CAPS Paper
Correlation of complex ascites with intestinal gangrene and perforation in neonates with necrotizing enterocolitis

https://doi.org/10.1016/j.jpedsurg.2010.02.011Get rights and content

Abstract

Background/Purpose

The purpose of this study was to determine whether a correlation exists between the finding of complex ascites on ultrasound (US) and the presence of intestinal perforation or gangrene in neonates with complicated necrotizing enterocolitis (NEC).

Methods

Charts of neonates with NEC (n = 76) whose care involved consultations with the pediatric surgery service between 2005 and 2008 were reviewed. Twenty-three babies with NEC without free air had a bedside abdominal US. Neonates with pneumoperitoneum were excluded from the study because this was an absolute indication for surgical intervention.

Results

Twelve of the 23 neonates who had a bedside abdominal US were found to have ascites with debris or complex ascites. One of these 12 patients improved with medical management, and the ascites resolved. One infant with complex ascites had an initial laparotomy that revealed extensive bowel necrosis and gangrene that required intestinal resection and ostomy creation. This infant survived and is currently doing well.

Ten patients were critically ill and were managed with bedside peritoneal drainage. Of those, 7 had drainage of intestinal contents after placement of the drain. Two of the babies who had a drain placed for complex ascites subsequently died of progressive disease. Five neonates with ascites with debris improved after peritoneal drainage and were subsequently subjected to laparotomy. All had gangrene with intestinal perforation. Three infants with complex ascites and intestinal contents were not observed during the initial peritoneal drainage. They improved after peritoneal drainage and had laparotomy. Free intestinal perforation was not demonstrated. The 3 infants in this group survived.

Conclusions

The presence of complex ascites with debris correlated well with intestinal gangrene or perforation. This correlation may also be a predictor of mortality. Neonates with complicated NEC without clear indication for surgical intervention would benefit from bedside abdominal US evaluation.

Section snippets

Methods

The pediatric surgery service at our institution was consulted in the management of 76 infants with NEC between 2005 and 2008. A retrospective review of their charts was performed. The radiographic reports were obtained and correlated with the clinical course and operative findings described at the time of surgery. Infants with an abdominal radiograph demonstrating free air were excluded from the study. A positive US consisted of particulate matter or debris within the ascites that was either

Results

In the group of patients (n = 76) whose charts were reviewed, 6 infants had free air on abdominal radiograph and were eliminated from the study. Because of clinical deterioration, 23 of the remaining 70 patients had bedside US that demonstrated ascites. Free air was not demonstrated in these patients. Eleven patients with clear ascites did not have a surgical intervention because of the inability to confirm intestinal perforation or complex ascites by US. Of those 11 patients, 3 recovered

Discussion

Surgery in the critically ill neonate can be a daunting intervention because of the fragile nature of the patient and multiple comorbidities. Equally important is a timely surgical intervention that optimizes the infant's chance for recovery and even survival. The difficulty in the early recognition of intestinal gangrene/perforation in the NEC population is well recognized. The most commonly accepted criteria for surgery remains the presence of free air on abdominal radiograph [4]. However,

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Presented at the 41st Annual Meeting of the Canadian Association of Paediatric Surgeons, Halifax, Nova Scotia, Canada, October 1-3, 2009.

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