BMC surgery · 2026
Peritoneal drainage versus primary laparotomy in premature newborns with intestinal perforation: a retrospective cohort study evaluating an etiology-driven surgical approach.
СтатьяСравнительное исследованиеНазвание и аннотация: Перевод в очереди
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Shalaby Mohamed M, Negm Ahmed R, Mahran Ibrahim A, Shehata Mohamed, Awad Mohammed
Аннотация
BACKGROUND: The surgical management of intestinal perforation in extremely low birth weight (ELBW) infants, stemming from necrotizing enterocolitis (NEC) or spontaneous intestinal perforation (SIP), is a subject of enduring debate. The comparative effectiveness of initial bedside peritoneal drainage (PD) versus formal primary laparotomy (PL) on mortality and major morbidity is not fully resolved.
OBJECTIVE: To compare 90-day mortality and comprehensive morbidity outcomes between PD-first and PL-first strategies in a homogeneous cohort of preterm infants with intestinal perforation, with rigorous subgroup analysis based on disease etiology (NEC vs. SIP).
METHODS: A single-center retrospective cohort study (2010-2023) included infants with gestational age < 32 weeks and/or birth weight < 1500 g undergoing surgery for pneumoperitoneum. Propensity score matching (PSM) with comprehensive illness severity covariates was used to balance baseline characteristics. Primary outcome was 90-day all-cause mortality, with secondary analysis of attributable versus non-attributable deaths. Secondary outcomes included short-term surgical morbidity, nutritional independence, long-term gastrointestinal outcomes, and incidence of short-bowel syndrome (SBS). Sensitivity analyses addressed temporal bias and confounding by non-GI comorbidities.
RESULTS: Of 126 eligible infants, 66 underwent PD-first and 60 PL-first. After PSM with 15 covariates (n = 94), overall mortality was comparable (PD: 34.0% vs. PL: 36.2%, p = 0.81; p-for-interaction between treatment and etiology = 0.02). In the SIP cohort (n = 41), PD was associated with significantly lower mortality (15.8% vs. 45.5%, p = 0.03; adjusted HR 0.32, 95% CI 0.11-0.91) and fewer major surgical complications (21.1% vs. 54.5%, p = 0.03). Among 14 SIP patients managed definitively with PD alone, median 24-month follow-up revealed no cases of intestinal obstruction or stricture. In the NEC cohort (n = 53), PL was associated with a non-significant trend towards lower mortality (38.5% vs. 55.6%, p = 0.24) but a significantly higher rate of surgical complications (57.7% vs. 29.6%, p = 0.04). Time to full enteral feeds was shorter in the PD group overall (median 42 vs. 55 days, p = 0.02), a finding that persisted after excluding patients with non-GI comorbidities. Sensitivity analyses restricted to 2015-2023 confirmed main findings.
CONCLUSION: The observed association between initial surgical strategy and survival is contingent upon underlying etiology. PD appears advantageous for SIP, was associated with lower mortality and morbidity with acceptable long-term outcomes. For NEC, PL may offer a survival trend advantage despite higher immediate surgical morbidity, likely due to definitive source control. These findings strongly advocate for an etiology-driven surgical decision-making paradigm.
OBJECTIVE: To compare 90-day mortality and comprehensive morbidity outcomes between PD-first and PL-first strategies in a homogeneous cohort of preterm infants with intestinal perforation, with rigorous subgroup analysis based on disease etiology (NEC vs. SIP).
METHODS: A single-center retrospective cohort study (2010-2023) included infants with gestational age < 32 weeks and/or birth weight < 1500 g undergoing surgery for pneumoperitoneum. Propensity score matching (PSM) with comprehensive illness severity covariates was used to balance baseline characteristics. Primary outcome was 90-day all-cause mortality, with secondary analysis of attributable versus non-attributable deaths. Secondary outcomes included short-term surgical morbidity, nutritional independence, long-term gastrointestinal outcomes, and incidence of short-bowel syndrome (SBS). Sensitivity analyses addressed temporal bias and confounding by non-GI comorbidities.
RESULTS: Of 126 eligible infants, 66 underwent PD-first and 60 PL-first. After PSM with 15 covariates (n = 94), overall mortality was comparable (PD: 34.0% vs. PL: 36.2%, p = 0.81; p-for-interaction between treatment and etiology = 0.02). In the SIP cohort (n = 41), PD was associated with significantly lower mortality (15.8% vs. 45.5%, p = 0.03; adjusted HR 0.32, 95% CI 0.11-0.91) and fewer major surgical complications (21.1% vs. 54.5%, p = 0.03). Among 14 SIP patients managed definitively with PD alone, median 24-month follow-up revealed no cases of intestinal obstruction or stricture. In the NEC cohort (n = 53), PL was associated with a non-significant trend towards lower mortality (38.5% vs. 55.6%, p = 0.24) but a significantly higher rate of surgical complications (57.7% vs. 29.6%, p = 0.04). Time to full enteral feeds was shorter in the PD group overall (median 42 vs. 55 days, p = 0.02), a finding that persisted after excluding patients with non-GI comorbidities. Sensitivity analyses restricted to 2015-2023 confirmed main findings.
CONCLUSION: The observed association between initial surgical strategy and survival is contingent upon underlying etiology. PD appears advantageous for SIP, was associated with lower mortality and morbidity with acceptable long-term outcomes. For NEC, PL may offer a survival trend advantage despite higher immediate surgical morbidity, likely due to definitive source control. These findings strongly advocate for an etiology-driven surgical decision-making paradigm.