Exploratory Laparoscopy for Necrotizing Enterocolitis: Cross Section Study

Conclusion

Regarding our results, we concluded that a statistically insignificant distinction has been observed among the investigated groups as regards Bell-Stages, surgical procedure and regarding outcome.

Introduction

Necrotizing enterocolitis is a serious gastroint-estinal emergency affecting kids globally, associated with significant morbidity and mortality. Exploratory laparotomy as a surgical treatment in kids. It predominantly impacts preterm newborns and those with very low birth weight (VLBW; birth weight less than 1500 grams) ¹.

The Bell staging criteria describe the severity of necrotizing enterocolitis according to clinical, laboratory, and radiographic signs. Cases may be categorized as stage one (suspected), stage two (confirmed), or stage three (advanced) illness. Additionally, operation is considered for kids with Bell’s stage two to three necrotizing enterocolitis, encompassing primary peritoneal drainage (PPD) and/or exploratory laparotomy with bowel resection, despite the absence of consensus regarding the optimal management ^2-3.

Prior clinical trials have established that exploratory laparotomy is utilized to manage intra-abdominal sepsis, remove necrotic bowel, and conserve maximal bowel length. Resection of bowel necrosis is succeeded by either primary anastomosis or enterostomy. Surgical necrotizing enterocolitis is associated with increased morbidity and prolonged hospital stays compared to non-surgical treatment ^4-5.

NEC is an acute condition in neonates and continues to be a primary etiology of neonatal morbidity and mortality. In the early stages, treatment predominantly involves utilizing antibiotics, enteral feeding cessation, and total parenteral nutrition, alongside regular repeat X-ray assessments and/or abdominal ultrasound (US) ⁶.

In certain cases, the condition worsens. despite medical treatments, necessitating operative procedures. In necrotizing enterocolitis cases requiring an operation, the mortality rate might reach fifty percent. Optimizing the timing and decision-making of operative intervention could lead to improved outcomes for cases with operative necrotizing enterocolitis ⁷.

Traditionally, plain abdominal radiography is the widely utilized imaging modality for assessing necrotizing enterocolitis; however, early stages of necrotizing enterocolitis can’t be detected by X-ray. Pathognomonic findings, such as free intraabdominal gas, represent a relatively late finding in illness progression, indicating perforation. Abdominal ultrasound has proven to be a valuable adjunct to radiography in the assessment of necrotizing enterocolitis. The identification of portal venous gas is a significant benefit of ultrasound compared to plain abdominal radiography. Moreover, ultrasound is superior to plain abdominal radiography for assessing accumu-lated intraperitoneal free fluid, and neonates are subjected to significantly lower radiation exposure ^8-9.

Initial investigations indicate that laparoscopy can be significant in assessing intestinal viability and the extent of necrotizing enterocolitis lesions, therefore assisting in the decision-making process for laparotomy necessity. It provides the possibility to aid the surgeon in diagnosing cases that might profit from a laparotomy. A recent global survey demonstrated that just eight percent of pediatric surgeons utilize laparoscopy for the diagnosis and/or management of necrotizing enterocolitis. ^10-11.

The goal of this investigation was to assess the effectiveness of exploratory laparoscopy in necrotizing enterocolitis on mid-term follow-up.

Rationale of the study

Numerous clinical trials have reported on short-term postoperative complications in children, and surgical morbidity and mortality from necrotizing enterocolitis continue to be a concern. Fortunately, there is limited data available for infants requiring surgery ¹².

Material & Methods

This was a prospective trial. conducted between April 2022 and October 2024. The study included 50 children who underwent surgical intervention for NEC, consisting of pediatric surgery combined with exploratory laparo-scopy. The cases have been divided into two groups based on their weight: Group A (35) (weight < 1000 g) and Group B (15) (weight ≥ 1000 g).

Inclusion Criteria: Neonates diagnosed with NEC (Bell’s stage 2 or 3) requiring surgical intervention and neonates with a birth weight of less than 1500 grams (very low birth weight, VLBW) or greater than or equal to 1000 grams.

Exclusion Criteria: Infants with congenital gastrointestinal anomalies and cases with severe hemodynamic instability precluding laparoscopic intervention.

