Surgical outcomes for necrotizing enterocolitis in Dutch infants born before 26 weeks' gestation

In infants born at < 26 weeks of gestational age (wGA) who develop necrotizing enterocolitis (NEC), medical and ethical considerations about whether surgery is the optimal treatment are complicated by a lack of group-specific outcome data. This study investigated nationwide 30-day mortality, surgical complications, and preoperative mortality risk factors in infants born at < 26 wGA who underwent surgery during the active phase of NEC.

This retrospective nationwide multicentre study included all infants born at < 26 wGA undergoing surgery for Bell's stage II/III NEC in the Netherlands between 2008 and 2022, regardless of outcome. Severe NEC was defined as Bell's stage III (confirmed by laparotomy and/or leading to death). The primary outcome was postoperative 30-day mortality. The incidence of major postoperative complications (Clavien-Madadi III-IV) was determined after excluding infants undergoing open-close procedures for massive bowel necrosis. Potential risk factors for death after surgery were assessed using multivariable logistic regression.

Of 288 infants with NEC Bell's stage ≥ II, 80 (27.8%) survived without surgery, 66 (22.9%) died before laparotomy, and 142 (49.3%) underwent laparotomy. In 142 surgically treated infants with severe NEC (57.0% male), the median gestational age was 25 + 0 (range 23 + 6 to 25 + 6) weeks + days, the median birthweight was 750 (range 485-1070) g, and the median age at surgery was 14 (range 2-66) days. Primary open-close surgery was performed in 34 of 142 infants (23.9%). In the remaining 108 infants, surgical management included stoma creation (63.0%), primary anastomosis (27.8%), or both (9.3%). Overall, the 30-day mortality rate among 142 infants was 47.2% (67 deaths). Death occurred after a primary or second-look open-close procedure in 37 infants, after multiorgan failure in 17, and from other causes in the remaining 13. After excluding 37 infants who died after open-close procedures, 30-day complications occurred in 23 (21.9%) of 105 surgically treated infants. There were 29 events in total, including reoperation for bowel perforation (5, 17%) or anastomotic leak/stenosis (5, 17%). Regression analysis identified no risk factors for 30-day mortality.

The 30-day mortality rate was 47.2% in infants born at < 26 wGA undergoing NEC surgery, most of whom died after an open-close procedure. Another 21.9% of infants experienced major complications.