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THE NEC CONUNDRUM

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THE NEC CONUNDRUM Powered By Docstoc
					THE NEC CONUNDRUM
NEC , WHAT IS IT?

• 1888 ? Possible first description of NEC
• 1943 ? Possible first NEC operation
• 1964 clinical and radiological
  characteristics of NEC officially
  described
• Today 25000 cases per annum in USA
THE FIRST OF THE
CONUNDRUMS….


WHAT ACTUALLY CAUSES IT?
• PREMS AND LBW
• INTESTINAL ISCHAEMIA & INFECTION
• BABY FACTORS
  •   PULMONARY IMMATURITY
  •   PDA
  •   LIVER IMMATURITY
  •   IMMUNOLOGICAL DEFICIENCIES
      •   COMPLEMENT SYSTEM COMPONENTS
      •   IMMUNOGLOBULIN DEFICIENCIES
      •   POLYMORPHONUCLEAR LEUKOCYTES
      •   T-CELL AND CYTOKINE PRODUCTION LIMITED
EXOGENOUS FACTORS
 •   BIRTH ASPHYXIA
 •   UMBILICAL ARTERY CANNULATION
 •   EXCHANGE TRANSFUSIONS
 •   FEEDS: FORMULA AND BREAST MILK

 Changing trends in NEC. JL Grosfeld. Ann Surg Vol 214 No 3 Sept 1991
SO YOU WOULD THINK THIS IS
SOMETHING PREVENTABLE…
•    Prophylactic antibiotics in prems and LBW
•    Prophylactic IgA and IgG
•    Rapid vs. slow rate of advancement feeds
•    Arginine
1. Cochrane Library, Neonatal Review Group
2. The Fear Of NEC versus achieving optimal growth in preterm infants-an opinion. O Flidel-Rimon et al. Acta
     Paediatrica 2006:95;1341-44


What’s new?
• Probiotics
Probiotics for prevention of NEC in preterm neonates with VLBW: a systematic review of RCT’s. G Deshpande
     et al. Lancet 2007;369:1614-20.
How do we diagnose it?
•   Abdominal distension 100%
•   Bilious vomiting 75%
•   Guaiac positive stools 60%
•   Diarrhoea 20%
    •   Lethargy
    •   Temperature instability
    •   Apnoea
    •   Shock
STAGING

BELL CRITERIA 1978, MODIFIED IN
 1986 BY WALSH.

• STAGE I:     suspected NEC
• STAGE II:    definite NEC
• STAGE III:   advanced NEC
MANAGEMENT


• Stage I & II usually medically, non-
  operatively

• Stage III often surgically. Usually
  directed at complications of NEC
INDICATIONS FOR SURGERY


ABSOLUTE: free intraperitoneal air

RELATIVE:    portal vein air
             failed medical
                   management
CONUNDRUMS CONTINUE

Radiological signs have a high specificity,
 but low sensitivity.

NEC: surgical decision making. AL Tam. JPS Dec 3 2002




WHAT’S NEW?
ABDOMINAL ULTRASOUND
• Intramural air
• Portal venous air
• Free intraperitoneal air
   • Intra-abdominal fluid
   • Bowel wall thickness
   • Bowel wall perfusion
   1.Necrotizing Enterocolitis: Review of State-of-the-Art Imaging Findings with Pathologic
       Correlation. M Epelman et al. Radiographics 2007:27: 287-305.
   2. Correlation of sonographic findings and outcome in necrotizing enterocolitis. S Cicero.
       Paediatric Radiology, Volume 37, Number 3, March 2007 , pg. 274-282(9)
SURGICAL OPTIONS


• Peritoneal Drainage
• Laparotomy
       •   Resection and anastomosis
       •   Resection and stoma
       •   Multiple resections with clip and drop back
       •   Patch, drain and wait
       •   Exploratory laparotomy and closure
PERITONEAL DRAINAGE
Introduced in the late 1970’s, specifically for VLBW babies, prior to
    laparotomy.

Trend for peritoneal drainage to become primary surgical procedure.
Dimmitt 2001: salvage laparotomy did not appear beneficial.
Demestre 2002: prospective study of peritoneal drainage, 86% improved,
   64% survived without need of laparotomy.
Blakely 2005: prospective cohort study of NEC III showed no difference in
   survival rate between drainage and laparotomy.
Moss 2006: The type of operation performed for perforated necrotizing
   enterocolitis does not influence survival or other clinically important
   early outcomes in preterm infants.
Blakely 2006: results favored laparotomy over peritoneal drainage
Cochrane review currently under way
CONCLUSION

• Etiology – not fully defined
• Prevention – no definitive strategy
• Management
  • Diagnosis - clinical
  • Type of intervention – medical vs surgical

				
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