Data Collection: Demographic Data: Birth weight, gestational age, sex, and Bell’s staging of NEC were recorded. Operative Data: Intraoperative parameters such as oxygen saturation, systolic and diastolic blood pressure, and duration of surgery were docum-ented. Outcome Measures: Post-operative out-comes, including survival, complications (e.g., anastomotic leakage, stoma-related issues), and length of hospital stay, were evaluated.

Surgical procedures

Laparotomy with stoma formation (Surgery) 1) involved a midline laparotomy to access the abdominal cavity, identify and resect necrotic or perforated bowel segments, and create a stoma by bringing the proximal end of the bowel to the abdominal wall for fecal diversion. This procedure was indicated in cases of severe NEC with extensive bowel necrosis or perforation, or when primary anastomosis was deemed unsafe due to poor bowel viability or hemodynamic instability. The technique included exteriorizing the bowel through a separate incision, maturing the stoma with interrupted sutures, and applying a stoma bag postoperatively. Advantages included allowing bowel rest, reducing the risk of anastomotic leakage, and facilitating monitoring of bowel viability and healing. Disadvantages included the need for a second surgery for stoma closure and potential complications such as stoma prolapse, necrosis, and skin excoriation. Laparotomy with anastomosis (Surgery 2) involved resection of necrotic bowel followed by primary anastomosis, reconnecting the healthy ends of the bowel using hand-sewn or stapled techniques. It was indicated in cases of focal or limited NEC with viable bowel margins and stable cases with adequate bowel perfusion and no signs of peritonitis. The technique included resecting the necrotic bowel, anastomosing the healthy ends, checking for leaks, and irrigating the abdominal cavity before closure. Advantages included avoiding the need for a stoma and subsequent closure surgery, shorter duration of parenteral nutrition, and faster recovery of intestinal function.

Disadvantages included a higher risk of anastomotic leakage in compromised or inflamed bowel and the need for careful patient selection to ensure bowel viability. Laparotomy for exploration only (Surgery 3) involved exploratory laparotomy to assess the extent of bowel necrosis and viability without perfor-ming definitive resection or anastomosis, often followed by a second-look procedure to reassess bowel viability. It was indicated in cases where bowel viability was uncertain due to extensive inflammation or ischemia, or in cases with peritonitis or sepsis requiring source control but not immediate resection.

The technique included exploring the abdominal cavity, assessing the extent of NEC, and, if bowel viability was questionable, leaving the abdomen open with a temporary closure device or planning a second-look laparotomy within 24–48 hours. Advantages included allowing thorough assessment of bowel viability and disease extent and reducing the risk of unnecessary resection or anasto-mosis in compromised bowel. Disadvantages included requiring a second surgical procedure, which increases the risk of complications, and prolonged hospitalization and recovery time. Laparoscopic-assisted surgery involved using laparoscopy as an adjunct to laparotomy in selected cases. A 3-mm or 5-mm trocar was inserted, and the abdominal cavity was insufflated with CO₂ to a pressure of 6–8 mmHg.

The extent of NEC lesions, bowel viability, and the presence of perforation or peritonitis were assessed laparoscopically. This approach was indicated in cases where the extent of NEC is unclear on imaging or in cases with suspected focal NEC who may benefit from minimally invasive assessment. The technique included performing laparoscopic exploration and making decisions regarding further surgical intervention, such as resection, anastomosis, or stoma formation, based on laparoscopic findings. Advantages included a minimally invasive approach with reduced postoperative pain and faster recovery, as well as providing real-time assessment of bowel viability and disease extent. Disadvantages included limitations due to the small abdominal cavity in preterm neonates and the requirement for expertise in neonatal laparoscopy. Each surgical approach had distinct indications, techniques, advantages, and disadvantages, tailored to the patient’s condition and the severity of the disease.

Postoperative Management

Postoperative management involved close monitoring of cases in the neonatal intensive care unit (NICU) for signs of sepsis, anastomotic leakage, or stoma-related compli-cations. Parenteral nutrition is initiated post-operatively, with gradual reintroduction of enteral feeds once bowel function resumes. Early detection and management of compli-cations, such as wound infection, anastomotic leakage, or stoma-related issues, are prioritized to ensure optimal recovery and outcomes.

Statistical analysis

Data will be collected and tabulated. Then SPSS 25 will be used for statistical analysis. Categorical data will be expressed as a percentage and number utilizing “chi square,” Fisher’s exact test, or “Z” test for analyzing them. Odds ratios will be computed to detect the risk factors. Continuous variables will be presented as standard deviation and mean utilizing the "Student t" test for analyzing them. Alternative appropriate tests of significance will be utilized if indicated based on the situation. The accepted level of significance in this work will be (P<0.05 will be considered significant). 

Discussion

Necrotizing enterocolitis (NEC) refers to the death of intestinal tissue. Primarily impacting premature infants or ill neonates, it happens when the intestinal wall's lining dies and the tissue falls off. Operation for Necrotizing enterocolitis is understandably related to an elevated death rate of thirty-five percent, escalating to fifty percent in very low birth weight infants (weighing less than 1500 grams), along with significant long-term morbidities, including intestinal failure and neurodevelopmental impairment ¹³.

Laparoscopy was initially documented as a diagnostic instrument for suspected necrotizing enterocolitis in 2004. The rate of death related to this method appeared low, with only fourteen percent of premature neonates experiencing a documented fatal result. While this low death rate can partially result from selection bias, the writers proposed that laparoscopy might serve as a diagnostic instrument that minimizes the delay among the start of digestive symptoms and surgical intervention ^14-15.

Additionally, laparoscopy could trigger an anti-inflammatory response via carbon dioxide (CO2) insufflation. Experimental investiga-tions indicate that carbon dioxide pneu-moperitoneum and laparoscopy reduce local and systemic inflammatory responses in various models of peritonitis or abdominal sepsis ^16-17.

Our findings showed that the mean weight of the investigated cases was 1225.26 ± 44.8 grams; 48% of cases were males, and 52% were females.

This came in concordance with Montalva et al.,¹⁰ aim was to compare post-operative result following early laparoscopy-assisted operation and classical laparotomy for Necrotizing enterocolitis, they reported that in the Laparoscopy necrotizing enterocolitis group, the median weight of the investigated cases was 1360 gram with range (1100-1868) gram. There were 23 (48%) males.

Also, Smith et al.,¹⁸ who aimed to review the present proof for the utilization of diagnostic and therapeutic laparoscopy in necrotizing enterocolitis, they reported that 44 infants with NCE (weighing 0.5–2.9 kg) were enrolled in their study.

In addition, Gfroerer et al.,¹⁹ who stated that Fifty-seven infants with NEC were enrolled in their investigation, there were 39 infants with a birth weight <1,000 grams (group A) and 18 infants with a birth weight ≥1,000 g (group B). The weight at surgery was <1,000 grams in 33 cases and ≥1,000 grams in 24 cases.

Moreover, Lamireau et al., ²⁰ who stated that, in infants with NEC, the median weight was 1245 gram, with a range of [925–1636] gram. Otherwise, there were 67 (59.3%) males.

Furthermore, Feng et al., ²¹ who stated that in NEC group, the mean weight of the investi-gated cases was 1,142.6 ± 220.30 gram. Otherwise, there were 27 (69.2%) males.

In the present investigation, our findings revealed that the mean saturation during surgery was 93.8 ± 0.6, mean Systolic pressure during surgery was 59.7 ± 2.3 and mean Diasto-lic pressure during surgery was 34.8 ± 1.8.

Our results matched with Gokce et al., ²² who reported that, in NEC group, the mean saturation was 94.9±1.3.

Similarly, Knudsen et al., ¹⁶ who stated that in NEC cases, the mean Saturation during surgery was 95.8 ± 0.5, the mean Systolic pressure throughout operation 57.7 ± 2.2 and the mean Diastolic pressure throughout operation was 32.8 ± 1.8.

Our current research revealed that a statistically insignificant distinction has been observed among the investigated groups as regards Bell-Stages. A statistically insignificant distinction has been observed among the investigated groups as regard surgical procedure. A statistically insignificant distinction has been observed among the investigated groups as regard outcome.

Our findings are supported by Gfroerer et al.,¹⁹ who stated that a statistically insignificant distinction has been observed among the investigated groups as regards Bell-Stages. A statistically insignificant distinction has been observed among the investigated groups as regard surgical procedure. A statistically insignificant distinction has been observed among the investigated groups as regard outcome.