- Email: [email protected]
Bedside peritoneal drainage in very low birth weight infants
The American Journal of Surgery 181 (2001) 416 – 419
Bedside peritoneal drainage in very low birth weight infants H. George S. Noble, M.D.*, Martha Driessnack, M.S.N., P.N.P. Department of Pediatric Surgery, Mary Bridge Children’s Hospital, 317 Martin Luther King Jr. Way, PO Box 5299, Tacoma, WA 98415-1299 USA Manuscript received December 22, 2000; revised manuscript March 1, 2001
Abstract Background: Bedside peritoneal drainage is emerging as a useful therapy for premature infants with intestinal perforation in the newborn period. Some authors recommend that bedside drainage be primary therapy for very low birth weight neonates. Surprisingly, some series report up to 70% of neonates so treated never require further or definitive surgery. Methods: This is a retrospective chart review of all premature newborns with a diagnosis of either necrotizing enterocolitis or bowel perforation between November 1996 and May 2000. Results: Sixty-seven patients were identified, of whom 27 were treated medically only and not considered here. Thirty-two neonates were treated with laparotomy primarily, with 26 survivors. Eight neonates were treated first with bedside peritoneal drainage. Of these, 4 survived, 6 required secondary surgery for obstruction or infection, and 2 died before any further intervention. Conclusions: Bedside peritoneal drainage is a useful adjunct in the approach to treating the very sick, very low birth weight neonate with evidence of intestinal perforation. Our experience does not support drainage as definitive therapy. © 2001 Excerpta Medica, Inc. All rights reserved. Keywords: Peritoneal drainage; Very low birth weight; Necrotizing enterocolitis
Traditional surgical management of perforated intra-abdominal viscus includes laparotomy with debridement of the offending intestinal segment and formation of stomas. Until recently, the same standard applied to the care of premature infants with perforations from necrotizing enterocolitis. In the middle 1970s, Ein and colleagues [1] began reporting a series [1–5] in which the most fragile of these premature infants were treated initially with simple placement of peritoneal drains at the bedside. Among these neonates, who were felt to be “too sick” to survive a trip to the operating room, there were a surprising number of survivors. Bedside peritoneal drainage (BSPD) was devised as a temporizing measure to get the child well enough for the traditional laparotomy. The most remarkable finding, from even the earliest series, was that some of the neonates thus treated never required formal laparotomy, but instead went on to recover with normal gastrointestinal function after removal of the drains. Since that time, there have been many reports from other institutions [6 –14] showing similar results to the point where some have stressed peritoneal drainage as primary or even definitive therapy [8] for these critically ill * Corresponding author. Tel.: ⫹1-253-403-4613; fax: ⫹1-253-403-1641. E-mail address: [email protected].
infants. This paper explores our first experience with this approach over the last 3 and a half years.
Methods We reviewed the charts of all patients at the Mary Bridge Children’s Hospital and Tacoma General Hospital with a diagnosis of prematurity and either necrotizing enterocolitis or perforated intestine from 1 November 1996 through 31 May 2000. Charts were examined for sex, gestational age at birth, age at diagnosis, birth weight, comorbid conditions, surgical treatment, if any, and outcomes. Because this was a nonrandomized, retrospective study of our early experience, there was insufficient information to distinguish reliably between necrotizing enterocolitis and isolated perforation in all cases. Similarly, no objective measure of the severity of illness could be made based on the chart review. Premature infants with evidence of intestinal perforation were managed, at the discretion of one of four pediatric surgeons, initially with either formal laparotomy or bedside peritoneal drainage (BSPD). Bedside peritoneal drainage, when elected, was accomplished in the neonatal intensive care unit (NICU). The patients, already intubated and ven-
0002-9610/01/$ – see front matter © 2001 Excerpta Medica, Inc. All rights reserved. PII: S 0 0 0 2 - 9 6 1 0 ( 0 1 ) 0 0 6 1 2 - 2
H.G.S. Noble and M. Driessnack / The American Journal of Surgery 181 (2001) 416 – 419
417
Table 1 Outcomes of neonates with intestinal perforation
Number Gestational age (weeks) Birth weight (g) Age at perforation (days) Sex
BSPD nonsurvivor
BSPD survivor
Laparatomy nonsurvivor
Laparatomy survivor
4
4
6
23–30 511–900 9–14 1 female 3 male
23–25 658–750 7–13 2 female 2 male
24–30 390–1335 6–35 3 female 3 male
26 23–32 475–1490 3–42 8 female 18 male
BSPD ⫽ bedside peritoneal drainage.
