Purpose: The prognostic significance of portal venous gas (PVG) in neonatal necrotizing enterocolitis (NEC) for operative intervention (OP), neonatal complications, and mortality remains uncertain.The authors designed...Purpose: The prognostic significance of portal venous gas (PVG) in neonatal necrotizing enterocolitis (NEC) for operative intervention (OP), neonatal complications, and mortality remains uncertain.The authors designed a long-term prospective study to describe the natural history of PVG related to these outcomes and to test the hypothesis that PVG does not mandate OP.Methods: All infants admitted to a single center between October 1991 and February 2003 were evaluated weekly to identify all cases of NEC (defined as Bell stage II or higher).Demographic, radiological, surgical, and outcome data were abstracted prospectively.Radiographic studies were performed at the onset of illness and at subsequent 6-to 8-hour intervals or as clinically indicated.A single pediatric radiologist reviewed all radiographs.Values are expressed asmean±SD.Odds ratios and relative risk ratios are reported with 95%CIs.The level of significance was P ≤.05.Results: After the exclusion of 24 infants with lethal diseases, major congenital or chromosomal anomalies, or recurrent episodes of NEC, 194 of 5891 infants developed NEC.The overall incidence of NEC was 3.7%.In 194 infants with NEC, the incidence of PVG was 33%(n = 64).Gestational age (30.8 ±4 vs 29.3 ±4.2 weeks; P =.02) but not birth weight (1609 ±761 vs 1434 ±810 g; P = NS) was greater in infants with PVG compared with infants without PVG (n = 130).Sixty-six (34%) infants with NEC underwent OP.Operative intervention occurredmore frequently in infants with PVG compared with infants without PVG (OR, 2.5; CI, 1.37-4.76; P =.003)-only 48%of infants with PVG underwent OP.Among the variables, gestational age, severe NEC (Bell stage III), severe intramural gas (in all 4 abdominal quadrants), and the presence of PVG, severe NEC was most highly associated with OP (OR, 77.47; CI, 10.36-580.16; P < .0001).Bell stage III NEC was present in 98%of infants who underwent OP compared with 40%of infants without OP (P < .0001).Of all infants with NEC, 37 (19%) died.Mortality was higher among infants who underwent OP (33%vs 12%; P < .0003).A multivariate regression model identified Bell stage III (OR, 3.74; CI, 1.20-11.62; P =.02), but neither PVG nor OP, to be significantly associated with mortality.Of interest is that survival in infants with PVG was greater (but not significantly so) than in infants without PVG in both OP (74%vs 59%) and non-OP (91%vs 87%) groups.Furthermore, 30 of 64 (47%)-infants with PVG survived without OP, and of all 33 infants with PVG who did not undergo OP, 30 (91%) infants survived.Conclusions: Decision for OP should be based on the severity of NEC and not on the presence of PVG alone because nearly half of infants with PVG survive without OP.Overall, the presence of PVG does not increase the risk of mortality among infants with NEC.Severe NEC, but not OP, is associated with higher mortality.展开更多
Objective: Gut disruption in very low birth weight follows 1 of 3 clinical pathways: isolated perforation with sudden free air,metabolic derangement (MD) complicated by appearance of free air,or progressive metabolic ...Objective: Gut disruption in very low birth weight follows 1 of 3 clinical pathways: isolated perforation with sudden free air,metabolic derangement (MD) complicated by appearance of free air,or progressive metabolic deterioration without evidence of free air. To refine evidence-based indications for peritoneal drainage (PD) vs laparotomy (LAP),we hypothesized that MD acuity is the determinant of outcome and should dictate choice of PD or LAP. Methods: Very low-birth-weight infants referred for surgical care because of free intraperitoneal air or MD associated with signs of enteritis were evaluated by univariate or multivariate logistic regression to investigate the effect on mortality of MD and initial surgical care (LAP vs PD). Metabolic derangement was scaled by assigning 1 point each for thrombocytopenia,metabolic acidosis,neutropenia,left shift of segmented neutrophils,hyponatremia,bacteremia,or hypotension. Laparotomy and PD were stratified by MD acuity,and odds of mortality were calculated for each surgical option. Results: From October 1991 to December 2003,65 very low-birth-weight infants with suspected gut disruption were referred for surgical care. Peritoneal drainage and LAP infants had similar birth weight and gastrointestinal age,neither of which predicted edmortality. Despite a higher incidence of isolated perforation with sudden free air in PD infants,the incidence of MD and overall mortality were similar for PD and LAP. Multivariate logistic regression demonstrated MD to be the best predictor of mortality (odds ratio [OR],4.76; confidence interval [CI],1.41-16.13,P = 0.012),which significantly increased with interval between diagnosis to surgical intervention (P < 0.05). Infants with MD receiving PD had a 4-fold increase in mortality (OR,4.43; CI,1.37-14.29; P = 0.0126). Conversely,those withoutMD and sudden free air who underwent LAP had a 3-fold increase in mortality (OR,2.915; CI,1.107-7.692; P = 0.03.) Of 5,3 failed PD were “ rescued” by LAP. Conclusions: The dramatic difference in mortality odds based on surgical option in the presence of MD defines the critical importance of a thorough assessment of physiological status to exclude MD. Absence of MD warrants consideration for PD,especially for sudden intraperitoneal free air. Overwhelming MD may limit options to PD; however,salvage of 3 of 5 infants with failed PD demonstrates the value of LAP,whenever possible,for infants with MD.展开更多
