Dilemmas with surgical intervention in neonates with Necrotizing Enterocolitis without pneumoperitoneum


  • Manika Boipai Department of Paediatric Surgery, SMS Medical College, Jaipur, Rajasthan, India
  • Rahul Gupta Department of Paediatric Surgery, SMS Medical College, Jaipur, Rajasthan, India




Necrotizing enterocolitis, Pneumoperitoneum, Perforation, Intestinal gangrene


Background: The diagnosis of perforation in the absence of pneumoperitoneum in necrotizing Enterocolitis (NEC) remains difficult. The decision to operate should be taken up during the “golden period” which occurs after the onset of intestinal gangrene, but before intestinal perforation. This study was done to analyse the outcomes of two groups of surgically managed NEC patients based on the radiographic findings (presence or absence of pneumoperitoneum) and compare the actual surgical findings.

Methods: A prospective observational study was performed from October 2018 to February 2020. The operated patients of NEC were divided into two groups based on the preoperative presence (Group A) or absence of pneumoperitoneum (Group B). A “p” value of less than 0.05 was considered significant for comparative analysis.

Results: There were 81 patients with clinico-radiological signs of NEC during the study tenure; 51 infants underwent surgery. Group A had 35 (69%) and Group B had 16 (31%) patients. In 11/16 (69%) patients of Group B, perforation was detected and 5/16 (31%) had only gangrenous and necrosis of bowel segment. Out of 16 patients (Group B), predictors of NEC like abdominal wall erythema (Modified Bell's stage IIB) were present in 4 (25%), fixed bowel loops (stage IA/IB) 3 (19%), pneumatosis intestinalis (stage IIA) 1(6%), portal venous gas (stage IIB) 1 (6%), and ascites (stage IIIA) 2 (12%) were observed. The complication rate was 77% among patients of Group A and 44% in Group B (p=0.01).  Survival was greater (63% vs. 29%) among Group B patients than Group A (p=0.02).    

Conclusions: The importance of not relying only on the pneumoperitoneum on radiographs; early diagnosis and prompt surgical intervention is emphasized. Surgical indication for NEC should always be based on the patient’s cumulative clinical and radiologic assessment, especially in the absence of pneumoperitoneum to improve survival rates.


Download data is not yet available.


Metrics Loading ...

Author Biography

Rahul Gupta, Department of Paediatric Surgery, SMS Medical College, Jaipur, Rajasthan, India

Associate Professor


Papillon S, Castle SL, Gayer CP, Ford HR. Necrotizing enterocolitis: contemporary management and outcomes. Adv Pediatr. 2013; 60:263-79.

Epelman M, Daneman A, Navarro OM, Morag I, Moore AM, Kim JH, et al. Necrotizing enterocolitis: review of state-of-the-art imaging findings with pathologic correlation. Radiographics. 2007; 27:285-305.

Raval MV, Moss RL. Current concepts in the surgical approach to necrotizing enterocolitis. Pathophysiol. 2014; 21:105-10.

Kosloske AM. Indications for operation in necrotizing enterocolitis revisited. J Pediatr Surg. 1994; 29:663-6.

Bell MJ, Ternberg JL, Feigin RD, Keating JP, Marshall R, Barton L, et al. Neonatal necrotizing enterocolitis. Therapeutic decisions based upon clinical staging. Ann Surg. 1978; 187:1-7.

Walsh MC, Kliegman RM. Necrotizing enterocolitis: treatment based on staging criteria. Pediatr Clin North Am. 1986; 33:179-201.

Najaf TA, Vachharajani NA, Warner BW, Vachharajani AJ. Interval between clinical presentation of necrotizing enterocolitis and bowel perforation in neonates. Pediatr Surg Int. 2010; 26:607-9.

Upadhyaya VD, Gangopadhyay AN, Pandey A, Upadhyaya A, Mohan TV, Gopal SC, et al. Is pneumoperitoneum an absolute indication for surgery in necrotizing enterocolitis? World J Pediatr. 2008; 4:41-4.

Kosloske AM, Papile LA, Burstein J. Indications for operation in acute necrotizing enterocolitis of the neonate. Surg. 1980; 87:502-8.

Lin PW, Stoll BJ. Necrotising enterocolitis. Lancet. 2006; 368:1271-83.

Rowe MI, Reblock KK, Kurkchubasche AG, Healey PJ. Necrotizing enterocolitis in the extremely low birth weight infant. J Pediatr Surg. 1994; 29:987-990.