tilated, were given sedation and local anesthetic. Under sterile conditions, a Penrose drain was placed through a right lower quadrant incision into the general peritoneal cavity. Drains were removed over 1 to 2 weeks as dictated by the presence or absence of ongoing drainage. Results Review of medical records found 67 premature infants with necrotizing enterocolitis or bowel perforation or both during this time period. Of these, 40 required some surgical intervention. The remaining 27 were managed medically with antibiotics and maximum supportive care. None of these 27 had evidence of intestinal perforation. Of the 40 with radiological evidence of perforation (free intraperitoneal air on plain x-ray film), 32 were taken to the operating room promptly for the traditional laparotomy, and 8 were initially treated with BSPD. One third of the operative patients were girls, evenly distributed between the laparotomy and BSPD groups. Mean weight was 946 g for the laparotomy group and 728 g for the BSPD group. Mean gestational age was 26.8 weeks for the laparotomy group and 24.6 for the BSPD group. There were 4 deaths in each group. Nonsurvivors ranged from 390 g to 1,335 g in the laparotomy group and from 511 g to 900 g in the BSPD group. Three of the patients in the laparotomy group had resection of perforated bowel with primary anastomosis and did not require further surgery within the observation period of this study. Two additional patients in the laparotomy group had BSPD as a desperate measure for recurrent perforation with demise after definitive laparotomy. Both of these patients died. In the BSPD group, 2 patients continued their rapid decline after drainage and died without further surgical intervention. All of the remaining 6 patients required subsequent laparotomy, after an initial period of stabilization, for recurrent instability or for evidence of bowel obstruction. Two of these 6 died late of complications. Comments This study records our early experience with this approach to the very low birth weight infant with intestinal
perforation. Bedside peritoneal drainage makes sense as a temporizing measure for the most desperately ill neonates to improve their condition prior to definitive laparotomy. In the series by Azarow et al [5], survival was significantly better in the neonates under 1,000 g when BSPD was used compared with primary laparotomy. In neonates over 1,000 g, the opposite was true. Although the mean birth weight of the BSPD group was lower than the laparotomy group in this series, weight was not used as a guide for the decision to drain at the bedside (except by one surgeon). In fact, death appears unrelated to gestational age or birth weight, including both the smallest and the largest in the BSPD group. The lower survival in the BSPD group (50% versus 87.5%) presumably reflects the more desperate status of the patients selected for BSPD. As with other reports, BSPD resulted in a gratifying improvement in physiologic status of 6 of the 8 patients. This report differs from the other reports, however, because none of the initial survivors of the BSPD continued without further abdominal surgery. Lessin et al [9] suggest that BSPD be considered “definitive” therapy in premature neonates with intestinal perforation. Dimmitt et al [11] had no survivors in the group treated initially with BSPD and followed by laparotomy, while having 7 of 13 survivors with no surgery after BSPD, and suggested that “salvage laparotomy” may not be indicated. In contrast, our results show that 4 of 6 BSPD patients who survived the initial illness also survived their subsequent, necessary, laparotomy. The experience of survival without further surgery of any kind, seen in multiple unrelated series, raises several questions about our traditional management of intestinal perforation in neonates. The first question is whether we are dealing with a different spectrum of disease. Necrotizing enterocolitis was unknown before modern neonatal intensive care allowed routine survival of very low birth weight infants. As the minimum birth weight and gestational age of survivability have decreased, the etiology of the perforation and the physiology of the repair may be different from our traditional understanding. Necrotizing enterocolitis is understood to be the complex interplay of gut ischemia, bacterial colonization, and the immature immune system resulting in patchy or extensive necrosis of the gut wall. A hallmark of that process is the radiologic finding of pneumatosis intestinalis. A number of the patients in the present
418
H.G.S. Noble and M. Driessnack / The American Journal of Surgery 181 (2001) 416 – 419
