review

1 Scopus citations

Abstract

Background: There is no clear consensus on the optimal operative management of premature infants with surgical necrotizing enterocolitis (sNEC) or spontaneous intestinal perforation (SIP); thus, a protocol was developed to guide surgical decision making regarding initial peritoneal drainage (PD) versus initial laparotomy (LAP). We sought to evaluate outcomes after implementation of the protocol. Methods: Pre-post study including multiple urban hospitals. Premature infants with sNEC/SIP were accrued after implementation of surgical protocol-directed care (June 2014-June 2019). Patients with a birth weight of <750 g and less than 2 wk of age without pneumatosis or portal venous gas were treated with PD on perforation. PD patients received subsequent LAP for clinical deterioration or continued meconium/bilious drainage. Postprotocol characteristics and outcomes were compared with institutional historical controls. Significance set at P < 0.05. Results: Preprotocol and postprotocol cohorts comprise 35 and 73 patients, respectively. There was a statistically significant difference in age at intervention between historical control PD (14 ± 13 d) and postprotocol PD (9 ± 4 d) groups (P = 0.01), PD patient's birth weight (716 ± 212 g versus 610 ± 141 g, P = 0.02) and estimated gestational age of LAP patients (27 ± 1.7 wk versus 31 ± 4 wk, P = 0.002). PD was definitive surgery in 27% (12 of 44) of postprotocol patients compared with 13% (3 of 23) historical controls. A trend in improved survival postprotocol occurred in all PD infants (73% versus 65%), all LAP (75% versus 70%), and for initial PD and subsequent LAP (82% versus 67%). Conclusions: Utilization of a surgical protocol in sNEC/SIP is associated with improved success of PD as definitive surgery and improved survival.

Original language	English (US)
Pages (from-to)	396-404
Number of pages	9
Journal	Journal of Surgical Research
Volume	255
DOIs	https://doi.org/10.1016/j.jss.2020.05.079
State	Published - Nov 2020

Keywords

Intestinal perforation
Necrotizing enterocolitis
Peritoneal drainage
Surgical protocol

ASJC Scopus subject areas

Surgery

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Protocol-Driven Surgical Care of Necrotizing Enterocolitis and Spontaneous Intestinal Perforation. / Quiroz, Hallie J.; Rao, Krishnamurti; Brady, Ann Christina; Hogan, Anthony R.; Thorson, Chad M.; Perez, Eduardo A.; Neville, Holly L.; Sola, Juan E.

In: Journal of Surgical Research, Vol. 255, 11.2020, p. 396-404.

Research output: Contribution to journal › Article › peer-review

@article{ee910eb31a69401580218e4ddd155f5f,

title = "Protocol-Driven Surgical Care of Necrotizing Enterocolitis and Spontaneous Intestinal Perforation",

abstract = "Background: There is no clear consensus on the optimal operative management of premature infants with surgical necrotizing enterocolitis (sNEC) or spontaneous intestinal perforation (SIP); thus, a protocol was developed to guide surgical decision making regarding initial peritoneal drainage (PD) versus initial laparotomy (LAP). We sought to evaluate outcomes after implementation of the protocol. Methods: Pre-post study including multiple urban hospitals. Premature infants with sNEC/SIP were accrued after implementation of surgical protocol-directed care (June 2014-June 2019). Patients with a birth weight of <750 g and less than 2 wk of age without pneumatosis or portal venous gas were treated with PD on perforation. PD patients received subsequent LAP for clinical deterioration or continued meconium/bilious drainage. Postprotocol characteristics and outcomes were compared with institutional historical controls. Significance set at P < 0.05. Results: Preprotocol and postprotocol cohorts comprise 35 and 73 patients, respectively. There was a statistically significant difference in age at intervention between historical control PD (14 ± 13 d) and postprotocol PD (9 ± 4 d) groups (P = 0.01), PD patient's birth weight (716 ± 212 g versus 610 ± 141 g, P = 0.02) and estimated gestational age of LAP patients (27 ± 1.7 wk versus 31 ± 4 wk, P = 0.002). PD was definitive surgery in 27% (12 of 44) of postprotocol patients compared with 13% (3 of 23) historical controls. A trend in improved survival postprotocol occurred in all PD infants (73% versus 65%), all LAP (75% versus 70%), and for initial PD and subsequent LAP (82% versus 67%). Conclusions: Utilization of a surgical protocol in sNEC/SIP is associated with improved success of PD as definitive surgery and improved survival.",

keywords = "Intestinal perforation, Necrotizing enterocolitis, Peritoneal drainage, Surgical protocol",

author = "Quiroz, {Hallie J.} and Krishnamurti Rao and Brady, {Ann Christina} and Hogan, {Anthony R.} and Thorson, {Chad M.} and Perez, {Eduardo A.} and Neville, {Holly L.} and Sola, {Juan E.}",

note = "Funding Information: The authors thank Rana A. El Tawil, MD, for her assistance in data collection. This research received no specific funding/grant from any funding agency in the public, commercial, or not-for-profit sectors. Authors' contributions: Study conception and design: J.E.S. H.L.N. and E.A.P.; acquisition of data: H.J.Q. and K.R.; analysis and interpretation of data: H.J.Q. E.A.P. C.M.T. and J.E.S.; drafting of manuscript: H.J.Q.; critical revision: J.E.S. A.-C.B. A.R.H. E.A.P. C.M.T. and H.L.N.",

year = "2020",

month = nov,

doi = "10.1016/j.jss.2020.05.079",

language = "English (US)",

volume = "255",

pages = "396--404",

journal = "Journal of Surgical Research",

issn = "0022-4804",

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T1 - Protocol-Driven Surgical Care of Necrotizing Enterocolitis and Spontaneous Intestinal Perforation

AU - Quiroz, Hallie J.

