Peritoneal Drainage as Primary Management in Necrotizing
Enterocolitis: A Prospective Study
By Xavier Demestre, Gemma Ginovart, Josep Figueras-Aloy, Roser Porta, Xavier Krauel,
Alfredo Garcia-Alix, and Frederic Raspall
Barcelona, Spain
Background-Purpose: The use of peritoneal drainage (PD) in
neonates with necrotizing enterocolitis (NEC) is controver-
sial. The authors began to perform it successfully in infants
with pneumoperitoneum, and subsequently they extended
its use to infants with peritonitis and advanced NEC before
radiologic evidence of peritoneal free air. To analyze the
efficacy of PD they began a prospective study.
Methods: A prospective study was conducted in 6 neonatal
intensive care units (NICU) in Spain: neonates with pneumo-
peritoneum or peritonitis and advanced NEC were all in-
cluded, whatever the birth weight and gestational age (GA).
Results: PD was performed in 47 infants, but 3 of them were
excluded because pneumoperitoneum was caused by pa-
thologies other than NEC. In a cohort of 44 infants, 86%
improved after PD, and 64% survived after only PD. After PD,
N ECROTIZING ENTEROCOLITIS (NEC) is the
most common life-threatening gastrointestinal
emergency in the neonatal period, but other etiologies
also can be present. Ein et al1 introduced peritoneal
drainage (PD) as a way of stabilizing and improving the
systemic signs and symptoms of premature infants with
intestinal perforation from necrotizing enterocolitis
(NEC) before laparotomy. Afterwards, several reports
recognized that PD may be a definitive treatment for
some infants.2-9
We first performed PD successfully in 2 consecutive
preterm babies with birth weight under 1,500 g and
pneumoperitoneum. Subsequently, we extended the in-
dication of PD to infants with pneumoperitoneum re-
gardless of their birth weight and gestational age. Most
recently, we have included infants with advanced NEC
From the Hospital de Barcelona, SCIAS; Hospital de la Santa Creu
i Sant Pau; Hospital Clinic, Institut de Ginecologia, Obstetricia i
Neonatologia, Unitat Integrada de Pediatria; Institut Universitari
Dexeus; Hospital de Sant Joan de Dèu, Barcelona, Spain and Hospital
Universitario Materno-Infantil de Las Palmas, Las Palmas de Gran
Canaria.
Address reprint requests to Dr Xavier Demestre, Servei de Pediatria-
Neonatologia, Hospital de Barcelona, SCIAS, Avda. Diagonal 660,
08034 Barcelona, Spain.
Copyright 2002, Elsevier Science (USA). All rights reserved.
0022-3468/02/3711-0004$35.00/0
doi:10.1053/jpsu.2002.36179
1534 Journal of Pediatric Surgery, Vol 37, No 11 (November), 2002: pp 1534-1539
54% of infants needed delayed surgery. Overall survival rate
was 82%; 57% infants with birth weight under 1,000 g, and
95% in infants over 1,000 g at birth. The main cause of
mortality was massive NEC in the tiniest babies. Only one
infant had a short bowel syndrome.
Conclusions: From the authors’ point of view, PD is the first
step in treating neonates with pneumoperitoneum or over-
whelming NEC, regardless of birth weight and GA. Laparot-
omy, if it is necessary, always must be performed after
clinical stability is achieved. Mortality rates remain higher in
the tiniest babies because of massive NEC.
J Pediatr Surg 37:1534-1539. Copyright 2002, Elsevier Sci-
ence (USA). All rights reserved.
INDEX WORDS: Necrotizing enterocolitis, peritoneal drain-
age, pneumoperitoneum, newborn.
(progressive abdominal distension, clinical and biochem-
ical deterioration).10 In addition to our center, other
neonatal intensive care units (NICU) in Spain have
adopted the same use of PD preferentially over laparot-
omy.11 We report the first prospective clinical series of
neonates with pneumoperitoneum and/or peritonitis
treated with PD.
MATERIALS AND METHODS
From January 1995 to July 2000 we performed PD in 47 consecutive
newborn infants in the NICU of 6 hospitals in Spain (Table 1).
Preestablished enrollment criteria are described in the algorithm treat-
ment (Fig 1). The indication for PD was: group 1, All newborns with
pneumoperitoneum, regardless of birth weight, gestational age, or
etiology (Fig 1A) and group 2, All newborns with peritonitis from
advanced NEC (according to Bell staging criteria modified by Walsh
and Kliegman).12 Biochemical and clinical impairment with progres-
sive abdominal distension, painful abdominal palpation increased,
hemodinamyc instability, and radiologic signs of ascites was indication
of PD (Fig 1B).
Information was delivered to the parents about the use of this
technique as a first step in treatment followed by laparotomy in
unsuccessful cases.
PD was performed at the bedside in the NICU, under sterile condi-
tions and with the use of sedation and local anesthesia. A small skin
