There is an association between disease location and gestational age at birth in newborns submitted to surgery due to necrotizing enterocolitis / Existe associação entre a localização da doença e a idade gestacional ao nascimento de recém-nascidos operados por enterocolite necrosante

Abstract Objectives To evaluate if there are differences regarding disease location and mortality of necrotizing enterocolitis, according to the gestational age at birth, in newborns submitted to surgery due to enterocolite. Methods A historical cohort study of 198 newborns submitted to surgery due to necrotizing enterecolitis in a tertiary hospital, from November 1991 to December 2012. The newborns were divided into different categories according to gestational age (<30 weeks, 30-33 weeks and 6 days, 34-36 weeks and 6 days, and ≥37 weeks), and were followed for 60 days after surgery. The inclusion criterion was the presence of histological findings of necrotizing enterocolitis in the pathology. Patients with single intestinal perforation were excluded. Results The jejunum was the most commonly affected site in extremely premature infants (p = 0.01), whereas the ileum was the most commonly affected site in premature infants (p = 0.002), and the colon in infants born at term (p < 0.001). With the increasing gestational age, it was observed that intestinal involvement decreased for the ileum and the jejunum (decreasing from 45% to 0% and from 5% to 0%, respectively), with a progressive increase in colon involvement (0% to 84%). Total mortality rate was 45.5%, and no statistical difference was observed in the mortality at different gestational ages (p = 0.287). Conclusions In newborns submitted to surgery due to necrotizing enterocolitis, the disease in extremely preterm infants was more common in the jejunum, whereas in preterm infants, the most affected site was the ileum, and in newborns born close to term, it was the colon. No difference in mortality was observed according to the gestational age at birth.

Resumo Objetivos Avaliar se há diferença de localização e de mortalidade da enterocolite necrosante de acordo com a idade gestacional ao nascimento, em neonatos operados por enterocolite. Métodos Coorte histórica de 198 neonatos operados por enterocolite necrosante em hospital terciário, de novembro de 1991 a dezembro de 2012. Os recém-nascidos operados foram divididos em diferentes categorias de acordo com a idade gestacional (< 30 semanas, 30 a 33 semanas e seis dias, 34 a 36 semanas e seis dias e ≥ 37 semanas) e foram seguidos por 60 dias depois da cirurgia. O critério de inclusão foi a presença de achados histológicos de enterocolite necrosante no anatomopatológico e o de exclusão foi a presença de perfuração intestinal única. Resultados O jejuno foi mais acometido pela ECN nos prematuros extremos (p = 0,01); o íleo mais afetado nos recém-nascidos prematuros (p = 0,002) e o cólon nos recém-nascidos a termo ou próximos ao termo (p < 0,001). Com o aumento da idade gestacional, observam-se redução do acometimento do jejuno e do íleo (regrediu de 45% para 0% e de 5% para 0%, respectivamente) e aumento progressivo do acometimento do cólon (0% para 84%). A mortalidade total das crianças operadas por ECN foi de 45,5%; não existiu diferença estatística na mortalidade nas diferentes idades gestacionais (p = 0,287). Conclusões Em recém-nascidos operados por enterocolite necrosante, a doença no jejuno foi mais comum no prematuro extremo, no íleo no prematuro, e a doença no cólon nos recém-nascidos próximos ao termo. Não foi observada diferença de mortalidade de acordo com a idade gestacional ao nascimento.

Anastomosis primaria en enterocolitis necrotizante / Primary anastomosis in necrotizing enterocolitis

Introduction: Necrotizing Enterocolitis (NE) is the most frequent gastrointestinal emergency among newborns (NB). Thirty percent of them require surgical treatment, with resection of the damaged intestinal segment and stoma formation. In some cases, primary resection and anastomosis can be considered. Objective: To review the use of primary anastomosis on NE in 2 pediatric centers, one public hospital and one private clinic. Patients and Method: A retrospective, descriptive study of all NB with NE managed with primary anastomosis at Hospital Exequiel González Cortés y Clínica Las Condes between December 2004 and december 2009. The population was divided into Group A: Unifocal, and Group B: Multifocal intestinal involvement. The following variables were evaluated and compared: gestational age, weight, use of peritoneal drains, characteristics of the resected segment, number of anastomoses, requirement of parenteral nutrition, postoperatory complications. Results: Sixty NB were surgically repaired with primary anastomosis. 12 percent presented birth weight <1.000grams, 22 percent between 1000-1500 grams. In 18 patients 2 anastomoses were performed in different intestinal segments. Postoperatory complications included wound infection in 3 cases and dehiscence of the anastomosis in 1 case. 7 percent evolved with short loop syndrome. Mortality was 11,6 percent, secondary to sepsis. Conclusions: In this experience, Primary Anastomosis in NE appears to be a safe option, with low morbimortality despite the age, weight, IP contamination or extension of the disease.

