Long-term outcome by sdsdfqw21


									 Long-term outcome
  in surgically-managed
necrotizing enterocolitis
    in a developing country-

     A high morbidity

     Arnold M, Moore SW, Sidler D, Kirsten GF
     Tygerberg Academic Hospital, Cape Town
       Introduction: NEC
5% premature neonates
Surgery:      30 - 50%
Mortality:    10%      50%
Multiple studies : ↓ longterm outcome
  neurological, cognitive, visual & psychomotor
Bell’s stage III disease (surgical treatment):
  ↑ risk neurodevelopmental impairment
128 neonates treated surgically for NEC
Tygerberg Academic Hospital 1992 - 1995
    119 -mortality & surgical morbidity data available
    108 -longterm follow-up & neurodevelopmental
    records available
Retrospective review of data from:
    Paediatric surgery departmental records
    hospital administrative database
    patient files
    High Risk Clinic records
    Gestation, birth weight, % VLBW & ELBW
o   Early (30 day post-operative)
o   Late (overall)
o   Surgical problems:
       Strictures, wound dehiscence, intra-abdominal abscesses/
       anastomotic breakdown, adhesive bowel obstruction, small
       bowel fistulae, stitch granulomas
o   Medical:
       Neurological, neurodevelopmental, infectious, cardiac,
       bronchopulmonary dysplasia, non-surgical gastrointestinal,
       visual & auditory
o   Good outcome: incidence
Mean gestational age
   32 weeks (22-40)
Mean birth weight
   1466g (655-3198)
VLBW (<1500g)
ELBW (<1000g)
          Early Mortality
<30 days post-
                             Causes of early mortality
operatively                                  extreme prematurity
                         sepsis with

37/119 died            cardiac problem
                           5% (n=2)
                                            (refused ICU) 3% (n=1)

  31% mortality
  69% early survival
                                                   49% (n=18)
                              sepsis with

VLBW and ELBW:                multi-organ

  71% early survival           43% (n=16)

  both subsets
                        Total = 37
              Late deaths
                                Causes of late mortality
  19 in1styear
  Death at 10 weeks - 36
  months age
                           32% n=7
50% overall survival                 unknown                         n=9

VLBW subset
  50% overall survival            intra-
                                ventricular      short
ELBW subset                    haemorrhage
  43% overall survival      5% n=1             syndrome

                                              23% n=5              Total = 22
   NEC Post-operative surgical morbidity

       7% stitch         4% Post-operative
    granuloma (n=8)       strictures (n=5)
                                 4% Incisional
                                 hernias (n=5)

                                       5% adhesive
                                     bowel obstruction
    13%                                    (n=6)
short bowel
                                     6% re-laparotomy
                                      for anastomotic
                                        leak or intra-
               4%           6%           abdominal
          small bowel     w ound       abscess (n=6)
            fistulae    dehiscence
              (n=5)        (n=7)             TOTAL= 57/ 119 patients
          Surgical morbidity
Surgery type
5   - peritoneal drains only
114 - laparotomy
[13 - resection with primary anastomosis]

Strictures (11/119 = 9%)
   6 - primary indication surgery after conservative management
   1 - early presentation at 2 weeks after surgery
   3 - identified & resected at colostomy closure
   1 - late presentation after 2 years 9 months

Adhesive bowel obstruction
   presentation 2 weeks - 10 years post-operatively
Long-term outcome of survivors
60/119 survived longterm (50%)

  19 (16%) lost to follow-up
    6 inadequate data to trace (wrong hospital no, name
    changed etc.)
    5 transferred to secondary hospitals for further management

  41 (68%) followed up at Tygerberg Hospital
    30 followed up >2 years age
        Average follow-up 39 months [4 - 124 months]

  GOOD OUTCOME in 23/60 (56%):
    discharged from follow-up care at various clinics
    (neurodevelopmental, neurological, GIT etc.)
                       Longterm morbidity in 41 survivors
                          of surgically managed NEC

             Foetal Alchol syndrome (5%)      2

                  Visual impairment (10%)         4

                Auditory impairment (12%)             5

                    Cardiac disease (15%)                 6

       Bronchopulmonary dysplasia (15%)                   6

          Severe neurological deficit (20%)                   8

          Gastro-intestinal problems (39%)                        16

                Recurrent infections (39%)                        16

Significant neurodevelopmental delay (49%)                             20
    Long-term outcome cont.
Visual impairment includes:
   Strabism, myopia
Auditory deficit includes:
   Sensory & conductive deafness, with varying degrees of
   associated speech development delay
GIT problems include:
   Constipation, encopresis, GERD, subacute bowel obstruction
   resolving with non-surgical management
Neurodevelopmental outcome
   Improvements by 2 years of age seen in 4 patients
Cardiac disease
   3 PDA’s requiring banding
   1 severe mitral valve prolapse requirng surgery
     Systemic review of 821 VLBW children
     with NEC in developed world*:

          2.3x increased odds ratio neurodevelopmental
          impairment in Bell’s stage III NEC

          45% incidence neurodevelopmental
          impairment in NEC overall
Rees CM , Pierro A, Eaton S. Neurodevelopmental outcomes of neonates with medically and surgically treated
               enterocolitis.                                              92(3):F193-
   necrotizing enterocolitis. Arch Dis Child Fetal Neoanatal Ed. 2007 May; 92(3):F193-8.
 NEC increases risk of:
Prolonged          Periventricular
intubation         leukomalacia
Sepsis             Chronic lung
Prolonged          disease
hospitalization    PDA requiring
Impaired           treatment
neurodevelopment   Cognitive
Psychomotor        impairment
impairment         Visual impairment
                   Cerebral palsy
      Surgical morbidity
Stricture, wound dehiscence & intra-
abdominal abscesses:
 comparable rates to other studies

↑ incidence short bowel syndrome
 associated high mortality and morbidity
          Limitations of study
Poor follow-up rates of survivors
  But similar to other retrospective studies
  (68% versus 72 to 78%)
  Limited period follow-up for some
Lack SA cohort/ ↑ spectrum birth weights
No specific measure neurodevelopment
   e.g. Griffiths Developmental Scale; Bayley scores (PDI, MDI)
     Clinical assessment (milestones + gross neurology)
      may miss children at risk
50% overall survival
despite good (69%) initial survival
in surgically-managed NEC

High long-term morbidity in survivors

50% survivors: good longterm
Advise parents
  High risk long-term morbidity
  Need regular, long-term follow-up

Clinician awareness:
  ↑ risk problems
    neurodevelopmental, infectious, gastro-intestinal,
  Early detection, longterm follow-up & support

Allocate resources
1.                                                                                                                     necrotizing
      Rees CM , Pierro A, Eaton S. Neurodevelopmental outcomes of neonates with medically and surgically treated necrotizing
      enterocolitis.                                                 92(3):F193-
      enterocolitis. Arch Dis Child Fetal Neoanatal Ed. 2007 May; 92(3):F193-8.
2.    Salhab WA, Perlman JM, Silver L, Sue Broyles R. Necrotizing enterocolitis and neurodevelopmental outcome in extremely low birth
                                  Perinatol. 2004;24(9):534-
      weight infants <1000g. J Perinatol. 2004;24(9):534-40.
3.                                Al-
      Souraisham AS, Amin HJ, Al-Hindi MY, Singhal N, Sauve RS. Does necrotising enterocolitis impact the neurodevelopmental and
      growth outcomes in preterm infants with birthweight < or =1250g? J Paediatr Child Health. 2006;42(9):499-504.
4.    Schulzke SM, Deshpande GC, Patole SK. Neurodevelopmental outcomes of very low birth weight infants with necrotizing
      enterocolitis:                                                                                 161(^):583-
      enterocolitis: a systemic review of observational studies. Arch Pediatr Adolesc Med. 2007 Jun; 161(^):583-90
5.                                                                enterocolitis:                                         Pediatrics.
      Walsh MC, Kliegman RM, Hack M. Severity of necrotizing enterocolitis: influence on outcome at 2 years of age. Pediatrics.
6.    Tobiansky R, Lui K, Roberts S, Veddovi M. Neurodevelopmental outcome in very low birthweight infants with necrotizing
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7.    Sonntag J, Grimmer I, Scholz T, Metze B, Wit J, Obladen M. Growth and neurodevelopmental outcome of very low birthweight
                                enterocolitis.     Paediatr.              528-
      infants with necrotizing enterocolitis. Acta Paediatr. 2000;89(5): 528-32.
8.                                                                                                                       NICHD
      Hintz SR, Kendrick DE, Stoll BJ, Vohr BR, Fanaroff AA, Donovan EF, Poole WK, Blakely ML, Wright L, Higgins R; NICHD Neonatal
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      Pediatrics. 2005;115(3):696-
      Pediatrics. 2005;115(3):696-703
9.                    O’
      Adesanya OA, O’Shea TM, Turner CS, Amoroso RM, Morgan TM, Aschner JL.Intestinal perforation in very low birth weight infants:
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10.                                                                                     Mid-     long-
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11.                                                                   weight
      Blakely et al. Postoperative outcomes of extremely low birth weight infants with necrotizing enterocolitis or isolated intestinal
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      perforation: a prospective cohort study by the NICHD Neonatal Research Network. Ann Surg. 2005;241(6):984-9
12.   Stoll et al. Neurodevelopmental and growth impairment among extremely low birth weight infants with neonatal infection. JAMA
13.                                                                                                                           laparotomy.
      Chacko J, Ford WD, Haslam R. Growth and neurodevelopmental outcome in extremely low birth weight infants after laparotomy.
      Pediatr Surg Int 1999;15(7):496-9

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