incision was made on the right or left lower quadrant of abdominal
wall, preferably over the air or fluid identified radiologically (the right
side was usually the site of choice). The drain never was placed where
an abdominal mass was identified. An 8F (2.7-mm diameter) catheter
was inserted carefully 2 to 3 cm into peritoneal cavity, and fluid was
collected for microbiologic cultures. The catheter was fixed at skin and
the end left free in a collection bag. Quantity and quality of drained
PERITONEAL DRAINAGE FOR NEC
Table 1. Distribution of Infants in the Six NICUs
Hospital No.
Sant Pau 15
Inst Dexeus 11
Clı́nic 7 quelae. Only one infant over 28 weeks died (survival rate
Barcelona 6
Sant Joan de Déu 4
Las Palmas de GC (since 1998) 4
Total 47
NOTE. NEC was diagnosed in 44 infants.
fluid was recorded daily. PD was removed 24 to 48 hours after fluid
drainage ceased, and clinical and radiologic improvement was evident.
If there was a recurrent pneumoperitoneum, and the clinical status was
unstable, a second PD was placed on the other side.
The clinical course was followed closely. Hemodynamic stability,
better oxygenation, and absence of clinical progression of disease were
signs of improvement. Decrease of abdominal distension, less painful
abdominal palpation, and remission of abdominal wall cellulitis were
the earliest clinical signs of improvement (24 hours). After this,
intestinal obstruction, metabolic acidosis, white cell count abnormali-
ties, thrombocytopenia, and elevated C-reactive protein levels recov-
ered more slowly (24 to 72 hours; Fig 1C).
Radiologically, in cases of pneumoperitoneum, free intraperitoneal
air must disappear soon after PD along with a progressive return to a
normal intestinal air distribution. Laparotomy was indicated when the
following occurred (Fig 1D): (1) no improvement or deterioration in
clinical findings, (2) radiologic signs of intestinal obstruction still were
present after clinical and biochemical improvement, (3) failure of a
second PD for recurrent pneumoperitoneum.
RESULTS
PD was performed in 47 babies. In 3 infants, pneu-
moperitoneum was secondary to an etiology other than
Fig 1. Algorithm for the treatment of necrotizing enterocolitis.
1535
NEC (Hirschsprung’s disease, appendicitis, and Meck-
el’s diverticulum with intestinal duplication) and were
excluded from the study.
Table 2 describes the survival rate and intestinal se-
96%); however, in infants under 29 weeks the survival
rate was 44%.
Group 1 (pneumoperitoneum) consisted of 18 babies,
and group 2 (peritonitis) consisted of 26. Table 3 records
the results of these 2 groups. Delayed surgery was that
performed once the infant had recovered intestinal func-
tion and showed late intestinal complications such as
strictures both clinically and radiologically.
The results obtained in both groups according to birth
weight greater than or less than 1,000 g are described in
Table 4.
Table 5 shows the data of the 11 newborns who died.
Ten infants of 11 who died had a birth weight less than
1,000 g and a GA under 29 weeks. In 3 infants (cases 3,
8, and 9) support was withdrawn because of grade IV
intraventricular hemorrhage (IVH). One of them (case
3), died 24 days after PD and showed complete gastro-
intestinal recovery at autopsy. In group 1, 6 babies died,
5 improved after PD, and 4 recovered intestinal function
before death. Another 2 infants from this group died after
PD plus laparotomy; one of them (case 2) died 12 days
later of pseudomonas sepsis, and the other (case 4) died
22 days later of renal failure. Both had recovered intes-
tinal function. Two infants died because of massive
NEC: The first (case 5), after having recovered from
NEC treated only with PD, and after successfully reini-
tiating enteral nutrition, had a NEC relapse secondary to
intestinal stenosis not detected earlier; he died 24 hours
after laparotomy. The second (case 6) died with pneu-
moperitoneum from gastric perforation. After improve-
ment post-PD and clinical stability, but without evidence
of recovered intestinal function, he had NEC 7 days later
and died one day after laparotomy for massive NEC and
multiple intestinal perforations. Finally, a premature
baby of 23 weeks GA and 620 g at birth (case 1)
presented with NEC and a pneumoperitoneum at 14 days
old and died one day after PD of a complication of
respiratory ventilation.
Table 2. Survival Rate According to Gestational Age
Gestational Age (wk) No. Survived (%) Intestinal Sequela
23-24 3 0
25-26 8 4 (50) 44%
27-28 7 4 (57)
29-30 4 4 (100)
31-32 6 6 (100)
33-34 5 5 (100)
96%
35-36 7 6 (86)
⬎36 4 4 (100) 1*
Totals 44 33 (82)
*Short bowel syndrome.
1536 DEMESTRE ET AL

Table 3. Distribution of Results According to Indication for Peritoneal Drainage

Pneumoperitoneum (Group 1) Peritonitis (Group 2)

No. 18 26
Birth weight (g) 1,280 ⫾ 790 (610-3,370) 1,394 ⫾ 667 (560-2,930)
Gestational age (wk) 29 ⫾ 4 (23-40) 31 ⫾ 4 (24-40)
Age at PD (d) 10 ⫾ 5 (2-19) 18 ⫾ 15 (2-55)
PD only (%) 10 (55) 18 (69)
PD ⫹ laparotomy (%) 8 (45) 8 (31)
Days after PD until laparotomy 11 (1-29) 5 (1-18)
Improvement after PD* (%) 17 (94) 22 (85)
Overall survival rate (%) 12 (67) 21 (81)
Survival rate after PD only (%) 8/10 (80) 16/18 (89)
Survival rate with PD at laparotomy (%) 4/8 (50) 5/8 (62)
Delayed surgery (%) 3/12 (25) 10/21 (48)
Intestinal sequela (%) 0 1†/21 (5)

*Clinical and biochemical improvement.

†Short bowel syndrome.

In group 2, 5 infants died. Only 2 of them improved
after PD. All of them died less than 7 days after PD or
laparotomy. In 2 newborns, support was withdrawn 5
days after PD because of grade IV IVH: one of them had
candida albicans septicemia (case 8) and evidence of
necrotizing tracheobronchitis and thrombosis of the ab-
dominal aorta at autopsy; the other had Escherichia coli
sepsis. The remaining 3 infants who died did so a few
days after laparotomy because of massive NEC (cases 7,
10, 11).
DISCUSSION
PD was proposed initially as a measure to stabilize
infants before laparotomy.1,2 However, some investiga-
tors have since reported that PD may be considered
definitive therapy in infants with rapid improve-
ment.3-5,8,14 Mortality associated with intestinal perfora-
tion caused by NEC and treated with primary laparotomy
remains at about 40% in premature infants with a birth
weight less than 1,000 g and about 50% in those under
750 g.6-8,13-16 The combined effects of general anesthesia
and major abdominal surgery increase the risk of hemo-
dynamic instability caused by hypotension, transfusion
requirements, third spacing of fluids, and hypothermia.
Furthermore, intestinal ischemia secondary to local va-
soconstrictive effects and visceral shunting (diving re-
flex) might be triggered leading to infarction.8
This prospective multicentered trial was performed
after a treatment algorithm (Fig 1), and the results was
compared with a historical control group (Tables 6,7).
We have divided our patients according to indication
of PD (group 1, pneumoperitoneum or group 2, perito-
nitis) and weight less than or greater than 1,000 g with
the aim of comparing the results with those of other
reports.
In our series 24 infants (64%) survived after only PD,

Table 4. Results According to Birth Weight and Indication for Peritoneal Drainage
⬍1,000 g at Birth ⬎1,000 g at Birth

Pneumoperitoneum Peritonitis Pneumoperitoneum Peritonitis

(Group 1) (Group 2) (Group 1) (Group 2)

No. 11 12 7 14
Birth weight (g) 763 (610-900) 826 (560-980) 2,093 (1,400-3,370) 1,882 (1,150-2,930)
GA (wk) 26 (23-29) 28 (24-32) 34 (31-40) 34 (29-40)
Age at PD (d) 11 (5-19) 21 (8-48) 8 (2-18) 16 (2-55)
Improvement after PD (%) 9 (82) 10 (83) 7 (100) 12 (86)
Overall survival rate (%) 5/11* (45) 8/12† (66) 7 (100) 13 (93)
PD only (%) 7 (64) 8 (67) 3 (43) 10 (71)
Survival rate after PD only (%) 5/7* (71) 6/8† (75) 3 (100) 10 (100)
Delayed surgery after PD only (%) 2/5 (40) 4/6 (67) 1/3 (33) 6/10 (60)
PD ⫹ laparotomy (%) 4 (36) 4 (33) 4 (57) 4 (28)
Days after PD until laparotomy 12 (1-20) 7 (2-18) 22 (7-40) 21 (4-51)
Survival after PD ⫹ laparotomy (%) 0/4 2/4 (50) 4/4 (100) 3/4 (75)
Delayed surgery after PD ⫹ laparotomy — 0/2 0/4 0/3
Intestinal sequela — — — 1‡

*One infant, vital support withdrawn (not excluded in the results).

†Two infants, vital support withdrawn (not excluded in the results).
‡Short bowel syndrome.
PERITONEAL DRAINAGE FOR NEC 1537

Table 5. Deaths After Peritoneal Drainage

Intestinal
Weight GA Age at PD Drain Improved Laparotomy Transit Death (days after PD
Case (g) (wk) (d) Groups* after PD (days after PD) Recovered or laparotomy) Cause of Mortality

1 620 23 14 1 No No No 1 Respiratory failure

2 610 24 19 1 Yes 1 Yes 12 Sepsis (pseudomons)
3 850 25 12 ⫹ 13 1 Yes No Yes 24 IVH†
4 710 26 14 1 Yes 6 Yes 22 Renal failure
5 875 26 13 1 Yes 10 Yes 1 NEC relapse, massive
NEC
6 685 28 5 1 Yes 12 No 1 Gastric perforation ⫹
massive NEC
7 560 24 48 ⫹ 59 2 Yes 18 No 6 Massive NEC
8 920 26 11 2 No No No 5 IVH†
Sepsis (E. coli)
9 930 27 8 2 Yes No Yes 5 IVH†
Sepsis (candida)
10 700 28 22 2 No 2 No 6 IVH
Massive NEC
11 1750 35 51 2 No 1 No 2 Multiorganic failure
⫹ NEC relapse

*Group 1, pneumoperitoneum; group, 2 peritonitis.

†Support withdrawn.

