O1048: Perceptions on the Surgical Management of Spontaneous Intestinal Perforation and Necrotizing Enterocolitis in Very Low Birthweight Newborns: A Survey of Pediatric Surgeons and Neonatologists

Background: Spontaneous intestinal perforation (SIP) and necrotizing enterocolitis (NEC) are the leading causes of pneumoperitoneum in very low birth weight (VLBW) and extremely low birth weight (ELBW) newborns. SIP is often considered distinct from NEC due to differences in pathophysiology, risk factors, and outcomes, which influence their respective management strategies. However, no consensus exists regarding the optimal surgical management of ELBW/VLBW neonates with suspected SIP or NEC. The objective of this study was to assess pediatric surgeons' and neonatologists' perspectives on the surgical management of SIP and NEC and identify patterns in clinical decision-making.

Methods: A web-based REDCap survey was distributed to members of the American Pediatric Surgical Association (APSA) and the Children’s Hospitals Neonatal Consortium (CHNC) in October 2024. The survey included questions regarding practice setting, experience, and surgical management preferences, focusing on indications for peritoneal drainage (PD) versus laparotomy (LP), criteria for salvage laparotomy, and drain management strategies. Clinical scenarios were presented to explore factors influencing decision-making. Statistical analyses included Chi-square and Fisher’s exact tests.

Results: Surveys were distributed to 1200 APSA members and to CHNC members at 42 participating centers. A total of 211 completed responses were analyzed, with APSA members having a response rate of 13.3%. Among respondents, 79% were pediatric surgeons and 21% were neonatologists. The majority (72%) considered SIP and NEC to be distinct clinical entities, though only 14% were very confident (>90%) in their ability to preoperatively differentiate between them. Intraoperative findings were most frequently selected as the gold standard for diagnosis (66%).
Regarding initial management, 56% of respondents favored PD for all SIP cases, while 40% selected PD only in specific cases, and 4% preferred primary LP. Factors influencing the choice of PD over LP included pressor support, periviability, and ELBW status. While 97% of surgeons and 98% of neonatologists believed PD could be definitive for SIP, only 79% of surgeons and 52% of neonatologists considered it definitive for NEC (p=0.002). Drain character did not influence removal timing for 60% of respondents, and 52% had no predefined timeline for drain removal. Criteria prompting salvage laparotomy at 48 hours included hypotension and pressor support (72%), persistent or recurrent pneumoperitoneum (59%), and ongoing coagulopathy (56%). Only 14% of respondents reported having a written institutional protocol for SIP management.

Conclusion: PD is widely accepted as an initial management strategy for both SIP and NEC among pediatric surgeons and neonatologists. However, significant variations exist in the criteria for salvage laparotomy and drain management. Further research and consensus-building efforts are needed to establish best practice guidelines for the surgical management of ELBW/VLBW neonates with SIP and NEC.