Necrotizing enterocolitis (NEC) can turn rapidly from intestinal inflammation into a life-threatening surgical emergency in premature infants, yet choosing when and how to operate remains difficult. A comprehensive review brings current operative strategies into one clinical framework, comparing peritoneal drainage (PD) with exploratory laparotomy, examining reconstruction after bowel resection, and outlining bowel-preserving options for extensive disease. It also evaluates emerging perioperative tools that may improve assessment of intestinal viability and postoperative recovery. The central message is that surgery should do more than control immediate disease: it should preserve as much functional bowel as possible, reduce long-term complications, and support survival with better quality of life in one of medicine's most vulnerable patient groups.
Necrotizing enterocolitis (NEC) mainly affects premature and low-birth-weight (LBW) newborns and carries poor outcomes once surgery is required. Mortality is about 7% in medically managed disease but rises to roughly 20%–30% in surgical NEC, while survivors may face strictures, nutritional problems, intestinal failure from short bowel syndrome (SBS), and impaired neurodevelopment. Clinical decisions are complicated by the lack of a disease-specific biomarker, overlap with spontaneous intestinal perforation (SIP), and uncertainty about when a deteriorating infant has crossed from medical to surgical disease. Surgeons must also balance removing damaged bowel against preserving enough intestine for future growth and nutrition. Given these challenges, deeper research is needed to improve early risk stratification, operative selection, bowel preservation, and perioperative support for infants with NEC.
Researchers from the Department of Pediatric Surgery at Nationwide Children's Hospital in Columbus, Ohio, published the review (DOI: 10.1136/wjps-2026-001200) online on June 2, 2026, in World Journal of Pediatric Surgery . The article synthesizes current evidence on how to identify infants who may require surgery, how to choose between peritoneal drainage (PD and exploratory laparotomy, how to reconstruct the intestine after resection, and how to use bowel-sparing techniques when disease is extensive. It also examines newer perioperative adjuncts intended to sharpen intraoperative decisions, preserve viable intestine, and improve recovery after surgery.
The review highlights that operative choice depends heavily on the infant's stability and the extent of intestinal injury. PD is less invasive and can be performed rapidly at the bedside, making it useful for extremely low-birth-weight LBW (ELBW) infants who may not tolerate laparotomy, but failure to improve often requires rescue surgery. Exploratory laparotomy permits direct inspection and removal of necrotic bowel. Earlier randomized trials found broadly similar survival between the two approaches, while a more recent multicenter randomized controlled trial (RCT) found that, among infants with a preoperative diagnosis of NEC, death or neurodevelopmental impairment (NDI) occurred in 69% after laparotomy versus 85% after PD; the analysis gave a 97% Bayesian probability that laparotomy was beneficial in this subgroup.
After resection, either stoma creation or primary anastomosis may be considered, with primary anastomosis most suitable when the infant is relatively stable and the remaining bowel is clearly viable. For extensive or multifocal disease, the review discusses damage control surgery, "clip and drop," diverting jejunostomy, "patch, drain and wait," and intraluminal stenting, all aimed at limiting unnecessary bowel loss. It also assesses indocyanine green fluorescence angiography (ICG-FA), direct peritoneal resuscitation (DPR), and mucous fistula refeeding as adjuncts that may improve perfusion assessment, bowel preservation, or nutritional recovery.
The authors said the review's main lesson is 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. They said the immediate goal is survival, but long-term intestinal function, growth, and neurodevelopment also have to shape surgical decisions. Emerging adjuncts are promising, they said, but several still rest on limited neonatal evidence and need stronger, well-controlled studies before they can be adopted broadly.
The review could help neonatal and pediatric surgical teams structure multidisciplinary decisions around timing, operative risk, and bowel preservation rather than treating all surgical NEC in the same way. Risk scores such as the Neonatal Sequential Organ Failure Assessment (nSOFA), together with imaging, laboratory findings, and the infant's overall clinical trajectory, may support earlier recognition of high-risk cases. In the operating room, perfusion imaging and staged bowel-preserving approaches may reduce avoidable resection, while postoperative strategies such as mucous fistula refeeding may reduce dependence on total parenteral nutrition (TPN) and speed progression toward full feeds. The authors emphasize, however, that many advanced techniques still need larger comparative trials and standardized protocols before becoming routine care.