series had, as their first clinical finding, free intraperitoneal air on x-ray film without pneumatosis. Many of the patients had, as operative findings, single or localized perforation with healthy, viable gut adjacent, as opposed to the more classic patchy ischemic gut of the patients with necrotizing enterocolitis. Some of the BSPD patients from this series had evidence at subsequent laparotomy to suggest that their initial event was an isolated perforation of small bowel. Several recent papers [9,10,12–14] have begun to look at these differences and their implications for clinical management. Unfortunately, because these two entities have heretofore been lumped under the diagnosis of necrotizing enterocolitis, it was not possible in the present series to separate the two reliably. In the report by Cass et al [13] that looked specifically at this difference, the patients with pneumatosis and classic necrotizing enterocolitis tended to be larger than those with isolated perforation. In addition, the neonates with isolated perforation or without pneumatosis were less likely to require further surgery. Moreover, if there are two distinct populations of neonates with perforated intestine, is it reasonable to consider different surgical therapies based on the different etiologies of the perforations? It is tempting to accept that the survivors without further laparotomy in some series were those with isolated perforations, well enough drained to allow sealing of the perforation with restoration of continuity of the gut. However, Moore [15] suggests that the ischemia of necrotizing enterocolitis contributes to angiogenesis in the healing of patients with perforations. Anecdotal experience from this series (3 patients in the laparotomy group) suggests that the neonates with the isolated perforations might have fared better with early resection and primary anastomosis. None of our BSPD patients survived without further intervention. Some of the patients with isolated perforation who initially did well with BSPD ultimately required significant resections because of the extent and density of the phlegmon remaining from the perforation and drainage. Although none of these patients has short gut syndrome, it is tempting to speculate that these might have survived with less gut resection if subjected to laparotomy and primary anastomosis as the first procedure. Morgan et al [8] speculated about the role of “scarless fetal healing” in these very premature infants who have survived BSPD without further surgical intervention. Our experience has not shown any diminution of phlegmon in the most premature infants requiring secondary surgery. In the group of patients who respond well initially to BSPD, the indications for subsequent laparotomy and the timing of that procedure are open to question. In 4 of the 6 patients who initially had a good response to BSPD, indications for laparotomy were the recurrence of a septic picture with abdominal distention, acidosis, and fluid retention 1 to 2 weeks after the drainage. The other 2 patients underwent laparotomy for failure of feedings, with an obstructive picture, 3 weeks after their initial good result from BSPD.
Because all of the patients in this series who survived initial BSPD subsequently required laparotomy for recurrent demise or for bona fide bowel obstruction, we have no answers. Some have suggested that we did not wait long enough after the BSPD to avoid subsequent laparotomy. We were more concerned that we had waited too long, after the initial response, especially in the 2 patients with the recurrent septic picture who went on to die after laparotomy. It is difficult to make sense of the contrast between this series and a similar-size series by Lessin et al [9] in which 9 patients were managed without subsequent laparotomy, with 8 early and 7 long-term survivors. Based on this limited experience, it is clear that BSPD belongs in the surgical armamentarium for the critically ill very low birth weight neonate with evidence of perforation of the intestine as evidenced by free intraperitoneal air, regardless of the etiology of perforation. This experience supports the use of BSPD as a temporizing measure in critically ill neonates with intestinal perforation, but not as definitive therapy. The indications and timing of laparotomy after BSPD remain to be defined. References [1] Ein SH, Marshall DG, Girvan D. Peritoneal drainage under local anesthesia for perforations from necrotizing enterocolitis. J Pediatr Surg 1977;12:963–7. [2] Janik JS, Ein SH. Peritoneal drainage under local anesthesia for necrotizing enterocolitis (NEC) perforation: a second look. J Pediatr Surg 1980;15:565– 8. [3] Ein SH, Shandling B, Wesson D, Filler RM. A 13-year experience with peritoneal drainage under local anesthesia for necrotizing enterocolitis perforation. J Pediatr Surg 1990;25:1034 –7. [4] Ahmed T, Ein S, Moore A. The role of peritoneal drains in treatment of perforated necrotizing enterocolitis: recommendations from recent experience. J Pediatr Surg 1998;33:1468 –70. [5] Azarow KS, Ein SH, Shandling B, et al. Laparotomy or drain for perforated necrotizing enterocolitis: who gets what and why? Pediatr Surg Int 1997;12:137–9. [6] Cheu HW, Sukarochana K, Lloyd DA. Peritoneal