Surgical decision-making for necrotizing enterocolitis (NEC) in premature infants remains one of the most challenging areas in neonatal care. A new comprehensive review, published in the World Journal of Pediatric Surgery, provides a clinical framework for operative strategies, comparing peritoneal drainage (PD) with exploratory laparotomy, and evaluating bowel-preserving techniques for extensive disease. The review underscores that surgery must not only control immediate disease but also preserve functional bowel, reduce long-term complications, and support better quality of life for these vulnerable patients.
NEC primarily affects premature and low-birth-weight infants, with mortality rising from about 7% in medically managed cases to 20%–30% when surgery is required. Survivors often face strictures, nutritional problems, and intestinal failure due to short bowel syndrome, along with impaired neurodevelopment. The lack of a disease-specific biomarker and overlap with spontaneous intestinal perforation (SIP) further complicate decisions, leaving surgeons to balance removing damaged bowel against preserving enough intestine for future growth.
Researchers from Nationwide Children's Hospital in Columbus, Ohio, published the review (DOI: 10.1136/wjps-2026-001200) online on June 2, 2026. The article synthesizes evidence on identifying infants who may need surgery, choosing between PD and laparotomy, reconstructing the intestine after resection, and using bowel-sparing techniques. It also examines emerging perioperative adjuncts like indocyanine green fluorescence angiography (ICG-FA), direct peritoneal resuscitation (DPR), and mucous fistula refeeding.
The choice between PD and laparotomy depends largely on the infant's stability and the extent of intestinal injury. PD is less invasive and can be performed at the bedside, making it suitable for extremely low-birth-weight infants who may not tolerate laparotomy, but failure to improve often requires rescue surgery. Exploratory laparotomy allows direct inspection and removal of necrotic bowel. Earlier randomized trials found similar survival, but a more recent multicenter RCT 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 resection, surgeons may create a stoma or perform a primary anastomosis, with the latter preferred when the infant is stable and the remaining bowel is clearly viable. For extensive disease, the review discusses damage control surgery, "clip and drop," diverting jejunostomy, "patch, drain and wait," and intraluminal stenting to limit bowel loss. Emerging adjuncts like ICG-FA may improve perfusion assessment, while DPR and mucous fistula refeeding could aid bowel preservation and nutritional recovery.
The authors emphasize that operative care for NEC cannot be reduced to a single preferred procedure. The best approach depends on how sick the infant is, whether the bowel is clearly non-viable, and how much intestine can safely be preserved. The immediate goal is survival, but long-term intestinal function, growth, and neurodevelopment must also shape surgical decisions. Emerging adjuncts are promising but rest on limited neonatal evidence and need stronger, well-controlled studies before broad adoption.
This review could help neonatal and pediatric surgical teams structure multidisciplinary decisions around timing, operative risk, and bowel preservation, rather than treating all surgical NEC the same way. Risk scores such as the Neonatal Sequential Organ Failure Assessment (nSOFA), combined with imaging and clinical trajectory, may support earlier recognition of high-risk cases. In the operating room, perfusion imaging and staged approaches may reduce avoidable resection, while postoperative strategies like mucous fistula refeeding may reduce dependence on total parenteral nutrition. However, many advanced techniques still require larger comparative trials and standardized protocols before becoming routine care.
