Optimal Closure Timing for Protective Jejunostomy in an Infant with Necrotizing Enterocolitis: A Case Report

BACKGROUND Necrotizing enterocolitis (NEC) is a prevalent, life-threatening gastrointestinal disease in premature neonates, characterized by intestinal inflammation, ischemia, and potential perforation. Protective measures such as ostomies of various types are a strategy to help patients during recovery from postoperative complications. Protective jejunostomy (PJ) in such cases aims to minimize intraluminal pressure and protect distal anastomoses or compromised bowel segments. However, the optimal timing for closure remains a matter of debate, between balancing bowel rest and avoiding complications associated with prolonged ostomies. CASE REPORT We report an unusual case of a 6-month-old female patient, who presented with NEC and extensive intestinal compromise. Emergency laparotomy revealed multiple areas of bowel perforation and partial ischemia without perfusion. Surgical management included selective resection of non-viable bowel segments, primary closure of smaller perforations, creation of a PJ, and a distal ileostomy. The "clip and drop" technique was not used; instead, distal bowel patency was confirmed by a second intraoperative assessment and through intestinal saline solution injection on the tenth postoperative day due to high stoma output and persistent hydroelectrolyte imbalance. Postoperatively, the patient developed 2 new ileal perforations, requiring reoperation. Following the third surgical intervention, the patient demonstrated gradual recovery without major complications, followed by elective ileostomy closure after 6 months. CONCLUSIONS This case highlights the complexity of the surgical option and timing of PJ closure in complicated NEC in a 6-month-old female patient. Early closure can mitigate complications related to the stoma but carries the risk of compromising the fragile and recovering intestine. Decision-making must be careful and individualized, balancing the risks and benefits.