Introducción: Enterocolitis Necrotizante (ECN) es la emergencia gastrointestinal más común del recién nacido (RN), 30 por ciento requiere tratamiento quirúrgico, con resección del segmento intestinal dañado, realizando luego una ostomía en la mayoría. En recientes casos la resección intestinal y anastomosis primaria han sido reportados en forma exitosa. Objetivo: Evaluar la experiencia del manejo con anastomosis primaria en ECN en 2 centros pediátricos, un Hospital público y una Clínica privada. Pacientes y Método: Estudio descriptivo retrospectivo. Se incluyó a RN del Hospital Exequiel González Cortés y Clínica Las Condes con ECN manejados con anastomosis primaria, entre diciembre de 2004 y diciembre de 2009. Se dividieron en Grupo A: Unifocal; Grupo B: Compromiso intestinal multifocal. Se comparó entre ambos grupos: edad gestacional, peso, utilización de drenajes peritoneales, características del segmento resecado, número de anastomosis, requerimientos de nutrición parenteral, complicaciones postoperatorias. Resultados: Se sometió a cirugía con anastomosis primaria a 60 recién nacidos. El peso de nacimiento fue < 1 000 g en el 12 por ciento, 1 000-1 500 g el 22 por ciento, y el resto >1 500 g. En 18 pacientes del grupo B se realizaron 2 anastomosis en segmentos intestinales diferentes. Las complicaciones postoperatorias fueron infección de herida operatoria (n:3) y dehiscencia de anastomosis (n:1). Un 7 por ciento evolucionó con síndrome de intestino corto. La mortalidad fue 11,6 por ciento, en todos los casos secundaria a sepsis. Conclusiones: En esta experiencia la Anastomosis Primaria en ECN aparece como una opción segura, con baja morbimortalidad independiente de la edad, peso, contaminación intraperitoneal o extensión de la enfermedad.

Intervenção cirúrgica e fatores associados em neonatos com enterocolite necrosante / Surgical intervention and associated factors in newborns with necrotizing enterocolitis

Enterocolite Necrosante (EN) é uma síndrome que afeta o trato gastrointestinal de recém-nascidos. A etiologia é desconhecida, no entanto, são conhecidos fatores associados ao desenvolvimento da doença, como prematuridade, peso ao nascer, asfixia/apneia, sepse, choque, ventilação mecânica, comorbidades concomitantes, uso de indometacina e surfactante. Sabe-se também que aqueles pacientes que foram submetidos a intervenção cirúrgica são os que apresentam uma doença mais avançada, logo, a cirurgia se torna fator de mau prognóstico. Assim, o conhecimento dos dados relacionados à intervenção cirúrgica se torna necessário para que se descubra mais fatores de mau prognóstico, para que seja possível intervir e tratar mais precocemente cada caso. Métodos: Estudo transversal, com revisão dos prontuários de amostra consecutiva de 50 pacientes com EN de dois hospitais. Resultados: Dos 50 pacientes, 19 foram a cirurgia. Desses, 9 (47,4%) eram do sexo feminino e 10 (52,6%) do masculino. A maioria era prematuro (84,2%) e pequena para a idade gestacional (52,6%). Das comorbidades, 16(84,2%) sofreram asfixia, 16 (84,2%) foram submetidos a ventilação mecânica, 18 (94,7%) apresentaram sepse, 14 (73,7%) apresentaram choque, 9 (47,4%) apresentaram apneia e 10 (52,6%) evoluíram para óbito. A indometacina foi usada em 2 (10,5%), o surfactante em 10 (52,6) e 14 (73,7%) tinham doença associada. Conclusão: O estudo reafirmou a relação entre cirurgia e um pior prognóstico. A presença de choque esteve associada à maior necessidade de intervenção cirúrgica. Os outros dados necessitam ser melhor avaliados quanto à significância prognóstica.