8 (80%) in group 1, and 16 (89%) in group 2. Eleven Azarow et al7 who found a higher survival rate with
infants (48%) survived after only PD with birth weight primary laparotomy in newborns with NEC perforation
less than 1,000 g. This means that approximately half of who weighed more than 1,000 g versus PD and advised
the infants, regardless of weight and gestational age, its use only in infants with very low birth weight (less
survived from severe NEC and PD. However, more than 1,000 g). Higher survival rates in our prospective series
half of them (54%) required delayed surgery because of is perhaps caused by use of PD in all infants, not only in
intestinal complications (stenosis, fistula, strictures) but those with perforation as in retrospective studies.
always in a more favorable clinical condition, without In our series, 10 of 11 infants who died weighed less
severe intestinal sequela. However, as reported previ- than 1,000 g at birth, and their GA was less than 28
ously,17 these type of intestinal complications are seen weeks; this was the population with the highest neonatal
more frequently in infants with advanced NEC treated mortality risk.7 Moreover, if we observe only the overall
with PD than after laparotomy. In our series, none of mortality rate in infants under 1,000 g at birth, without a
those infants who survived after PD plus laparotomy careful study of the mortality causes, we do not really
needed delayed surgery. evaluate the true efficacy of PD. We found that 86% of
About 36% needed laparotomy after PD because of the infants improved after PD, with similar percentages
clinical worsening or not enough improvement. The in all studied groups according to the indications of PD
results were extremely poor in infants under 1,000 g at or birth weight. Rovin et al9 also reported a 100%
birth and pneumoperitoneum (all 4 infants died), and in improvement after PD. When the main cause of mortality
infants under 1,000 g and peritonitis only 50% survived. was analyzed, we observed that it was massive NEC (5
However, in infants with birth weight over 1,000 g the of 11) in infants less than 1,000 g at birth. However, in
results were outstanding: 100% survived in group 1 after
only PD or PD plus laparotomy. In group 2, only one
infant died after peritonitis and PD (survival rate 93%). Table 7. Results According to Birth Weight in an Historical Control
From 1990 to 1994
These results are in disagreement with those reported by
⬍1,000 g ⬎1,000 g
at Birth at Birth
Table 6. Results in an Historical Control From 1990 to 1994
No. 15 21
No. 36 Birth weight (g) 862 (608-990) 1,889 (1,100-3,680)
Birth weight (g) 1,461 ⫾ 746 (608-3680) GA (wk) 27 (25-31) 34 (29-40)
Gestational age (wk) 31 ⫾ 4 (25-40) Overall survival rate (%) 7/15 (47) 15/21 (71)
Overall survival rate (%) 22 (61) Intestinal sequela (%) 3/7 (43)* 1/15 (7)*
Intestinal sequela (%) 4 (18%)
NOTE. All infants with pneumoperitoneum caused by NEC and
NOTE. All infants with pneumoperitoneum caused by NEC and primary laparotomy.
primary laparotomy. *Short bowel syndrome.
1538
2 (cases 5 and 6), an earlier laparotomy may have been
indicated when clinical stabilization was obtained. We
are in agreement with Ataken et al18 in considering it
necessary to have diagnostic criteria to identify those
infants in whom only PD may be sufficient; however,
definite surgical treatment must not be delayed when
clinical stabilization is achieved. In the remaining 3
infants, all with peritonitis caused by massive NEC,
laparotomy was not successful, but there are no reports
with successful results in massive NEC.7,9,15,19-21 In such
cases, laparotomy generally is associated with extensive
intestinal resections with poor outcome7,14; an early PD
and wait-and-see attitude may be better.22 Sonntag et al23
proposes that the prognostic value of multisystem organ
failure and capillary leak syndrome is higher than that of
the classification criteria in NEC of very low birth weight
by Walsh and Kliegman.12 We want to underline that in
the 3 infants with birth weight less than 1,000 g who
died, support was withdrawn, and one of them died after
intestinal function was restored completely.
A very important aspect in our series is the absence of
severe intestinal sequela in our infants with pneumoperi-
toneum or weight less than 1,000 g at birth, in contrast
with other reports.14,24 Moreover, we found that in in-
fants over 1,000 g at birth, only one of them had a short
bowel syndrome; in such situations, to perform a lapa-
rotomy on a highly hemodynamically unstable infant
leads to unfavorable results.22
We began to perform PD in infants with advanced
NEC and peritonitis because we had previously seen
infants with large intestinal necrosis on laparotomy who
did not have pneumoperitoneum. Kazez et al25 showed
that intestinal distension increased the damaging effects
of hypoxia-reoxygenation on the gut. Therefore, we
performed PD when abdominal distension appeared and
peritoneal fluid increased on radiologic examination sug-
gesting advanced NEC. It is in this group of infants, it is
more difficult to determine when more aggressive ther-
apy is indicated. We believe that PD is an easy procedure
with minimal risk. Neonatologists and pediatric surgeons
must diagnose and treat these problems sooner before
impairment progresses, taking into account the wide
variability in interpretation of abdominal radiographs of
infants with suspected NEC.26
Current evidence suggests that the immature neonatal
gut barrier may be particularly susceptible to splanchnic
hypoperfusion. Perinatal insults that impair mesenteric
circulation may, therefore, induce intestinal mucosal in-
jury and permit local intestinal microbial flora to breach
the mucosal barrier. This process, in turn, initiates an
inflammatory cascade leading to full-blown NEC.27,28
Edelson et al29 describes that interleukin-8 (IL-8); IL-1
receptor antagonist (IL-1ra), and IL-10 are released more
slowly after such a stimulus and may be more useful than
DEMESTRE ET AL
IL-6 or tumor necrosis factor alpha (TNF ␣) to identify
more severe cases earlier. However, the role of inflam-
matory cytokines and nitric oxide in the pathogenesis of
NEC still is undefined.30 Therefore, if we can identify,
within hours of onset of symptoms, which babies have
bowel damage, this treatment (PD) can be initiated ear-
lier.
Furthermore, Lessin et al8 proposed PD followed by
irrigation with normal saline solution until the fluid
drained is clear, and Birk et al31 included the use of a
continuous lavage system for postoperative treatment to
eliminate endotoxines and cytokines.
We want to point out another aspect of confusion in 3
infants who had pneumoperitoneum caused by some-
thing other than NEC (intestinal perforation from Meck-
el’s diverticulum and intestinal duplication, appendicitis
and Hirschsprung’s disease); all 3 patients had over-
whelming sepsis, and it was not indicated to perform
laparotomy because of their severe instability. All 3
infants survived after PD, and surgery was performed
some days later when their clinical condition was appro-
priate. Therefore, we suggest performing PD as an emer-
gency on any infant with pneumoperitoneum or massive
abdominal distension and suspected of having some risk of
mesenteric blood-flow impaired, especially anyone who
needs to be transported to another hospital for surgery.
From data obtained from retrospective studies, there is
no unanimous evidence that PD or primary laparotomy is
better in treating advanced NEC, especially in the tiniest
babies.32 Richter33 noted that Moss et al33 have begun a
prospective, controlled and randomized trial that may
clear the air, however, there are many variables that may
make any study difficult. Perhaps, as Ehrlich et al recently
reported34, “the outcome of perforated NEC may be inde-
pendent of the type of surgical treatment,” and he suggests
that selection of therapeutic options for the patient requires
evaluating all comorbid factors that may impact survival,
rather than applying a single treatment strategy for all
patients.
The results obtained in this prospective study suggest
that an early and primary peritoneal drainage is not a
definitive solution in all patients, but are not poor com-
pared with results obtained in the historical control with
primary laparotomy, many infants survived without need
surgery, and the number of infants with severe intestinal
sequela are decreased.
ACKNOWLEDGMENTS
The authors thank all the pediatric surgeons who have participated in
our project and have assisted these infants, especially Drs A Blasco and
J.L. Gonzalez (Hospital Santa Creu i Sant Pau), who encouraged us to
begin the procedure. The authors thank the many neonatologists who,
because of their daily care, have helped infants to survive. The authors
also thank Sigmund Ein for the review of this paper.
PERITONEAL DRAINAGE FOR NEC
REFERENCES
1. Ein SH, Marshall DG, Girvan D: Peritoneal drainage under local
anesthesia for necrotizing enterocolitis. J Pediatr Surg 12:963-967,
1977
2. Janik JS, Ein SH: Peritoneal drainage under local anesthesia for
necrotizing enterocolitis perforation: A second look. J Pediatr Surg
15:565-568, 1980
3. Cheu HW, Sukarochana K, Lloyd DA: Peritoneal drainage for
necrotizing enterocolitis. J Pediatr Surg 23:557-561, 1988
4. Ein SH, Shandling B, Wesson D, et al: A 13-year experience with
peritoneal drainage under local anesthesia for necrotizing enterocolitis.
J Pediatr Surg 25:1034-1037, 1990
5. Takamatsu H, Akiyama H, Ibara S, et al: Treatment for necrotiz-
ing enterocolitis perforation in the extremely premature infants (weigh-
ing ⬍ 1000g). J Pediatr Surg 27:741-743, 1992
6. Morgan LJ, Shochat SJ, Hartman E: Peritoneal drainage as
