Negative Pressure Wound Therapy for a Complicated Abdominal Laparotomy in Neonatal Necrotizing Enterocolitis: A Case Report
Necrotizing enterocolitis (NEC) is the most common surgical emergency in neonatal intensive care units, and patients who require surgery have high mortality and morbidity rates. The utility of negative pressure in the management of adults with complicated abdominal wounds has been documented, but there are few reports describing the use of negative pressure wound therapy (NPWT) in children or following neonatal surgery. The case of a 6 day old, 5-weeks premature neonate with NEC is presented.
An exploratory midline laparotomy was performed on day 3 of life owing to rectal bleeding and abdominal distension that did not respond to gastric decompression, bowel rest, and intravenous antibiotics. Ten (10) cm of necrosis in the distal ileum were noted and resected; in addition, an ileostomy was performed, and a Penrose drain was left in the surgical site. On postoperative day 5, the laparotomy dehisced. Continuous NPWT (50 mm Hg) was initiated and changed owing to patient tolerance to intermittent therapy (5 minutes on, 30 seconds off) at 80 mm Hg. By postoperative day 11, granulation tissue formation was complete. No surgical procedures were required for the complete closure of the abdominal wall, and no adverse reactions were noted. The baby was discharged from the hospital on postop day 15. In this patient, the use of negative pressure was found to be safe and facilitated management of a complicated abdominal wound in the presence of a stoma and the formation of healthy granulation tissue. Additional research is needed to help clinicians provide optimal, evidence-based care for dehisced wounds in this vulnerable population.
Necrotizing enterocolitis (NEC) is an inflammatory intestinal disorder primarily seen in preterm infants; it is characterized by variable damage to the intestinal tract, ranging from mucosal injury to full-thickness necrosis and perforation. NEC is the most common gastrointestinal emergency in the preterm infant and is associated with high mortality and morbidity.1 The incidence of NEC varies between countries and neonatal intensive care units,2,3 and despite advances in neonatal care overall, mortality ranges from 10% to 50%.4
The spectrum of NEC severity varies from feeding intolerance to sepsis and death; approximately half of NEC cases can be managed medically using gastric decompression, bowel rest, and intravenous antibiotics.5,6 However, in up to 50% of infants with the condition, the disease progresses in severity and surgical treatment is needed.7 According to a review of this subject,8 the vast majority of the morbidity and mortality occurs in infants requiring surgical intervention.
The standard surgical approach for NEC is an open laparotomy with gangrenous or perforated bowel resection and stoma creation. However, according to a prospective cohort study9 and a retrospective data review10 patients frequently are in a critical state that complicates their wound healing and causes complications such as infection, dehiscence of the surgical wound, or opening of the abdominal wall.
The use of negative pressure wound therapy (NPWT) for the treatment of a variety of soft tissue wounds has been well documented in adults and children in large case series and retrospective studies.11,12 However, using NPWT for the management of open abdominal wounds has been documented only case reports or small series in adults. A retrospective study13 (N = 48) of the open abdomen using NPWT with instillation in severe abdominal sepsis was published. More recently, NPWT has been used in children with complex wounds and abdominal wall defects, as shown in case reports or case series.14 Publication on the use of NPWT in the postoperative care of a laparotomy performed in a newborn suffering from NEC remains scant.
The purpose of this study is to describe the use of NPWT in a newborn following laparotomy complicated by NEC and a stoma.
Ethical consideration. The study was carried out according to the principles of the Declaration of Helsinki and ensuring compliance with Spanish Decree 29/2009, which regulates the use of and access to electronic medical records. Informed consent of the parents was obtained for the use of photographs of their son.
History. The patient was a 3-day-old premature baby boy, delivered vaginally at Coruña’s Hospital, Coruña, Spain at gestational week 35 of a twin pregnancy. The baby’s birthweight was 1785 g. The mother had received prenatal care; the pregnancy was unremarkable and all prenatal ultrasounds were normal.
Thirty-six (36) hours after birth, the baby presented with rectal bleeding and abdominal distension. Initially, he was managed medically, using gastric decompression, bowel rest, and intravenous antibiotics. Simple abdominal radiography showed pneumatosis intestinalis; laboratory tests revealed decreased platelet counts (35 000 x 10^9/L) and leucopenia (2500 x 10^9/L). After 48 hours of medical management, the baby showed signs of clinical deterioration, including temperature instability, apnea, and an increase of abdominal distension with abdominal erythema.
On day 3 of life, an exploratory midline laparotomy was performed during which 10 cm of necrosis in the distal ileum were noted and resected. An ileostomy also was performed to control the associated peritonitis, and a Penrose drain was left in the surgical site.
On postoperative day 3, the laparotomy dehisced, including fascial dehiscence and skin necrosis (see Figure 1). The decision was made to apply NPWT. White gauze was manually trimmed to the size of the dehiscence (approximately 12 cm). White gauze was used instead of black foam because in the authors’ experience it fits better in the small abdominal wall of the premature infant.
