Necrotizing enterocolitis (NEC) is a devastating intestinal disease that primarily affects premature and low-birth-weight infants. While some cases can be managed medically, many require surgical intervention, and the decision of when and how to operate remains one of the most challenging in pediatric surgery. A new comprehensive review, published in the World Journal of Pediatric Surgery, aims to consolidate current evidence into a practical framework for surgeons and neonatologists.
The review, authored by researchers from the Department of Pediatric Surgery at Nationwide Children's Hospital in Columbus, Ohio, was published online on June 2, 2026, and is available under DOI: 10.1136/wjps-2026-001200. It synthesizes findings on operative strategies, including peritoneal drainage (PD) versus exploratory laparotomy, bowel reconstruction options, and techniques for preserving intestinal length in cases of extensive disease. The authors stress that surgical care for NEC must be individualized, balancing the immediate goal of survival with long-term outcomes such as intestinal function, growth, and neurodevelopment.
The stakes are high: mortality in surgical NEC ranges from 20% to 30%, compared to about 7% in medically managed cases. Survivors face significant morbidity, including strictures, nutritional problems, short bowel syndrome, and neurodevelopmental impairment. The review highlights the lack of a specific biomarker for NEC and the diagnostic overlap with spontaneous intestinal perforation, which complicates early decision-making.
When surgery is needed, the choice between PD and laparotomy depends on the infant's stability and the extent of bowel injury. PD is less invasive and can be performed at the bedside, making it attractive for extremely low-birth-weight infants who may not tolerate a full laparotomy. However, PD often fails, requiring rescue surgery. Laparotomy allows direct inspection and removal of necrotic tissue. Early randomized trials showed similar survival between the two, 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 bowel resection, surgeons may choose to create a stoma or perform a primary anastomosis. The latter is preferred 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" technique, diverting jejunostomy, "patch, drain and wait," and intraluminal stenting, all aimed at preserving as much bowel as possible.
Emerging perioperative tools are also evaluated, including indocyanine green fluorescence angiography (ICG-FA) to assess intestinal perfusion, direct peritoneal resuscitation (DPR), and mucous fistula refeeding to improve nutritional recovery. These adjuncts hold promise but currently rest on limited neonatal evidence, and the authors call for larger comparative trials and standardized protocols before they become routine.
The review offers a structured approach to NEC surgery, emphasizing that there is no one-size-fits-all procedure. It encourages multidisciplinary teams to use risk scores like the Neonatal Sequential Organ Failure Assessment (nSOFA), along with imaging and laboratory findings, to identify high-risk infants earlier. In the operating room, perfusion imaging and staged bowel-preserving strategies may reduce avoidable resection, while postoperative strategies like mucous fistula refeeding may reduce dependence on total parenteral nutrition and speed the transition to full feeds.
This review is a valuable resource for neonatal and pediatric surgical teams, providing a framework that could help improve outcomes for these fragile patients. By focusing on bowel preservation and long-term quality of life, it underscores the need for a thoughtful, individualized approach to surgical NEC.