drainage for necrotizing enterocolitis. J Pediatr Surg 1988;23:557– 61. [7] Takamatsu H, Akiyama H, Ibara S, et al. Treatment for necrotizing enterocolitis perforation in the extremely premature infant (weighing ⬍1,000 g). J Pediatr Surg 1992;27:741–3. [8] Morgan LJ, Schochat SJ, Hartman GE. Peritoneal drainage as primary management of perforated NEC in the very low birth weight infant. J Pediatr Surg 1994;29:310 –15. [9] Lessin MS, Luks FI, Wesselhoeft CW, et al. Peritoneal drainage as definitive treatment for intestinal perforation in infants with extremely low birth weight (⬍750 g). J Pediatr Surg 1998;33:370 –2. [10] Rovin JD, Rodgers BM, Burns RC, McGahren ED. The role of peritoneal drainage for intestinal perforation in infants with and without necrotizing enterocolitis. J Pediatr Surg 1999;34:143–7. [11] Dimmitt RA, Meier AH, Skarsgard ED, et al. Salvage laparotomy for failure of peritoneal drainage in necrotizing enterocolitis in infants with extremely low birth weight. J Pediatr Surg 2000;35:856 –9. [12] Downard C, Curran T, Campbell T. Peritoneal drainage for neonatal intestinal perforation. Presented at the Pacific Association of Pediatric Surgeons, Las Vegas, Nevada, May 15-19, 2000.
H.G.S. Noble and M. Driessnack / The American Journal of Surgery 181 (2001) 416 – 419 [13] Cass DL, Brandt ML, Patel DL, et al. Peritoneal drainage as definitive treatment for neonates with isolated intestinal perforation. J Pediatr Surg 2000;35:1531– 6. [14] Takamatsu H, Noguchi H, Ikee T, et al. Small intestinal perforation in infants less than 1000 g treated initially by peritoneal drainage.
419
Presented at the Pacific Association of Pediatric Surgeons, Las Vegas, Nevada, May15–19, 2000. [15] Moore TC. Successful use of the “patch, drain, and wait” laparotomy approach to perforated necrotizing enterocolitis: is hypoxia-triggered “good angiogenesis” involved? Pediatr Surg Int 2000;16:356 – 63.
Bedside peritoneal drainage in very low birth weight infants H. George S. Noble, M.D.*, Martha Driessnack, M.S.N., P.N.P. Department of Pediatric Surgery, Mary Bridge Children’s Hospital, 317 Martin Luther King Jr. Way, PO Box 5299, Tacoma, WA 98415-1299 USA Manuscript received December 22, 2000; revised manuscript March 1, 2001
Abstract Background: Bedside peritoneal drainage is emerging as a useful therapy for premature infants with intestinal perforation in the newborn period. Some authors recommend that bedside drainage be primary therapy for very low birth weight neonates. Surprisingly, some series report up to 70% of neonates so treated never require further or definitive surgery. Methods: This is a retrospective chart review of all premature newborns with a diagnosis of either necrotizing enterocolitis or bowel perforation between November 1996 and May 2000. Results: Sixty-seven patients were identified, of whom 27 were treated medically only and not considered here. Thirty-two neonates were treated with laparotomy primarily, with 26 survivors. Eight neonates were treated first with bedside peritoneal drainage. Of these, 4 survived, 6 required secondary surgery for obstruction or infection, and 2 died before any further intervention. Conclusions: Bedside peritoneal drainage is a useful adjunct in the approach to treating the very sick, very low birth weight neonate with evidence of intestinal perforation. Our experience does not support drainage as definitive therapy. © 2001 Excerpta Medica, Inc. All rights reserved. Keywords: Peritoneal drainage; Very low birth weight; Necrotizing enterocolitis
Traditional surgical management of perforated intra-abdominal viscus includes laparotomy with debridement of the offending intestinal segment and formation of stomas. Until recently, the same standard applied to the care of premature infants with perforations from necrotizing enterocolitis. In the middle 1970s, Ein and colleagues [1] began reporting a series [1–5] in which the most fragile of these premature infants were treated initially with simple placement of peritoneal drains at the bedside. Among these neonates, who were felt to be “too sick” to survive a trip to the operating room, there were a surprising number of survivors. Bedside peritoneal drainage (BSPD) was devised as a temporizing measure to get the child well enough for the traditional laparotomy. The most remarkable finding, from even the earliest series, was that some of the neonates thus treated never required formal laparotomy, but instead went on to recover with normal gastrointestinal function after removal of the drains. Since that time, there have been many reports from other institutions [6 –14] showing similar results to the point where some have stressed peritoneal drainage as primary or even definitive therapy [8] for these critically ill * Corresponding author. Tel.: ⫹1-253-403-4613; fax: ⫹1-253-403-1641. E-mail address: [email protected].
infants. This paper explores our first experience with this approach over the last 3 and a half years.
