Laparotomy versus peritoneal drainage for necrotizing enterocolitis and perforation.
BACKGROUND
Perforated necrotizing enterocolitis is a major cause of morbidity and mortality in premature infants, and the optimal treatment is uncertain. We designed this multicenter randomized trial to compare outcomes of primary peritoneal drainage with laparotomy and bowel resection in preterm infants with perforated necrotizing enterocolitis.


METHODS
We randomly assigned 117 preterm infants (delivered before 34 weeks of gestation) with birth weights less than 1500 g and perforated necrotizing enterocolitis at 15 pediatric centers to undergo primary peritoneal drainage or laparotomy with bowel resection. Postoperative care was standardized. The primary outcome was survival at 90 days postoperatively. Secondary outcomes included dependence on parenteral nutrition 90 days postoperatively and length of hospital stay.


RESULTS
At 90 days postoperatively, 19 of 55 infants assigned to primary peritoneal drainage had died (34.5 percent), as compared with 22 of 62 infants assigned to laparotomy (35.5 percent, P=0.92). The percentages of infants who depended on total parenteral nutrition were 17 of 36 (47.2 percent) in the peritoneal-drainage group and 16 of 40 (40.0 percent) in the laparotomy group (P=0.53). The mean (+/-SD) length of hospitalization for the 76 infants who were alive 90 days after operation was similar in the primary peritoneal-drainage and laparotomy groups (126+/-58 days and 116+/-56 days, respectively; P=0.43). Subgroup analyses stratified according to the presence or absence of radiographic evidence of extensive necrotizing enterocolitis (pneumatosis intestinalis), gestational age of less than 25 weeks, and serum pH less than 7.30 at presentation showed no significant advantage of either treatment in any group.


CONCLUSIONS
The type of operation performed for perforated necrotizing enterocolitis does not influence survival or other clinically important early outcomes in preterm infants. (ClinicalTrials.gov number, NCT00252681.).
Moss
R Lawrence
RL
Section of Pediatric Surgery, Yale University School of Medicine, New Haven, Conn 06520-8062, USA. larry.moss@yale.edu
Dimmitt
Reed A
RA
Barnhart
Douglas C
DC
Sylvester
Karl G
KG
Brown
Rebeccah L
RL
Powell
David M
DM
Islam
Saleem
S
Langer
Jacob C
JC
Sato
Thomas T
TT
Brandt
Mary L
ML
Lee
Hanmin
H
Blakely
Martin L
ML
Lazar
Eric L
EL
Hirschl
Ronald B
RB
Kenney
Brian D
BD
Hackam
David J
DJ
Zelterman
Daniel
D
Silverman
Bonnie L
BL
D001724:Birth Weight; D004322:Drainage; D020345:Enterocolitis, Necrotizing / Q000150:complications / Q000401:mortality / Q000601:surgery / Q000628:therapy*; D005260:Female; D006801:Humans; D007231:Infant, Newborn; D007234:Infant, Premature; D007235:Infant, Premature, Diseases / Q000401:mortality / Q000601:surgery / Q000628:therapy*; D019102:Infant, Very Low Birth Weight; D007416:Intestinal Perforation / Q000209:etiology / Q000401:mortality / Q000601:surgery / Q000628:therapy*; D007813:Laparotomy; D008297:Male; D010289:Parenteral Nutrition, Total; D010537:Peritoneum; D016016:Proportional Hazards Models; D016019:Survival Analysis; D016896:Treatment Outcome