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THE NEC CONUNDRUM

THE NEC CONUNDRUM. NEC , WHAT IS IT?. 1888 ? Possible first description of NEC 1943 ? Possible first NEC operation 1964 clinical and radiological characteristics of NEC officially described Today 25000 cases per annum in USA. THE FIRST OF THE CONUNDRUMS…. WHAT ACTUALLY CAUSES IT?.

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THE NEC CONUNDRUM

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  1. THE NEC CONUNDRUM

  2. NEC , WHAT IS IT? • 1888 ? Possible first description of NEC • 1943 ? Possible first NEC operation • 1964 clinical and radiological characteristics of NEC officially described • Today 25000 cases per annum in USA

  3. THE FIRST OF THE CONUNDRUMS…. WHAT ACTUALLY CAUSES IT?

  4. PREMS AND LBW • INTESTINAL ISCHAEMIA & INFECTION • BABY FACTORS • PULMONARY IMMATURITY • PDA • LIVER IMMATURITY • IMMUNOLOGICAL DEFICIENCIES • COMPLEMENT SYSTEM COMPONENTS • IMMUNOGLOBULIN DEFICIENCIES • POLYMORPHONUCLEAR LEUKOCYTES • T-CELL AND CYTOKINE PRODUCTION LIMITED

  5. EXOGENOUS FACTORS • BIRTH ASPHYXIA • UMBILICAL ARTERY CANNULATION • EXCHANGE TRANSFUSIONS • FEEDS: FORMULA AND BREAST MILK Changing trends in NEC. JL Grosfeld. Ann Surg Vol 214 No 3 Sept 1991

  6. SO YOU WOULD THINK THIS IS SOMETHING PREVENTABLE… • Prophylactic antibiotics in prems and LBW • Prophylactic IgA and IgG • Rapid vs. slow rate of advancement feeds • Arginine 1. Cochrane Library, Neonatal Review Group 2. The Fear Of NEC versus achieving optimal growth in preterm infants-an opinion. O Flidel-Rimon et al. Acta Paediatrica 2006:95;1341-44 What’s new? • Probiotics Probiotics for prevention of NEC in preterm neonates with VLBW: a systematic review of RCT’s. G Deshpande et al. Lancet 2007;369:1614-20.

  7. How do we diagnose it? • Abdominal distension 100% • Bilious vomiting 75% • Guaiac positive stools 60% • Diarrhoea 20% • Lethargy • Temperature instability • Apnoea • Shock

  8. STAGING BELL CRITERIA 1978, MODIFIED IN 1986 BY WALSH. • STAGE I: suspected NEC • STAGE II: definite NEC • STAGE III: advanced NEC

  9. MANAGEMENT • Stage I & II usually medically, non-operatively • Stage III often surgically. Usually directed at complications of NEC

  10. INDICATIONS FOR SURGERY ABSOLUTE: free intraperitoneal air RELATIVE: portal vein air failed medical management

  11. CONUNDRUMS CONTINUE Radiological signs have a high specificity, but low sensitivity. NEC: surgical decision making. AL Tam. JPS Dec 3 2002 WHAT’S NEW?

  12. ABDOMINAL ULTRASOUND • Intramural air • Portal venous air • Free intraperitoneal air • Intra-abdominal fluid • Bowel wall thickness • Bowel wall perfusion 1.Necrotizing Enterocolitis: Review of State-of-the-Art Imaging Findings with Pathologic Correlation. M Epelmanet al. Radiographics 2007:27: 287-305. 2. Correlation of sonographic findings and outcome in necrotizing enterocolitis. S Cicero. Paediatric Radiology, Volume 37, Number 3, March 2007 , pg. 274-282(9)

  13. SURGICAL OPTIONS • Peritoneal Drainage • Laparotomy • Resection and anastomosis • Resection and stoma • Multiple resections with clip and drop back • Patch, drain and wait • Exploratory laparotomy and closure

  14. PERITONEAL DRAINAGE Introduced in the late 1970’s, specifically for VLBW babies, prior to laparotomy. Trend for peritoneal drainage to become primary surgical procedure. Dimmitt 2001: salvage laparotomy did not appear beneficial. Demestre 2002: prospective study of peritoneal drainage, 86% improved, 64% survived without need of laparotomy. Blakely 2005: prospective cohort study of NEC III showed no difference in survival rate between drainage and laparotomy. Moss 2006: The type of operation performed for perforated necrotizing enterocolitis does not influence survival or other clinically important early outcomes in preterm infants. Blakely 2006: results favored laparotomy over peritoneal drainage Cochrane review currently under way

  15. CONCLUSION • Etiology – not fully defined • Prevention – no definitive strategy • Management • Diagnosis - clinical • Type of intervention – medical vs surgical

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