The role of laparotomy for intestinal perforation in very low birth weight infants

The management of intestinal perforation in very low birth weight (VLBW) infants (less than 1500 g) is controversial. Current practice favors peritoneal drainage (PD) with or without a delayed laparotomy over primary laparotomy (PL). We compared the outcomes of PD +/- delayed laparotomy vs PL in VLBW infants using the Score for Neonatal Acute Physiology with Perinatal Extension (SNAPPE-II) as a validated predictor of mortality.

A retrospective analysis (1998-2003) of VLBW infants with intestinal perforation at 2 pediatric centers was undertaken. Data retrieval included neonatal demographics and parameters for SNAPPE-II calculation. The primary end point was 30-day mortality. Other outcome measures included in-hospital mortality, days fasting, days to extubation, and length of stay. Statistical analysis was performed with either Student's t test or chi2 analysis. Subgroup and multivariate analyses were also performed. P values < .05 were considered significant.

Fifty-two neonates (25 PD, 27 PL) were reviewed. Overall, 10 (19.2%) infants died. Observed 30-day mortality rates in PD and PL groups were 32% and 7.4% (P = .028), respectively. Average SNAPPE-II scores for PD (42.5 +/- 20.8) and PL (25.1 +/- 14.6) groups yielded predicted mortality rates of 15.7% and 4.9% (P = .001), respectively. PD group 30-day mortality far exceeded the rate predicted by the SNAPPE-II score. Days fasting (13.7 vs 20.4; P = .0001), days to extubation (26.7 vs 51.5; P = .014), and length of stay (56.1 vs 83.6; P = .031) all favored the PL group despite incorporating SNAPPE-II score as a covariate into the multivariate analysis. Of the 25 patients receiving drainage, 9 underwent PD alone (SNAPPE-II = 46.6 +/- 27.9), whereas 16 patients underwent delayed laparotomy (SNAPPE-II = 37.8 +/- 17.6). The PD-only group had a greatly elevated mortality rate (77.8% vs 15.7% predicted), whereas the delayed laparotomy group had a reduced mortality rate (6.3% vs 9.3% predicted).

Our data suggest that laparotomy, either alone or after PD, provides an improved outcome in VLBW infants with intestinal perforation. PD should be used as a temporizing measure until laparotomy can be performed.