Nonadherent (silicone) dressing was applied over the wound bed before the gauze to protect underlying structures (bowel wall), and an adhesive drape (see Figure 2) and vacuum pad (see Figure 3) were placed.
Initially, negative pressure was applied continuously at 50 mm Hg (lowest setting available); after 2 hours, the pressure was increased to 80 mm Hg and changed to intermittent therapy (5 minutes on, 30 seconds off). Limited reports of NPWT use in preterm infants do not include protocols to guide the practitioner; the authors relied on anecdotal experience in preterm and neonatal patients. In their center, NPWT is initiated at the lowest setting and increased depending on patient tolerance. Tolerance was evaluated using subjective (signs of pain, irritability, or requirement of analgesics) and objective (hemodynamic changes, monitoring cardiac frequency, arterial pressure, and cardiac output) parameters. Electrolyte balance was monitored every 12 hours. These parameters remained stable and the baby’s health was satisfactory after the device placement. The ileostomy was isolated from the NPWT system without difficulty despite the small space between the 2 sites and protected with a pertrolatum gauze. The surrounding skin tolerated the NPWT system without any complications.
The NWPT system was applied 4 times in 11 days. The dressing was changed every 48 to 72 hours. The amount of fluid exudate removed by the system was measured daily by a trained nurse and replenished — the same amount of fluid excreted was replaced plus basic fluid requirements. After 11 days, the abdominal wall was completely granulated and chlorhexidine applied as a antiseptic. No additional surgical procedures such as suturing of the skin or flap/graft were required for the complete closure of the abdominal wall (see Figure 4). No complications occurred; the baby was discharged on postop day 15 with the stoma and the abdominal wall completely healed, anticipating reconstructive intestinal surgery.
Despite advances in the management of most neonatal morbidities, the mortality and morbidity related to NEC remain high, especially in babies that require surgery. This case study describes the successful use of NPWT in a 6-day-old baby with a dehisced laparotomy wound and an ileostomy. Healthy granulation tissue formation and complete wound closure with no adverse events were noted with NPWT treatment.
In a 2011 case series (N = 10), Lorca García et al15 reported the use of vacuum-assisted closure in 2 cases of NEC (1 baby was 7 days old, and the other baby was 23 days old when the device was applied) in which wound closure was achieved without other concerns. In this study, NPWT was applied with a continuous pressure of 75 mm Hg using polyurethane foam changed every 3 days for 17 days. Good results were achieved, with only 1 patient requiring a decrease in negative pressure related to pain.
In 2008, Lopez et al16 presented a review of the use of negative pressure for complicated abdominal wounds in neonates (total of 8 neonates with 10 NPWT applications in a period of 3 years) that included 3 patients with NEC. The patients were 141, 45, and 51 days old at NPWT application. Black foam with a nonadherent dressing was placed over the wound at a pressure of 50 mm Hg with dressing changes every 48 to 72 hours. Although the study did not include time to wound closure, wound closure was achieved in all cases and did not result in any local or systemic complications.
More recently, Gutierrez and Gollin17 presented a case series (N = 25) involving infants and children with an open abdomen managed with NPWT that included 2 cases of NEC, 10 and 11 days of age at NPWT application, with different results. The authors reported a median duration for NPWT of 4.5 days. In 16 patients, the abdomen was closed successfully after NPWT; in 14 children, the abdominal wall fascia was successfully approximated, and 2 children underwent a patch abdominal closure. Nine (9) patients died before an abdominal closure could be attempted, and 2 children developed enterocutaneous fistulae.
Compared to the use of conventional wet-to-dry bandages in the treatment of complex wounds in neonatal patients, NPWT holds the potential to decrease the time necessary for wound closure, avoid multiple daily dressing changes, shorten hospital length of stay, and improve quality of life.11 In both adult and pediatric studies. NPWT was shown to have many advantages over conventional wet-to-dry bandages in the management of a variety of soft tissue wounds.18 The literature comparing NPWT with traditional care of abdominal wounds in neonates (especially premature infants) in terms of time to healing and costs is lacking. For similar reasons, the authors started treatment at a continuous pressure of 50 mm Hg; after the first 2 hours, the negative pressure was increased to 80 mm Hg, considered the ideal pressure of actuation. However, NPWT intolerance often is related to the pain generated with higher pressures or intermittent rhythm. It is for that reason therapy commenced with low, continuous pressure.
Because case study findings cannot be applied to other populations, research is needed to increase understanding about outcomes and optimal NPWT usage criteria in this vulnerable population.
A 6-day-old, premature male neonate with a dehisced abdomen and additional complications (consequences of his intestinal perforation) that resulted in an ileostomy was provided NPWT as part of treatment. The wound was fully granulating after 11 days. The treatment was well-tolerated and no adverse events were observed. Following careful consideration of all alternatives and potential complications, NPWT may be a viable option for the treatment of a complex abdominal wound in the presence of a stoma in very young patients. n
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Potential Conflicts of Interest: none disclosed
Dr. García González is a pediatric surgeon; and Dr. Casal Beloy is a pediatric surgeon-in-training, Department of Pediatric Surgery, University Hospital A, Coruña, Spain. