Operative strategies for necrotizing enterocolitis: The prevention and treatment of short-bowel syndrome

Necrotizing enterocolitis (NEC) is the leading cause of short-bowel syndrome (SBS) in infancy. Studies on the acute medical and surgical management of NEC have traditionally focused on short-term morbidity and mortality, with less emphasis on long-term outcomes. Acute surgical management of NEC involves the often competing priorities of controlling sepsis and preserving bowel length. Bowel-preserving strategies for NEC, designed to limit SBS, are based on peritoneal drainage, limited resection, or a combination of both. Drainage-based strategies are generally favored in smaller neonates, while laparotomy-based strategies are favored in larger patients, especially those with a more limited extent of intestinal injury. Comparisons of drainage-based approaches and resection-based approaches are limited by confounding variables, and neither approach is clearly superior with regard to subsequent SBS. These traditional as well as more creative approaches to bowel preservation have application in NEC, yet they depend on a series of patient and treatment characteristics that include the ability of diseased but viable bowel to recover both absorptive and motility function after acute NEC, the ability of the infant to tolerate appropriately drained intraperitoneal contamination, and the ability of the injured intestine to subsequently undergo intestinal adaptive change. In addition, there are a series of operative options that have been designed to mitigate the impact of SBS once it is established. These procedures are not uniquely applied exclusively for NEC-induced SBS. However, strategies that slow intestinal transit, improve peristaltic function, or enhance mucosal absorptive function each have application in the management of SBS.