title: The clip and drop back technique in the management of multifocal necrotizing enterocolitis: a single centre experience.
abstract: OBJECTIVE
  The surgical management of multifocal necrotizing enterocolitis (NEC) remains a major challenge. The "clip-and-drop" strategy with a second-look laparotomy permits re-assessment of bowel viability after optimization, thus offering the potential of both improving survival and conserving bowel length. This study reviews the outcome of this strategy in a single regional center.
  
  
  METHODS
  Since 2000, NEC patients undergoing emergency laparotomy selectively underwent a "clip-and-drop" operation if there was peri-operative instability and/or multifocal disease with uncertain bowel viability. Bowel with full thickness gangrene was resected and bowel-ends were temporarily tied-off; a second-look definitive procedure was performed when the patient had stabilized. For this review, in-hospital and follow-up records were studied retrospectively for demographics, 30-day mortality and long-term outcome.
  
  
  RESULTS
  Between 2000 and 2010, 16 patients underwent a "clip-and-drop" operation. The mean post-conception age was 32.8 weeks (27.7-41.7 weeks) with a median body weight of 1.4 kg (0.76-4.4 kg) at first operation. Preoperative radiograph showed free gas in 43.8% and portal venous gas in 37.5% of patients. 2 patients did not survive to the second laparotomy. 14 patients received a second laparotomy, after a mean of 51 h (35-74 h). 2 patients were found to suffer from NEC totalis on the second laparotomy and died without further procedures. All other patients (n = 12) had stoma formation. 1 patient died 4 days after stoma formation. The 30-day mortality for NEC with the "clip-and-drop" strategy was 31.6% (5/16). Among the 11 survivors, 1 died from liver failure complicated by short bowel syndrome at 5 months post operation, 2 others died from respiratory complications of prematurity despite adequate gastrointestinal function. The median follow-up time for the 8 long-term survivors was 45 months (7-129 months). Their median time to achieving full feeds was 41 days (range 21-105 days) after the second operation.
  
  
  CONCLUSIONS
  The "clip-and-drop" strategy, when used in selected patients with multifocal NEC, may help bowel conservation in survivors.
authors.affiliation: Division of Paediatric Surgery,  Department of Surgery, Queen Elizabeth Hospital, Hong Kong.
authors.forename: K K Y
authors.initials: KK
authors.lastname: Pang
authors.forename: N S Y
authors.initials: NS
authors.lastname: Chao
authors.forename: B P Y
authors.initials: BP
authors.lastname: Wong
authors.forename: M W Y
authors.initials: MW
authors.lastname: Leung
authors.forename: K K W
authors.initials: KK
authors.lastname: Liu
mesh_terms: D020345:Enterocolitis, Necrotizing / Q000601:surgery*; D005260:Female; D005500:Follow-Up Studies; D006801:Humans; D007223:Infant; D007231:Infant, Newborn; D007813:Laparotomy / Q000379:methods*; D008297:Male; D012189:Retrospective Studies; D024162:Second-Look Surgery; D013525:Surgical Instruments; D016896:Treatment Outcome