From the Guidelines
The correct indication for laparotomy in neonatal necrotizing enterocolitis is evidence of bowel perforation, which can be suggested by abdominal wall erythema (option c), among other signs. Abdominal wall erythema in a neonate with NEC suggests advanced disease with possible intestinal perforation or impending perforation, requiring immediate surgical intervention, as stated in the guidelines by the Surgical Infection Society and the Infectious Diseases Society of America 1. This finding indicates inflammation has extended beyond the intestinal wall to involve the peritoneum and abdominal wall, representing a surgical emergency. While distended bowel loops, thickened bowel wall, and pneumatosis intestinalis are all concerning findings in NEC, they are not absolute indications for surgery by themselves and may be managed medically with bowel rest, antibiotics, and supportive care, according to the guidelines 1. Other definitive surgical indications for NEC include pneumoperitoneum (free air), portal venous gas, fixed dilated intestinal loop on serial imaging, and clinical deterioration despite maximal medical therapy. Early surgical consultation is essential in all cases of NEC, as clinical status can rapidly deteriorate, requiring prompt surgical intervention to remove necrotic bowel and prevent further complications, as recommended in the guidelines 1. Key considerations in the management of NEC include:
- Fluid resuscitation
- Intravenous broad-spectrum antibiotics (potentially including antifungal agents)
- Bowel decompression
- Urgent or emergent operative intervention, consisting of either laparotomy or percutaneous drainage, when there is evidence of bowel perforation, as stated in the guidelines 1. Intraoperative Gram stains and cultures should be obtained to guide further management, including the selection of appropriate antimicrobial therapy, as recommended in the guidelines 1. Broad-spectrum antibiotics that may be useful in neonates with NEC include ampicillin, gentamicin, and metronidazole; ampicillin, cefotaxime, and metronidazole; or meropenem, according to the guidelines 1. Vancomycin may be used instead of ampicillin for suspected MRSA or ampicillin-resistant enterococcal infection, and fluconazole or amphotericin B should be used if the Gram stain or cultures of specimens obtained at operation are consistent with a fungal infection, as recommended in the guidelines 1.
From the Research
Indications for Laparotomy in Neonatal Necrotizing Enterocolitis
The following are indications for laparotomy in neonatal necrotizing enterocolitis:
- Abdominal wall erythema is not a direct indication for laparotomy, but it can be a sign of severe disease 2
- Distended bowel loops and thickened bowel wall are clinical findings associated with necrotizing enterocolitis, but they are not specific indications for laparotomy 3, 4
- Pneumatosis intestinalis is a radiological finding that is considered pathognomonic for necrotizing enterocolitis and can be an indication for laparotomy, especially if there are signs of perforation or peritonitis 3, 2, 5
Specific Indications for Laparotomy
Laparotomy is usually considered in advanced cases of necrotizing enterocolitis, such as: