Necrotizing enterocolitis (NEC) is a devastating intestinal disease that primarily affects premature and low-birth-weight infants, and when surgery becomes necessary, mortality rates can rise to 20–30%. A new comprehensive review, published online on June 2, 2026, in the World Journal of Pediatric Surgery, provides a framework for surgeons to navigate the complex decision-making process, balancing immediate survival with long-term intestinal function and quality of life.
The review, led by researchers from the Department of Pediatric Surgery at Nationwide Children's Hospital in Columbus, Ohio, addresses the critical question of when and how to operate on infants with NEC. It compares two primary surgical approaches: peritoneal drainage (PD) and exploratory laparotomy. PD, a less invasive bedside procedure, has been used for extremely low-birth-weight infants who are too unstable for laparotomy. However, a recent multicenter randomized controlled trial (RCT) found 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 that laparotomy was beneficial. This suggests that despite its risks, laparotomy may offer better outcomes for certain infants.
After bowel resection, surgeons must choose between creating a stoma or performing a primary anastomosis. Primary anastomosis is favored when the infant is stable and the remaining bowel is clearly viable. For extensive or multifocal disease, the review discusses damage control surgery, "clip and drop," diverting jejunostomy, "patch, drain and wait," and intraluminal stenting—all techniques aimed at preserving as much functional bowel as possible. These strategies are crucial because preserving intestinal length can prevent short bowel syndrome, a major cause of long-term morbidity.
The review also evaluates emerging perioperative tools that may improve outcomes. Indocyanine green fluorescence angiography (ICG-FA) can help assess intestinal viability during surgery, potentially reducing unnecessary bowel resection. Direct peritoneal resuscitation (DPR) and mucous fistula refeeding are other adjuncts that may improve perfusion and nutritional recovery, helping infants transition off total parenteral nutrition (TPN) more quickly. However, the authors caution that many of these techniques require more robust evidence before they become standard practice.
The authors emphasize that there is no one-size-fits-all approach to surgical NEC. The best strategy depends on the infant's clinical stability, the extent of intestinal injury, and the potential for bowel preservation. They advocate for a multidisciplinary approach, using tools like the Neonatal Sequential Organ Failure Assessment (nSOFA) score, imaging, and laboratory findings to identify high-risk infants earlier. In the operating room, perfusion imaging and staged procedures can help avoid excessive resection, while postoperative strategies like mucous fistula refeeding can improve nutritional outcomes.
This review is significant because it consolidates current evidence into a practical framework for pediatric surgeons and neonatologists. By highlighting the importance of bowel preservation and individualized care, it aims to improve survival and quality of life for these vulnerable patients. However, the authors stress that more comparative trials and standardized protocols are needed to validate the promising adjuncts. The full review is available at https://doi.org/10.1136/wjps-2026-001200.