Methods We reviewed the charts of all patients at the Mary Bridge Children’s Hospital and Tacoma General Hospital with a diagnosis of prematurity and either necrotizing enterocolitis or perforated intestine from 1 November 1996 through 31 May 2000. Charts were examined for sex, gestational age at birth, age at diagnosis, birth weight, comorbid conditions, surgical treatment, if any, and outcomes. Because this was a nonrandomized, retrospective study of our early experience, there was insufficient information to distinguish reliably between necrotizing enterocolitis and isolated perforation in all cases. Similarly, no objective measure of the severity of illness could be made based on the chart review. Premature infants with evidence of intestinal perforation were managed, at the discretion of one of four pediatric surgeons, initially with either formal laparotomy or bedside peritoneal drainage (BSPD). Bedside peritoneal drainage, when elected, was accomplished in the neonatal intensive care unit (NICU). The patients, already intubated and ven-
0002-9610/01/$ – see front matter © 2001 Excerpta Medica, Inc. All rights reserved. PII: S 0 0 0 2 - 9 6 1 0 ( 0 1 ) 0 0 6 1 2 - 2
H.G.S. Noble and M. Driessnack / The American Journal of Surgery 181 (2001) 416 – 419
417
Table 1 Outcomes of neonates with intestinal perforation
Number Gestational age (weeks) Birth weight (g) Age at perforation (days) Sex
BSPD nonsurvivor
BSPD survivor
Laparatomy nonsurvivor
Laparatomy survivor
4
4
6
23–30 511–900 9–14 1 female 3 male
23–25 658–750 7–13 2 female 2 male
24–30 390–1335 6–35 3 female 3 male
26 23–32 475–1490 3–42 8 female 18 male
BSPD ⫽ bedside peritoneal drainage.
tilated, were given sedation and local anesthetic. Under sterile conditions, a Penrose drain was placed through a right lower quadrant incision into the general peritoneal cavity. Drains were removed over 1 to 2 weeks as dictated by the presence or absence of ongoing drainage. Results Review of medical records found 67 premature infants with necrotizing enterocolitis or bowel perforation or both during this time period. Of these, 40 required some surgical intervention. The remaining 27 were managed medically with antibiotics and maximum supportive care. None of these 27 had evidence of intestinal perforation. Of the 40 with radiological evidence of perforation (free intraperitoneal air on plain x-ray film), 32 were taken to the operating room promptly for the traditional laparotomy, and 8 were initially treated with BSPD. One third of the operative patients were girls, evenly distributed between the laparotomy and BSPD groups. Mean weight was 946 g for the laparotomy group and 728 g for the BSPD group. Mean gestational age was 26.8 weeks for the laparotomy group and 24.6 for the BSPD group. There were 4 deaths in each group. Nonsurvivors ranged from 390 g to 1,335 g in the laparotomy group and from 511 g to 900 g in the BSPD group. Three of the patients in the laparotomy group had resection of perforated bowel with primary anastomosis and did not require further surgery within the observation period of this study. Two additional patients in the laparotomy group had BSPD as a desperate measure for recurrent perforation with demise after definitive laparotomy. Both of these patients died. In the BSPD group, 2 patients continued their rapid decline after drainage and died without further surgical intervention. All of the remaining 6 patients required subsequent laparotomy, after an initial period of stabilization, for recurrent instability or for evidence of bowel obstruction. Two of these 6 died late of complications. Comments This study records our early experience with this approach to the very low birth weight infant with intestinal
perforation. Bedside peritoneal drainage makes sense as a temporizing measure for the most desperately ill neonates to improve their condition prior to definitive laparotomy. In the series by Azarow et al [5], survival was significantly better in the neonates under 1,000 g when BSPD was used compared with primary laparotomy. In neonates over 1,000 g, the opposite was true. Although the mean birth weight of the BSPD group was lower than the laparotomy group in this series, weight was not used as a guide for the decision to drain at the bedside (except by one surgeon). In fact, death appears unrelated to gestational age or birth weight, including both the smallest and the largest in the BSPD group. The lower survival in the BSPD group (50% versus 87.5%) presumably reflects the more desperate status of the patients selected for BSPD. As with other reports, BSPD resulted in a gratifying improvement in physiologic status of 6 of the 8 patients. This report differs from the other reports, however, because none of the initial