Necrotizing enterocolitis (NE) is a syndrome that affects the gastrointestinal tract of newborns. Its etiology is unknown. Risk factors associated with the development of the disease are prematurity, birth weight, asphyxia/apnea, sepsis, shock, mechanical ventilation, co-morbidities, and use of indomethacin and surfactant. It is also known that patients who underwent surgical intervention are those with more advanced disease, so surgery becomes a bad prognostic factor. Thus, knowledge of the data related to surgical intervention becomes necessary in order to discover prognostic factors, so that we can intervene and treat each case as early as possible. Methods: Cross-sectional study with the review of medical records of a consecutive sample of 50 patients with NE of two hospitals. Results: Of the 50 patients, 19 underwent surgery. Of these, 9 (47.4%) were female and 10 (52.6%) were male. Most were premature (84.2%) and small for gestational age (52.6%). With regard to co-morbidities, 16 (84.2%) had asphyxia, 16 (84.2%) underwent mechanical ventilation, 18 (94.7%) had sepsis, 14 (73.7%) had shock, 9 (47.4%) had apnea, and 10 (52.6%) died. Indomethacin was used in two (10.5%) and surfactant in 10 (52.6). Fourteen (73.7%) had combined diseases. Conclusion: The study confirmed the relationship between surgery and a worse prognosis. Shock was associated with an increased need for surgical intervention. The other data need to be better evaluated for prognostic significance.

Enterocolitis necrosante en un niño prematuro hijo de padres VIH+ / Necrotizing enterocolitis observed in a premature newborn with HIV+parents

En Cuba, entre el 1ero. de enero de 1986 y el 30 de abril de 2007 nacieron 280 niños hijos de madres VIH+. De ellos solo 22 (7,8 por ciento) nacieron con edad gestacional menor de 37 semanas y solo uno (4,5 por ciento) presentó una enterocolitis necrosante. En el presente artículo se describe un episodio de esta enfermedad en un niño prematuro hijo de padres VIH+, supuestamente asociado al uso profiláctico de zidovudina en las madres seropositivas por la posibilidad de producir toxicidad mitocondrial en el feto. Con el tratamiento quirúrgico empleado, la evolución del niño fue favorable. El caso presentado constituye una evidencia que el personal médico debe tener en cuenta para el cuidado y diagnóstico de estos pacientes.

In Cuba, from January 1, 1986 to April 30, 2007 were born 280 children from HIV+ mothers. Only 22 (7, 8 percent) had a gestational age under 37 weeks and only one (4, 5 percent) presented with a necrotizing enterocolitis. In present paper we describe an episode of this disease in a premature baby son of HIV+ parents, supposedly associated with prophylactic use of Zidovudine in seropositive mothers by possibility to produce mitochondria toxicity in fetus. This case is an evidence that family physician must to assess for care and diagnosis of these patients.

O tratamento cirúrgico da enterite necrosante / The necrotizing enterocolitis surgical treatment

Objetivo: avaliar a necessidade e tipo de intervenção cirúrgica no tratamento da enterite necrosante. Fontes pesquisadas: foram selecionados artigos originais e metanálises das bases de dados MEDLINE, SCIELO, LILACS E COCHRANE database reviews, com as palavras-chave: tratamento cirúrgico, enterite necrosante, complicações...

Objective: to analyze the surgical indication and different possibilities regarding the surgical treatment for necrotizing enterocolitis. Data source: original articles and meta-analyses from MEDLINE, SCIELO, LILACS AND COCHRANE database reviews were selected, using the keywords: surgical treatment, necrotizing enterocolitis, complications...

Enterocolite necrosante em serviço com banco de leite humano / Necrotizing enterocolitis in service with human milk banking

Objetivo: avaliar a frequência e a evolução dos casos de enterocolite necrosante (ECN) em uma unidade neonatal que possui banco de leite humano. Métodos: estudo retrospectivo que avaliou os recém-nascidos com ECN no período entre janeiro de 2000...

