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2 Procedures Equal for Preemie Bowel Complication

Study finds intestinal infection can be treated with drainage or laparotomy

WEDNESDAY, May 24, 2006 (HealthDay News) -- Necrotizing enterocolitis is a serious complication that can occur in premature infants, and there has been much debate over the best way to treat this condition.

A new study, appearing in the May 25 issue of the New England Journal of Medicine, found that the outcomes for premature infants with this serious intestinal complication were similar whether the babies underwent laparotomy or peritoneal drainage.

"Necrotizing enterocolitis remains a big problem. Mortality rates have remained unchanged for the past 30 years," said the study's lead author, Dr. R. Lawrence Moss, surgeon-in-chief at Yale New Haven Children's Hospital in New Haven, Conn.

"One issue has been the choice of operation. One is very invasive, and one is minimally invasive, but there's been no good data on outcomes upon which to base a decision," he explained. This study, he added, found "the choice of operation did not appear to affect outcome in any way."

In the simplest terms, necrotizing enterocolitis is an infection that occurs in premature infants' bowels. There are many reasons why this occurs, including an immature digestive system and the fact that premature babies probably don't regulate blood flow to the intestines as well as full-term babies do, according to Dr. Michael Giuliano. He is chief of the division of neonatology/neonatal intensive care unit at the Joseph M. Sanzari Children's Hospital at Hackensack University Medical Center, in New Jersey.

Necrotizing enterocolitis is a very serious complication of prematurity that can destroy part of the bowels and can even cause death or long-term neurodevelopmental problems.

Laparotomy has been the standard surgical procedure for babies with severe necrotizing enterocolitis. In this procedure, the abdomen is opened and the dead portions of the bowel are removed. The problem is, even with this procedure, many babies still did poorly.

With the hope of improving outcomes for these young babies, surgeons in Toronto attempted a less-invasive procedure called peritoneal drainage. This procedure is much less invasive and allows the infection to drain and relieves some pressure in the abdomen. But, in these tiny babies, somehow the body reabsorbs the dead tissue. Moss said doctors weren't really sure why or how this happens in premature infants.

Both procedures appear to be somewhat effective, but there had been no clear, compelling evidence to support either one, according to Moss and Giuliano.

To try to settle the debate over which procedure is better or safer, Moss and his colleagues randomly assigned 117 preterm babies from 15 different medical centers to undergo peritoneal drainage or laparotomy with bowel resection. The babies were assessed 90 days after their surgeries.

Fifty-five infants received peritoneal drainage while 62 underwent laparotomy. Twenty-one babies from the peritoneal drainage group eventually had laparotomy due to bowel complications. These babies were still included in the peritoneal drainage group.

After 90 days, 35 percent of the babies in the peritoneal drainage group had died, compared to 36 percent of the babies in the laparotomy group.

The length of hospital stay was slightly less for the laparotomy group: 116 days vs. 126 days for the peritoneal drainage group.

"It's tempting to say do the peritoneal drainage, because the outcomes are similar and it's less invasive, but for individual surgeons and centers, I'd say do the procedure you and your center are most comfortable doing," Moss said.

Giuliano said, "This study adds an immense amount of information to the literature, but it doesn't settle the debate."

Moss added that he'd like to see a shifting of the debate to focus on the prevention of these infections in the first place.

More information

To learn more about the health consequences of premature birth, visit the March of Dimes.

SOURCES: R. Lawrence Moss, M.D., chief of pediatric surgery, Yale Medical School, surgeon-in-chief, Yale New Haven Children's Hospital, New Haven, Conn.; Michael Giuliano, M.D., M.Ed., chief of the division of neonatology/neonatal intensive care unit, the Joseph M. Sanzari Children's Hospital at Hackensack University Medical Center, N.J., and associate professor of pediatrics, State University of New York Downstate, New York City; May 25, 2006, New England Journal of Medicine
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