Ng S. Necrotizing enterocolitis in the full-term neonate. J Paediatr Child Health. 2001; 37:1-4.

Staryszak J, Stopa J, Kucharska-Miasik I, Osuchowska M, Guz W, Błaz W. Usefulness of ultrasound examinations in the diagnostics of necrotizing enterocolitis. Pol J Radiol. 2015; 80:1-9.

Wertheimer F, Arcinue R, Niklas V. Necrotizing enterocolitis: enhancing awareness for the general practitioner. Pediatr Rev. 2019; 40:517-27.

Morrison SC, Jacobson JM. The radiology of necrotising enterocolitis. Clin Perinatol. 1994; 21:347-63.

Dilli D, SunaO˘guz S, Erol R, Ozkan-Ulu H, Dumanlı H, Dilmen U. Does abdominal sonography provide additional information over abdominal plain radiography for diagnosis of necrotizing enterocolitis in neonates? Pediatr Surg Int. 2011; 27:321-7.

Coursey CA, Hollingsworth CL, Gaca AM, Maxfield C, Delong D, Bisset G 3rd. Radiologists’ agreement when using a 10-point scale to report abdominal radiographic findings of necrotizing enterocolitis in neonates and infants. Am J Roentgenol. 2008; 191:190-7.

Gupta R. Spontaneous pneumoperitoneum in pediatric patients: Dilemmas in Management. J Indian Assoc Pediatr Surg. 2018; 23:115-22.

Cheu HW, Sukarochana K, Lloyd DA. Peritoneal drainage for necrotizing enterocolitis. J Pediatr Surg. 1988; 23:557-61.

Villamil V, Ibieta MF, Ubeda MAG. Correlation between pneumoperitoneum and surgical findings and morbidity and mortality in newborns with necrotising enterocolitis. An Pediatr. (Barc) 2018; 89:205-10.

Faingold R, Daneman A, Tomlinson G, Babyn PS, Manson DE, Mohanta A, et al. Necrotizing enterocolitis: assessment of bowel viability with color doppler US. Radiol. 2005; 235:587-94.

Pandey A, Singh SP, Gupta V, Verma R. Conservative management of pneumoperitoneum in necrotising enterocolitis- is it possible? J Neonatal Surg. 2016; 5:12.

Tepas JJ 3rd, Sharma R, Hudak ML, Garrison RD, Pieper P. Coming full circle: an evidence-based definition of the timing and type of surgical management of very low-birth-weight (<1000 g) infants with signs of acute intestinal perforation. J Pediatr Surg. 2006; 41:418-22.

Neu J, Walker WA. Necrotizing enterocolitis. N Engl J Med. 2011; 364:255-64.

Coursey CA, Hollingsworth CL, Wriston C, Beam C, Rice H, Bisset G 3rd. Radiographic predictors of disease severity in neonates and infants with necrotizing enterocolitis. AJR Am J Roentgenol. 2009; 193:1408-13.

Tam AL, Camberos A, Applebaum H. Surgical decision making in necrotizing enterocolitis and focal intestinal perforation: predictive value of radiologic findings. J Pediatr Surg. 2002; 37:1688-91.

Silva CT, Daneman A, Navarro OM, Moore AM, Moineddin R, Gerstle JT, et al. Correlation of sonographic findings and outcome in necrotizing enterocolitis. Pediatr Radiol. 2007; 37:274-2.

Frey EE, Smith W, Franken Jr EA, Wintermeyer KA. Analysis of bowel perforation in necrotizing enterocolitis. Pediatr Radiol. 1987; 17:380-2.

Evennett N, Alexander N, Petrov M, Pierro A, Eaton S. A systematic review of serologic tests in the diagnosis of necrotizing enterocolitis. J Pediatr Surg. 2009; 44:2192-201.

Agnoni A, Amendola CL. Necrotizing enterocolitis: Current concepts in practice. JAAPA 2017; 30:16-21.

Lim JC, Golden JM, Ford HR. Pathogenesis of neonatal necrotizing enterocolitis. Pediatr Surg Int. 2015; 31:509-18.



How to Cite

Boipai M, Gupta R. Dilemmas with surgical intervention in neonates with Necrotizing Enterocolitis without pneumoperitoneum. J Neonatal Surg [Internet]. 2021Jul.9 [cited 2024May21];10:34. Available from: https://www.jneonatalsurg.com/ojs/index.php/jns/article/view/974



Original Article

Most read articles by the same author(s)

1 2 3 > >>