Objective: to evaluate the frequency and evolution of necrotizing enterocolitis cases (NEC) in a newborn unit supported by a human milk banking. Methods: a retrospective study evaluated the newborns affected by ECN admitted to a university...

Tratamento cirúrgico da enterocolite necrosante: experiência de 5 anos / Surgical treatment of necrotizing enterocolitis: a five-years experience

A enterocolite necrosante é a doença gastrointestinal adquirida mais frequente do período neonatal, especialmente em recém-nascidos prematuros. Mesmo em centros especializados a taxa de mortalidade é alta e varia de 20 por cento a 40 por cento. OBJETIVO - descrever a experiência do serviço de Cirurgia do Hospital Universitário Evangélico de Curitiba no tratamento da enterocolite necrotizante / Necrotizing enterocolitis is a gastrointestinal pathology more frequently acquired during neonatal period, mainly in premature newborns. Even in especialized center, the mortality rate varies from 20 per cent to 40 per cent. Aim - describe the experience of the service on the necrotizing enterocolitis treatment...

Leuconostoc Bacteremia in a child with short - gut syndrome

In the last decade Leuconostoc species have been reported with increasing frequency as human pathogens, causing bacteremia, meningitis and peritonitis. We report here a child with short-bowel syndrome who developed bacteremia following multiple surgeries for necrotizing enterocolitis. Leuconostoc species was isolated from the blood cultures. The child was successfully treated with ampicillin and gentamycin. He however remained total parenteral nutrition dependent due to his multiple abnormalities. We call the attention of microbiologists and pediatricians to this emerging pathogen, which is intrinsically resistant to vancomycin and can be misidentified in the microbiology laboratory as Viridans streptococci or Enterococci. Increased awareness by clinicians of this organism is called for, if it is to be recognized and appropriately treated

Concomitant involvement of the small intestine and the distal esophagus in an infant with massive necrotizing enterocolitis

A enterite necrosante é uma doença típica do período neo-natal que pode acometer o intestino delgado, colo e/ou estômago. Até o presente, a necrose maciça do intestino delgado com o acometimento concomitante do esôfago nunca foi relatada. É apresentado o caso de um lactente com 6 meses de idade com enterite necrosante e acometimento de todo intestino delgado, ceco e terço inferior do esôfago. Após setenta dias de tratamento, o trânsito intestinal foi re-estabelecido por anastomose entre o primeiro centímetro do jejuno e o colo ascendente. Finalmente, o trânsito esofagiano foi refeito pela transposição gástrica total e anastomose esôfago-gástrica cervical. O paciente foi mantido em nutrição parenteral durante 19 meses e ao fim deste período desenvolveu falência hepática aguda, tendo sido submetido a transplante duplo de fígado e intestino delgado. Dois meses após, faleceu em decorrência de complicações neurológicas, provavelmente relacionadas à infecção ou ao tratamento imunossupressor.

Outcome in definite and advanced neonatal necrotizing enterocolitis

To evaluate and compare the outcome of newborns with definite [Bells stage II] and advanced [Bells stage III] necrotizing enterocolitis [NEC] and to assess the role of primary peritoneal drainage. This study was conducted in the Department of Pediatric Surgery, Maternity and Children's Hospital, Dammam, Kingdom of Saudi Arabia. Medical records of all cases diagnosed with NEC or suspected NEC between May 1993 and June 2003 were reviewed retrospectively. A total of 67 cases meeting the criteria for Modified Bells stage II and III disease were selected for the study. Twenty-five [37%] cases were treated medically and 42 [63%] needed surgical intervention, namely primary peritoneal drainage [PPD] with or without salvage laparotomy [SL] [n=25], or primary laparotomy [PL] [n=17]. Data regarding patient demographics, neonatal history, clinical presentation, laboratory and radiological features, operative findings, complications and mortality were collected and compared between the medical and surgical group and between the 2 surgical groups. The overall mortality was 37%, 8% in the medical group versus 55% in the surgically treated group. The PPD group had the highest mortality [72%] versus 29% in the PL group. In the PPD group, 14 [56%] needed SL and only 3 [12%] survived without laparotomy. The mean gestational age and birthweight were 32.1 weeks and 1713 gms in the PPD group as compared to 35.7 weeks and 2484 gms in the PL group. The PPD group were more critically sick than the PL group. The average length of time from onset to laparotomy was longer, 6.6 days in the PPD group versus 2.2 days in the PL group. In the 31 cases undergoing laparotomy, the terminal ileum was involved most frequently followed by the cecum and right colon. The PPD + SL group had a higher mortality in isolated, multifocal, and pan involvement of bowel when compared to the PL group. All babies with only isolated involvement in the PL group survived. The surgical mortality of NEC in our hospital is very high due to advanced disease. The PPD group in our study fared badly, as it comprised a poor risk group with ongoing sepsis, with the bias being in favor of PPD as these babies were unfit to undergo major surgery. Early SL after PPD in those showing signs of persistent disease may improve the outcome in this group

