Surgical decision-making for necrotizing enterocolitis (NEC) in premature infants remains one of the most challenging areas in pediatric surgery. A new comprehensive review, published in the World Journal of Pediatric Surgery, provides a clinical framework for choosing between peritoneal drainage (PD) and exploratory laparotomy, and outlines strategies for bowel preservation and reconstruction. The review underscores that surgery should not only control the immediate disease but also preserve functional bowel, reduce long-term complications, and support better quality of life for these vulnerable patients.
NEC is a devastating condition that primarily affects premature and low-birth-weight infants. While mortality is around 7% in medically managed cases, it rises to 20%–30% when surgery is required. Survivors often face significant long-term issues, including strictures, nutritional problems, intestinal failure due to short bowel syndrome, and neurodevelopmental impairments. The lack of a specific biomarker, overlap with spontaneous intestinal perforation, and uncertainty about the optimal timing of surgery further complicate clinical decisions. Surgeons must delicately balance removing necrotic bowel against preserving enough intestine for future growth and nutrition. Given these challenges, the review calls for deeper research to improve early risk stratification and operative selection.
Researchers from the Department of Pediatric Surgery at Nationwide Children's Hospital in Columbus, Ohio, synthesized current evidence to guide surgical management. The review highlights that 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 showed broadly similar survival between the two approaches, but a more recent multicenter randomized controlled trial 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 in this subgroup.
After resection, surgeons may choose between stoma creation and primary anastomosis. Primary anastomosis is most suitable when the infant is relatively 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 aimed at limiting unnecessary bowel loss. It also evaluates emerging adjuncts such as indocyanine green fluorescence angiography (ICG-FA), direct peritoneal resuscitation (DPR), and mucous fistula refeeding, which may improve perfusion assessment, bowel preservation, or nutritional recovery.
The authors emphasize that operative care for NEC cannot be reduced to a single preferred procedure. The best approach depends on how sick the infant is, whether the bowel is clearly non-viable, and how much intestine can safely be preserved. The immediate goal is survival, but long-term intestinal function, growth, and neurodevelopment must also shape surgical decisions. Emerging adjuncts are promising, but several still rest on limited neonatal evidence and need stronger, well-controlled studies before widespread adoption.
The review could help neonatal and pediatric surgical teams structure multidisciplinary decisions around timing, operative risk, and bowel preservation rather than treating all surgical NEC the same way. Risk scores such as the Neonatal Sequential Organ Failure Assessment (nSOFA), along with imaging, laboratory findings, and clinical trajectory, may support earlier recognition of high-risk cases. In the operating room, perfusion imaging and staged bowel-preserving approaches may reduce avoidable resection, while postoperative strategies like mucous fistula refeeding may reduce dependence on total parenteral nutrition and speed progression toward full feeds. However, the authors caution that many advanced techniques still need larger comparative trials and standardized protocols before becoming routine care.
For more details, the full review is available in the World Journal of Pediatric Surgery, DOI: 10.1136/wjps-2026-001200. The journal, sponsored by Zhejiang University and Children's Hospital, Zhejiang University School of Medicine, and published by BMJ Group, is indexed in PubMed, ESCI, Scopus, CAS, DOAJ, and CSCD, with an Impact Factor of 2.1/Q2 and a CiteScore of 2.5.
