Refining the Surgical Necrotizing Enterocolitis Protocol: Impact of Clinical Factors on Laparotomy Risk

No universally accepted surgical management of spontaneous intestinal perforation (SIP) and surgical necrotizing enterocolitis (NEC) exists in low birth weight premature infants. In 2014, our institution implemented a protocol stratifying infants with surgical NEC or SIP to peritoneal drain (PD) insertion or laparotomy (LAP). This study aimed to identify factors associated with conversion from PD to LAP.

We conducted a retrospective review of infants who underwent PD (CPT 49020) between June 2014 and October 2024. Per protocol, infants ≥750 g, ≥14 d old, or with pneumatosis or portal venous gas on X-ray underwent LAP. All others received PD, with standard postoperative management including antibiotics, and drain removal on day 7. Conversion from PD to LAP occurred for persistent clinical deterioration. Demographic, clinical, and treatment variables were analyzed to identify predictors of progression to LAP.

Sixty-six infants underwent primary peritoneal drainage, with protocol nonadherence in 38% due to birth weight >750 g (21%) or postnatal age >14 d (17%). Blood transfusion within 7 d of intervention was more common among infants who progressed to exploratory LAP compared with those managed without LAP (96.4% versus 57.1%, P = 0.003). In contrast, preoperative NeoProfen exposure was less frequent among infants requiring LAP than among those who did not progress to LAP (10.7% versus 42.9%, P = 0.017).

In this single institutional review of patients with surgical NEC or SIP who underwent protocol driven intervention, blood transfusion within 7 d of diagnosis was associated with progression from PD to LAP, while NeoProfen administration was negatively associated. These modifiable factors may inform future refinements of protocol-based management for surgical NEC and SIP.