506 - Laparotomy versus Peritoneal Drainage as Initial Surgical Treatment for Necrotizing Enterocolitis or Spontaneous Intestinal Perforation in Preterm Infants: A Systematic Review and Meta-Analysis

Poster Number: 506
Publication Number: 506.426

Gonzalo Solis-Garcia, The Hospital for Sick Children, Toronto, ON, Canada; Bonny Jasani, The Hospital for Sick Children, Toronto, ON, Canada

Background: Necrotizing enterocolitis (NEC) remains one of the main contributors to mortality and morbidity in preterm infants. To date, the first-line surgical treatment for surgical NEC (sNEC) or spontaneous intestinal perforation (SIP) remains controversial due to limited evidence from few randomized controlled trials (RCTs).

Objective: To systematically review and meta-analyze the impact on morbidity and mortality of peritoneal drainage (PD) compared to laparotomy (LAP) as primary surgical treatment in preterm infants with sNEC or SIP.

Design/Methods: Electronic databases PubMed, Embase, Cochrane CENTRAL and CINAHL were searched until December 2021 for RCTs and observational studies comparing PD and LAP as primary surgical treatment of preterm infants with sNEC or SIP. The primary outcome was survival in preterm infants. Pre-specified secondary outcomes included survival in extremely low birth weight (ELBW < 1000 g at birth) infants, need for parenteral nutrition at 90 days, time to full feeds, duration of hospital stay in survivors, need for subsequent LAP and complications including abdominal abscess, intestinal stricture and intestinal fistula. The Cochrane risk of bias (ROB) tool was used to assess bias for included RCTs. A random-effects model was used for meta-analyses using Mantel-Haenszel, and certainty of evidence was rated according to GRADE.

Results: Three RCTs (Nf 493) and 37 observational studies (Nf18463) were included. All three RCTs had low risk of bias in all categories except for the blinding of the intervention. Compared to LAP, infants with sNEC/SIP who underwent PD had lower survival [40 studies, Nf18956, Relative risk (RR) 0.83, 95% confidence interval (CI) 0.77-0.89, I2 =71%, GRADE: low] but the results were not significant when meta-analyzing only RCTs (3 studies, Nf493, RR=0.98, 95% CI 0.87-1.10, GRADE: moderate). In ELBW infants, PD was associated with lower survival (17 studies, Nf1569, RR=0.86, CI 95% 0.78-0.94, GRADE: Low) but not significant when including only RCTs (3 studies, 466 patients, RR=0.96, 95% CI 0.85-1.08, GRADE: Moderate). PD was associated with higher risk of subsequent laparotomy compared to LAP; no significant differences were found between the two groups for other pre-specified secondary outcomes. Conclusion(s): Compared to LAP, PD as primary surgical treatment is associated with lower survival rates in preterm infants with NEC/SIP. Adequately powered randomized trials comparing these two approaches are needed especially in ELBW infants.  
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