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Leaving Necrotic Bowel In Situ At Nec Laparotomy Leads To Increased Mortality

Authors
Rashmi D’Souza, Caroline Pardy, Joe Davidson, Grenville Fox, Iain Yardley

Institution(s): Evelina Children’s Hospital, London, UK & GOS-UCL Institute of Child Health, London, UK

Introduction
Necrotising enterocolitis (NEC) is the commonest surgical emergency in neonates with a high mortality rate. There are various surgical strategies at laparotomy and no consensus as to which offers the best outcomes. We aim to determine outcomes in neonates undergoing laparotomy for NEC in our tertiary unit.

Methods
Neonates with NEC undergoing laparotomy between May 2015 and March 2019 were identified and NEC totalis excluded. Demographic data and surrogate markers of severity of NEC were recorded including gestation, birthweight, inotropic or ventilatory support, and inflammatory markers. Cases were classified according to whether necrotic bowel was resected (R) or left in-situ (LIS). Primary outcome was survival. Secondary outcomes included ongoing inflammatory burden (CRP levels over 14 days post-operatively) and time to enteral autonomy.

Data are presented as median[IQR]. Mann-Whitney U tests were used for continuous data, and odds ratios (OR[95% CI]) for categorical data. Factors associated with mortality were assessed using logistic regression.

Results
50 patients were included (21 LIS vs 29 R). Groups were comparable with regard to both demographic and severity characteristics. Patients with all necrotic bowel resected were more likely to survive, (R vs. LIS, 5/29(17%) vs. 13/21(62%), OR 7.8[2.1-28.8], p<0.005). Those patients with necrotic bowel left in-situ who survived were less likely to achieve enteral independence (6/9(66.7%) vs. 24/25(96.0%), OR 12[1.05-136.8], p<0.05). Among survivors, post-operative inflammatory burden was higher in patients with bowel left in situ (1191[417-1818] vs. 504[277-1080], p=0.05). On logistic regression, leaving necrotic bowel in-situ was strongly associated with mortality (OR 8.67[1.86-40.42], p<0.01).

Conclusions
Overall mortality at our centre appears comparable to previous studies, however, cases with necrotic bowel left in situ have more than double the mortality rate of those undergoing total resection. Additionally, leaving necrotic bowel in situ does not improve the likelihood of achieving enteral autonomy.

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