survivors of the BSPD continued without further abdominal surgery. Lessin et al [9] suggest that BSPD be considered “definitive” therapy in premature neonates with intestinal perforation. Dimmitt et al [11] had no survivors in the group treated initially with BSPD and followed by laparotomy, while having 7 of 13 survivors with no surgery after BSPD, and suggested that “salvage laparotomy” may not be indicated. In contrast, our results show that 4 of 6 BSPD patients who survived the initial illness also survived their subsequent, necessary, laparotomy. The experience of survival without further surgery of any kind, seen in multiple unrelated series, raises several questions about our traditional management of intestinal perforation in neonates. The first question is whether we are dealing with a different spectrum of disease. Necrotizing enterocolitis was unknown before modern neonatal intensive care allowed routine survival of very low birth weight infants. As the minimum birth weight and gestational age of survivability have decreased, the etiology of the perforation and the physiology of the repair may be different from our traditional understanding. Necrotizing enterocolitis is understood to be the complex interplay of gut ischemia, bacterial colonization, and the immature immune system resulting in patchy or extensive necrosis of the gut wall. A hallmark of that process is the radiologic finding of pneumatosis intestinalis. A number of the patients in the present
418
H.G.S. Noble and M. Driessnack / The American Journal of Surgery 181 (2001) 416 – 419
series had, as their first clinical finding, free intraperitoneal air on x-ray film without pneumatosis. Many of the patients had, as operative findings, single or localized perforation with healthy, viable gut adjacent, as opposed to the more classic patchy ischemic gut of the patients with necrotizing enterocolitis. Some of the BSPD patients from this series had evidence at subsequent laparotomy to suggest that their initial event was an isolated perforation of small bowel. Several recent papers [9,10,12–14] have begun to look at these differences and their implications for clinical management. Unfortunately, because these two entities have heretofore been lumped under the diagnosis of necrotizing enterocolitis, it was not possible in the present series to separate the two reliably. In the report by Cass et al [13] that looked specifically at this difference, the patients with pneumatosis and classic necrotizing enterocolitis tended to be larger than those with isolated perforation. In addition, the neonates with isolated perforation or without pneumatosis were less likely to require further surgery. Moreover, if there are two distinct populations of neonates with perforated intestine, is it reasonable to consider different surgical therapies based on the different etiologies of the perforations? It is tempting to accept that the survivors without further laparotomy in some series were those with isolated perforations, well enough drained to allow sealing of the perforation with restoration of continuity of the gut. However, Moore [15] suggests that the ischemia of necrotizing enterocolitis contributes to angiogenesis in the healing of patients with perforations. Anecdotal experience from this series (3 patients in the laparotomy group) suggests that the neonates with the isolated perforations might have fared better with early resection and primary anastomosis. None of our BSPD patients survived without further intervention. Some of the patients with isolated perforation who initially did well with BSPD ultimately required significant resections because of the extent and density of the phlegmon remaining from the perforation and drainage. Although none of these patients has short gut syndrome, it is tempting to speculate that these might have survived with less gut resection if subjected to laparotomy and primary anastomosis as the first procedure. Morgan et al [8] speculated about the role of “scarless fetal healing” in these very premature infants who have survived BSPD without further surgical intervention. Our experience has not shown any diminution of phlegmon in the most premature infants requiring secondary surgery. In the group of patients who respond well initially to BSPD, the indications for subsequent laparotomy and the timing of that procedure are open to question. In 4 of the 6 patients who initially had a good response to BSPD, indications for laparotomy were the recurrence of a septic picture with abdominal distention, acidosis, and fluid retention 1 to 2 weeks after the drainage. The other 2 patients underwent laparotomy for failure of feedings, with an obstructive picture, 3 weeks after their initial good result from BSPD.
