Is there a benefit of peritoneal drainage for necrotizing enterocolitis in newborn infants?

Abstract

Primary peritoneal drainage in infants with perforated necrotizing enterocolitis (NEC) has been used for many years [1-3]. Pediatric surgeons have viewed peritoneal drainage as a definitive treatment in some patients [3] but also as a temporizing measure, facilitating stabilization of very sick infants for a subsequent laparotomy before or after transfer to a pediatric surgical center [1,2]. Two multicenter randomized controlled trials comparing survival after primary peritoneal drainage or primary laparotomy have recently been published [4,5] Neither trial reached the recruitment target nor showed a significant benefit from drain or laparotomy. A meta-analysis of these 2 trials indicates no clear benefit from either treatment [4]. A third randomized controlled trial has been initiated in the United States (ClinicalTrials.gov Identifier: NCT01029353) with the primary outcome of death or neurodevelopmental impairment at 18 to 22 months of corrected age. Unless this current trial shows a dramatically different result from the others, it would seem unlikely that peritoneal drainage has a role in the future as a definitive treatment in NEC. The value of peritoneal drainage as a temporizing measure is less clear. The trial protocol of Moss et al [5] did not encourage early laparotomy following drain placement in patients with persistent metabolic acidosis, hemodynamic instability, and respiratory failure (although it did allow it). Consequently, only 9% of drain patients had a rescue laparotomy, and the trial of Moss et al was therefore mainly a trial of peritoneal drain as a definitive treatment [5]. In contrast, in the trial of Rees et al [4], 74% of the patients randomized to a drain required rescue laparotomy for clinical deterioration after 2.5 days (range, 0.4-21 days). Importantly, only 4 patients survived with a drain as definitive treatment [4]. Rees et al [4] concluded that primary peritoneal drainage is ineffective as either a temporizing measure or definitive treatment and that if a drain is inserted, a timely “rescue” laparotomy should be considered [4]. A survey of pediatric surgeons in the UK [6] showed that 95% used drains, with the indications being (i) stabilization

DOI: 10.1016/j.jpedsurg.2010.09.001

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Cite this paper

@article{Pierro2010IsTA, title={Is there a benefit of peritoneal drainage for necrotizing enterocolitis in newborn infants?}, author={Agostino Pierro and Simon Eaton and Clare M. Rees and Paolo De Coppi and Edward Matthew Kiely and Mark J. Peters and Joe Brierley}, journal={Journal of pediatric surgery}, year={2010}, volume={45 11}, pages={2117-8} }