AU - Rao, Krishnamurti

AU - Brady, Ann Christina

AU - Hogan, Anthony R.

AU - Thorson, Chad M.

AU - Perez, Eduardo A.

AU - Neville, Holly L.

AU - Sola, Juan E.

N1 - Funding Information: The authors thank Rana A. El Tawil, MD, for her assistance in data collection. This research received no specific funding/grant from any funding agency in the public, commercial, or not-for-profit sectors. Authors' contributions: Study conception and design: J.E.S. H.L.N. and E.A.P.; acquisition of data: H.J.Q. and K.R.; analysis and interpretation of data: H.J.Q. E.A.P. C.M.T. and J.E.S.; drafting of manuscript: H.J.Q.; critical revision: J.E.S. A.-C.B. A.R.H. E.A.P. C.M.T. and H.L.N.

PY - 2020/11

Y1 - 2020/11

N2 - Background: There is no clear consensus on the optimal operative management of premature infants with surgical necrotizing enterocolitis (sNEC) or spontaneous intestinal perforation (SIP); thus, a protocol was developed to guide surgical decision making regarding initial peritoneal drainage (PD) versus initial laparotomy (LAP). We sought to evaluate outcomes after implementation of the protocol. Methods: Pre-post study including multiple urban hospitals. Premature infants with sNEC/SIP were accrued after implementation of surgical protocol-directed care (June 2014-June 2019). Patients with a birth weight of <750 g and less than 2 wk of age without pneumatosis or portal venous gas were treated with PD on perforation. PD patients received subsequent LAP for clinical deterioration or continued meconium/bilious drainage. Postprotocol characteristics and outcomes were compared with institutional historical controls. Significance set at P < 0.05. Results: Preprotocol and postprotocol cohorts comprise 35 and 73 patients, respectively. There was a statistically significant difference in age at intervention between historical control PD (14 ± 13 d) and postprotocol PD (9 ± 4 d) groups (P = 0.01), PD patient's birth weight (716 ± 212 g versus 610 ± 141 g, P = 0.02) and estimated gestational age of LAP patients (27 ± 1.7 wk versus 31 ± 4 wk, P = 0.002). PD was definitive surgery in 27% (12 of 44) of postprotocol patients compared with 13% (3 of 23) historical controls. A trend in improved survival postprotocol occurred in all PD infants (73% versus 65%), all LAP (75% versus 70%), and for initial PD and subsequent LAP (82% versus 67%). Conclusions: Utilization of a surgical protocol in sNEC/SIP is associated with improved success of PD as definitive surgery and improved survival.

AB - Background: There is no clear consensus on the optimal operative management of premature infants with surgical necrotizing enterocolitis (sNEC) or spontaneous intestinal perforation (SIP); thus, a protocol was developed to guide surgical decision making regarding initial peritoneal drainage (PD) versus initial laparotomy (LAP). We sought to evaluate outcomes after implementation of the protocol. Methods: Pre-post study including multiple urban hospitals. Premature infants with sNEC/SIP were accrued after implementation of surgical protocol-directed care (June 2014-June 2019). Patients with a birth weight of <750 g and less than 2 wk of age without pneumatosis or portal venous gas were treated with PD on perforation. PD patients received subsequent LAP for clinical deterioration or continued meconium/bilious drainage. Postprotocol characteristics and outcomes were compared with institutional historical controls. Significance set at P < 0.05. Results: Preprotocol and postprotocol cohorts comprise 35 and 73 patients, respectively. There was a statistically significant difference in age at intervention between historical control PD (14 ± 13 d) and postprotocol PD (9 ± 4 d) groups (P = 0.01), PD patient's birth weight (716 ± 212 g versus 610 ± 141 g, P = 0.02) and estimated gestational age of LAP patients (27 ± 1.7 wk versus 31 ± 4 wk, P = 0.002). PD was definitive surgery in 27% (12 of 44) of postprotocol patients compared with 13% (3 of 23) historical controls. A trend in improved survival postprotocol occurred in all PD infants (73% versus 65%), all LAP (75% versus 70%), and for initial PD and subsequent LAP (82% versus 67%). Conclusions: Utilization of a surgical protocol in sNEC/SIP is associated with improved success of PD as definitive surgery and improved survival.

KW - Intestinal perforation

KW - Necrotizing enterocolitis

KW - Peritoneal drainage

KW - Surgical protocol

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