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
• Today 25000 cases per annum in USA
THE FIRST OF THE
WHAT ACTUALLY CAUSES IT?
• PREMS AND LBW
• INTESTINAL ISCHAEMIA & INFECTION
• BABY FACTORS
• PULMONARY IMMATURITY
• LIVER IMMATURITY
• IMMUNOLOGICAL DEFICIENCIES
• COMPLEMENT SYSTEM COMPONENTS
• IMMUNOGLOBULIN DEFICIENCIES
• POLYMORPHONUCLEAR LEUKOCYTES
• T-CELL AND CYTOKINE PRODUCTION LIMITED
• 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
• Prophylactic antibiotics in prems and LBW
• Prophylactic IgA and IgG
• Rapid vs. slow rate of advancement feeds
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
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%
• Temperature instability
BELL CRITERIA 1978, MODIFIED IN
1986 BY WALSH.
• STAGE I: suspected NEC
• STAGE II: definite NEC
• STAGE III: advanced NEC
• Stage I & II usually medically, non-
• Stage III often surgically. Usually
directed at complications of NEC
INDICATIONS FOR SURGERY
ABSOLUTE: free intraperitoneal air
RELATIVE: portal vein air
Radiological signs have a high specificity,
but low sensitivity.
NEC: surgical decision making. AL Tam. JPS Dec 3 2002
• 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)
• Peritoneal Drainage
• Resection and anastomosis
• Resection and stoma
• Multiple resections with clip and drop back
• Patch, drain and wait
• Exploratory laparotomy and closure
Introduced in the late 1970’s, specifically for VLBW babies, prior to
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
• Etiology – not fully defined
• Prevention – no definitive strategy
• Diagnosis - clinical
• Type of intervention – medical vs surgical