Necrotizing enterocolitis (NEC) remains one of the most daunting surgical emergencies in neonatal medicine, with mortality rates climbing from approximately 7% in medically managed cases to 20%–30% once surgery is required. Survivors often face long-term complications including intestinal strictures, nutritional deficiencies, short bowel syndrome, and neurodevelopmental impairments. Despite its severity, clinical decisions are complicated by the lack of a specific biomarker, overlap with spontaneous intestinal perforation, and uncertainty about the optimal timing and type of surgical intervention.
A comprehensive review published in the World Journal of Pediatric Surgery (DOI: 10.1136/wjps-2026-001200) provides a unified framework for operative management, comparing peritoneal drainage (PD) with exploratory laparotomy, discussing reconstruction options after bowel resection, and outlining bowel-sparing techniques for extensive disease. The review also evaluates emerging perioperative adjuncts such as indocyanine green fluorescence angiography (ICG-FA), direct peritoneal resuscitation (DPR), and mucous fistula refeeding, which may improve assessment of intestinal viability and postoperative recovery.
According to the authors from the Department of Pediatric Surgery at Nationwide Children's Hospital, the choice between PD and laparotomy depends heavily on the infant's stability and the extent of intestinal injury. PD is less invasive and can be performed at the bedside, making it suitable for extremely low-birth-weight infants who may not tolerate laparotomy. However, failure to improve often necessitates rescue surgery. Exploratory laparotomy allows direct inspection and removal of necrotic bowel. Earlier randomized trials found similar survival rates between the two approaches, but a recent multicenter randomized controlled trial showed that among infants with a preoperative diagnosis of NEC, death or neurodevelopmental impairment occurred in 69% after laparotomy versus 85% after PD, with a 97% Bayesian probability favoring laparotomy in this subgroup.
After resection, surgeons may choose between stoma creation or primary anastomosis, with the latter preferred when the infant is stable and the remaining bowel is viable. For extensive or multifocal disease, the review discusses damage control surgery, “clip and drop,” diverting jejunostomy, “patch, drain and wait,” and intraluminal stenting to minimize bowel loss. Emerging adjuncts like ICG-FA can help assess perfusion during surgery, while DPR and mucous fistula refeeding may support bowel preservation and nutritional recovery.
The review emphasizes that operative care for NEC cannot be reduced to a single preferred procedure. The best approach depends on the infant's clinical status, the extent of bowel necrosis, and the potential for preserving functional intestine. The immediate goal is survival, but long-term intestinal function, growth, and neurodevelopment must also guide surgical decisions. While emerging techniques are promising, the authors note that many require stronger evidence from well-controlled studies before they can be widely adopted.
This review offers a valuable resource for neonatal and pediatric surgical teams, aiding in multidisciplinary decision-making around timing, operative risk, and bowel preservation. Risk scores like the Neonatal Sequential Organ Failure Assessment (nSOFA) combined with imaging and laboratory findings may help identify high-risk infants earlier. In the operating room, perfusion imaging and staged bowel-preserving approaches could reduce avoidable resections, while postoperative strategies like mucous fistula refeeding may reduce dependence on total parenteral nutrition. However, the authors caution that advanced techniques need larger comparative trials and standardized protocols before becoming routine care.