Enterocolite necrosante: experiência clínico-cirúrgica de 10 anos na Unidade Neonatal da Universidade Federal de Säo Paulo, Escola Paulista de Medicina (Unifesp-EPM) / Necrotizing enterocolitis: clinical and surgical experiency of ten year at Säo Paulo Hospital - Federal University of Säo Paulo

A enterocolite necrosante (ECN) é a afecçäo gastrointestinal adquirida mais frequentemente no período neonatal, acometendo preferencialmente os neonatos prematuros. O objetivo deste estudo reetrospectivo é analisar a evoluçäo clínico-cirúrgica dos recém-nascidos (RNs) que apresentaram ECN na Unidade Neonatal do Hospital Säo Paulo/Escola Paulista de Medicina, entre janeiro de 1986 e dezembro de 1996. Nesse período houve 14.260 nascidos vivos, dos quais 62 RNs tiveram diagnóstico de ECN (0,43 por cento), sendo 52(por cento) (32/62) do sexo feminino e 48 (por cento) (30/62) do masculino. A idade gestacional média foi de 33,4 semanas e a média do peso de nascimento, de 1.622 gramas. Desse total 24 (por cento) dos pacientes (15/62) eram portadores de malformaçöes cardíacas e 27 (por cento) (16/62) apresentaram asfixia perinatal ao nascimento. O tratamento foi exclusivamente clínico em 72,5 (por cento) dos casos (45/62). Baseados nesses dados, pretendemos estabelecer um protocolo prospectivo de intervençäo diagnóstica e terapêutica com o objetivo de obter maior sobrevidaa e menor morbidade dessa afecçäo no período neonatal, além de estimular a aplicaçäo de medidas preventivas, como o uso do leite humano

Necrotising enterocolitis: a management protocol for developing countries

28 cases of necrotising enterocolitis (NEC) comprising 11 term and 17 preterm patients were diagnosed between January 1990 and December 1995 at the University Hospital of the West Indies (UHWI). Treatment was in accordance with a management protocol which emphasised aggressive screening of potential cases, early laparotomy for bowel perforation and primary anastomosis after small bowel resection. There were three deaths among the 13 cases of bowel perforation. Centres in developing countries can achieve rates of survival comparable to those in the developed world in babies with NEC weighing over 1000 grams by adopting the UHWI management protocol.

Enterocolitis necrotizante neonatal NEC: tratamiento quirúrgico / Neonatal necrotizing enterocolitis: surgical treatment

Desde diciembre de 1984 a julio de 1987 se estudiaron 18 pacientes con enterocolitis necrotizante neonatal (NEC), aplicándose el protocolo de Vásquez-Estévez para determinar el momento de la intervención quirúrgica, considerando parámetros clínicos y de laboratorio que se ponderan en escala de 0-3 puntos con un total de 30 puntos. Todos los pacientes con más de 15 puntos fueron operados, lo que correspondió a 30% de nuestra serie. Los pacientes bajo 15 puntos no requirieron operación. La necrosis intestinal fue el hallazgo constante en el grupo operado, encontrándose perforación intestinal establecida en solo 2 de ellos. No hubo fallecimientos en el grupo de manejo médico y los quirúrgicos presentaron un 16% de mortalidad neonatal