文摘Purpose: The prognostic significance of portal venous gas (PVG) in neonatal necrotizing enterocolitis (NEC) for operative intervention (OP), neonatal complications, and mortality remains uncertain.The authors designed a long-term prospective study to describe the natural history of PVG related to these outcomes and to test the hypothesis that PVG does not mandate OP.Methods: All infants admitted to a single center between October 1991 and February 2003 were evaluated weekly to identify all cases of NEC (defined as Bell stage II or higher).Demographic, radiological, surgical, and outcome data were abstracted prospectively.Radiographic studies were performed at the onset of illness and at subsequent 6-to 8-hour intervals or as clinically indicated.A single pediatric radiologist reviewed all radiographs.Values are expressed asmean±SD.Odds ratios and relative risk ratios are reported with 95%CIs.The level of significance was P ≤.05.Results: After the exclusion of 24 infants with lethal diseases, major congenital or chromosomal anomalies, or recurrent episodes of NEC, 194 of 5891 infants developed NEC.The overall incidence of NEC was 3.7%.In 194 infants with NEC, the incidence of PVG was 33%(n = 64).Gestational age (30.8 ±4 vs 29.3 ±4.2 weeks; P =.02) but not birth weight (1609 ±761 vs 1434 ±810 g; P = NS) was greater in infants with PVG compared with infants without PVG (n = 130).Sixty-six (34%) infants with NEC underwent OP.Operative intervention occurredmore frequently in infants with PVG compared with infants without PVG (OR, 2.5; CI, 1.37-4.76; P =.003)-only 48%of infants with PVG underwent OP.Among the variables, gestational age, severe NEC (Bell stage III), severe intramural gas (in all 4 abdominal quadrants), and the presence of PVG, severe NEC was most highly associated with OP (OR, 77.47; CI, 10.36-580.16; P < .0001).Bell stage III NEC was present in 98%of infants who underwent OP compared with 40%of infants without OP (P < .0001).Of all infants with NEC, 37 (19%) died.Mortality was higher among infants who underwent OP (33%vs 12%; P < .0003).A multivariate regression model identified Bell stage III (OR, 3.74; CI, 1.20-11.62; P =.02), but neither PVG nor OP, to be significantly associated with mortality.Of interest is that survival in infants with PVG was greater (but not significantly so) than in infants without PVG in both OP (74%vs 59%) and non-OP (91%vs 87%) groups.Furthermore, 30 of 64 (47%)-infants with PVG survived without OP, and of all 33 infants with PVG who did not undergo OP, 30 (91%) infants survived.Conclusions: Decision for OP should be based on the severity of NEC and not on the presence of PVG alone because nearly half of infants with PVG survive without OP.Overall, the presence of PVG does not increase the risk of mortality among infants with NEC.Severe NEC, but not OP, is associated with higher mortality.
文摘Objective: Gut disruption in very low birth weight follows 1 of 3 clinical pathways: isolated perforation with sudden free air,metabolic derangement (MD) complicated by appearance of free air,or progressive metabolic deterioration without evidence of free air. To refine evidence-based indications for peritoneal drainage (PD) vs laparotomy (LAP),we hypothesized that MD acuity is the determinant of outcome and should dictate choice of PD or LAP. Methods: Very low-birth-weight infants referred for surgical care because of free intraperitoneal air or MD associated with signs of enteritis were evaluated by univariate or multivariate logistic regression to investigate the effect on mortality of MD and initial surgical care (LAP vs PD). Metabolic derangement was scaled by assigning 1 point each for thrombocytopenia,metabolic acidosis,neutropenia,left shift of segmented neutrophils,hyponatremia,bacteremia,or hypotension. Laparotomy and PD were stratified by MD acuity,and odds of mortality were calculated for each surgical option. Results: From October 1991 to December 2003,65 very low-birth-weight infants with suspected gut disruption were referred for surgical care. Peritoneal drainage and LAP infants had similar birth weight and gastrointestinal age,neither of which predicted edmortality. Despite a higher incidence of isolated perforation with sudden free air in PD infants,the incidence of MD and overall mortality were similar for PD and LAP. Multivariate logistic regression demonstrated MD to be the best predictor of mortality (odds ratio [OR],4.76; confidence interval [CI],1.41-16.13,P = 0.012),which significantly increased with interval between diagnosis to surgical intervention (P < 0.05). Infants with MD receiving PD had a 4-fold increase in mortality (OR,4.43; CI,1.37-14.29; P = 0.0126). Conversely,those withoutMD and sudden free air who underwent LAP had a 3-fold increase in mortality (OR,2.915; CI,1.107-7.692; P = 0.03.) Of 5,3 failed PD were “ rescued” by LAP. Conclusions: The dramatic difference in mortality odds based on surgical option in the presence of MD defines the critical importance of a thorough assessment of physiological status to exclude MD. Absence of MD warrants consideration for PD,especially for sudden intraperitoneal free air. Overwhelming MD may limit options to PD; however,salvage of 3 of 5 infants with failed PD demonstrates the value of LAP,whenever possible,for infants with MD.