Because all of the patients in this series who survived initial BSPD subsequently required laparotomy for recurrent demise or for bona fide bowel obstruction, we have no answers. Some have suggested that we did not wait long enough after the BSPD to avoid subsequent laparotomy. We were more concerned that we had waited too long, after the initial response, especially in the 2 patients with the recurrent septic picture who went on to die after laparotomy. It is difficult to make sense of the contrast between this series and a similar-size series by Lessin et al [9] in which 9 patients were managed without subsequent laparotomy, with 8 early and 7 long-term survivors. Based on this limited experience, it is clear that BSPD belongs in the surgical armamentarium for the critically ill very low birth weight neonate with evidence of perforation of the intestine as evidenced by free intraperitoneal air, regardless of the etiology of perforation. This experience supports the use of BSPD as a temporizing measure in critically ill neonates with intestinal perforation, but not as definitive therapy. The indications and timing of laparotomy after BSPD remain to be defined. References [1] Ein SH, Marshall DG, Girvan D. Peritoneal drainage under local anesthesia for perforations from necrotizing enterocolitis. J Pediatr Surg 1977;12:963–7. [2] Janik JS, Ein SH. Peritoneal drainage under local anesthesia for necrotizing enterocolitis (NEC) perforation: a second look. J Pediatr Surg 1980;15:565– 8. [3] Ein SH, Shandling B, Wesson D, Filler RM. A 13-year experience with peritoneal drainage under local anesthesia for necrotizing enterocolitis perforation. J Pediatr Surg 1990;25:1034 –7. [4] Ahmed T, Ein S, Moore A. The role of peritoneal drains in treatment of perforated necrotizing enterocolitis: recommendations from recent experience. J Pediatr Surg 1998;33:1468 –70. [5] Azarow KS, Ein SH, Shandling B, et al. Laparotomy or drain for perforated necrotizing enterocolitis: who gets what and why? Pediatr Surg Int 1997;12:137–9. [6] Cheu HW, Sukarochana K, Lloyd DA. Peritoneal drainage for necrotizing enterocolitis. J Pediatr Surg 1988;23:557– 61. [7] Takamatsu H, Akiyama H, Ibara S, et al. Treatment for necrotizing enterocolitis perforation in the extremely premature infant (weighing ⬍1,000 g). J Pediatr Surg 1992;27:741–3. [8] Morgan LJ, Schochat SJ, Hartman GE. Peritoneal drainage as primary management of perforated NEC in the very low birth weight infant. J Pediatr Surg 1994;29:310 –15. [9] Lessin MS, Luks FI, Wesselhoeft CW, et al. Peritoneal drainage as definitive treatment for intestinal perforation in infants with extremely low birth weight (⬍750 g). J Pediatr Surg 1998;33:370 –2. [10] Rovin JD, Rodgers BM, Burns RC, McGahren ED. The role of peritoneal drainage for intestinal perforation in infants with and without necrotizing enterocolitis. J Pediatr Surg 1999;34:143–7. [11] Dimmitt RA, Meier AH, Skarsgard ED, et al. Salvage laparotomy for failure of peritoneal drainage in necrotizing enterocolitis in infants with extremely low birth weight. J Pediatr Surg 2000;35:856 –9. [12] Downard C, Curran T, Campbell T. Peritoneal drainage for neonatal intestinal perforation. Presented at the Pacific Association of Pediatric Surgeons, Las Vegas, Nevada, May 15-19, 2000.
H.G.S. Noble and M. Driessnack / The American Journal of Surgery 181 (2001) 416 – 419 [13] Cass DL, Brandt ML, Patel DL, et al. Peritoneal drainage as definitive treatment for neonates with isolated intestinal perforation. J Pediatr Surg 2000;35:1531– 6. [14] Takamatsu H, Noguchi H, Ikee T, et al. Small intestinal perforation in infants less than 1000 g treated initially by peritoneal drainage.
419
Presented at the Pacific Association of Pediatric Surgeons, Las Vegas, Nevada, May15–19, 2000. [15] Moore TC. Successful use of the “patch, drain, and wait” laparotomy approach to perforated necrotizing enterocolitis: is hypoxia-triggered “good angiogenesis” involved? Pediatr Surg Int 2000;16:356 – 63.