primary management of perforated NEC in the very low birth weight
infant. J Pediatr Surg 29:310-315, 1994
7. Azarow KS, Ein SH, Shandling B, et al: Laparotomy or drain for
perforated necrotizing enterocolitis: Who gets what and why?. Pediatr
Surg Int 12:137-139, 1997
8. Lessin MS, Luks FI, Wesselhoeft CW, et al: Peritoneal drainage
as definitive treatment for intestinal perforation in infants with ex-
tremely low birth weight (⬍750 g). J Pediatr Surg 33:370-372, 1998
9. Rovin JD, Rodgers BM, Burns RC, et al: The role of peritoneal
drainage for intestinal perforation in infants with and without necro-
tizing enterocolitis. J Pediatr Surg 34:143-147, 1999
10. Demestre X, Ginovart G, Fraga G, et al: El drenaje peritoneal en
el tratamiento de la enterocolitis ulceronecrosante del recién nacido con
peso ⬍1500 g. An Esp Pediatr 42:133-136, 1995
11. Demestre X, Ginovart G, Figueras J, et al: Peritoneal drainage in
the management of neonatal necrotizing enterocolitis. Prenatal and
Neonatal Medicine 1:78, 1998 (suppl 3)
12. Walsh MC, Kliegman RM: Necrotizing enterocolitis: Treatment
based on staging criteria. Pediatr Clin North Am 33:179-201, 1986
13. Ricketts RR, Jerles ML: Neonatal necrotizing enterocolitis:
Experience with 100 consecutive patients. World J Surg 14:600-605,
1990
14. Horwitz JR, Lally KP, Cheu HW, et al: Complications after
surgical interventions for necrotizing enterocolitis: A multicenter re-
view. J Pediatr Surg 30:994-999, 1995
15. Rowe MI, Reblock KK, Kurkchubasche AG, et al: Necrotizing
enterocolitis in the extremely low birth weight infant. J Pediatr Surg
29:987-991, 1994
16. Ladd AP, Rescorla FJ, West KW, et al: Long-term follow-up
after bowel resections for necrotizing enterocolitis: Factors affecting
outcome. J Pediatr Surg 33:967-972, 1998
17. Ahmed T, Ein S, Moore A: The role of peritoneal drainage in
treatment of perforated necrotizing enterocolitis: Recommendations
from recent experience. J Pediatr Surg 33:1468-1470, 1998
18. Atakent YS, Wasserman R, Ozek E, et al: Percutaneous perito-
1539
neal drainage in the management of acute intestinal perforation. J
Perinatol 17:46-51, 1997
19. Snyder CL, Gittes GK, Murphy JP, et al: Survival after necro-
tizing enterocolitis in infants weighing less than 1000 g: 25 years’
experience at a single institution. J Pediatr Surg 32:434-437, 1997
20. Fasoli L, Turi RA, Spitz L, et al: Necrotizing enterocolitis:
Extent of disease and surgical treatment. J Pediatr Surg 34:1096-1099,
1999
21. Voss M, Moore SW, van der Merwe I, et al: Fulminanting
necrotising enterocolitis: Outcome and prognostic factors. Pediatr Sur
Int 13:576-580, 1998
22. Dimmit RA, Meier AH, Skarsgard ED, et al: Salvage laparot-
omy for failure of peritoneal drainage in necrotizing enterocolitis in
infants with extremely low birth weight. J Pediatr Surg 35:856-859,
2000
23. Sonntag J, Wagner MH, Waldshmidt J, et al: Multisystem organ
failure and capillary leak syndrome in severe necrotizing enterocolitis
of very low birth weight infants. J Pediatr Surg 33:481-484, 1998
24. O’Connor A, Sawin RS: High morbidity of enterostomy and its
closure in premature infants with necrotizing enterocolitis. Arch Surg
133:875-880, 1998
25. Kazez A, Küçükaydin M, Kontas O, et al: A model of hypoxia-
induced necrotizing enterocolitis: The role of distension. J Pediatr Surg
32:1466-1469, 1997
26. Rehan VK, Seshia MM, Johnston B, et al: Observer variability
in interpretation of abdominal radiographs of infants with suspected
necrotizing enterocolitis. Clin Pediatr (Phila) 38:637-643, 1999
27. Morecroft JA, Spitz L, Hamilton PA, et al: Plasma cytokine
levels in necrotizing enterocolitis. Acta Paediatr Suppl 396:18-20, 1994
28. Ford H, Watkins S, Reblock K, et al: The role of inflammatory
citokines and nitric oxide in the pathogenesis of necrotizing enteroco-
litis. J Pediatr Surg 32:275-282, 1994
29. Edelson MB, Bagwell CE, Rozycki HJ: Circulating pro- and
counterinflammatory levels and severity in necrotizing enterocolitis.
Pediatrics 103:766-771, 1999
30. Caplan MS, Jilling T: New concepts in necrotizing enterocolitis.
Curr Op Pediatr 13:111-115, 2001
31. Birk D, Berger D, Limmer J, et al: Is the elimination of
endotoxin and cytokines with continuous lavage an alternative proce-
dure in necrotizing enterocolitis? Acta Paediatr Suppl 396:24-26, 1994
32. Moss RL, Dimmit RA, Henry MCW, et al: A meta-analysis of
peritoneal drainage versus laparotomy for perforated necrotizing en-
terocolitis. J Pediatr Surg 36:1210-1213, 2001
33. Richter R: Pediatric surgery trial is unorthodox approach to
addressing disorder. Http://www.stanford.edu/dept/news/report/news/
august9/pediatric-89.html.
34. Ehrlich PF, Sato tt, Short BL, et al: Outcome of perforated
necrotizing enterocolitis in the very low-birth weight neonate may be
independent of the type of surgical treatment. Am Surg 67:752-756,
2001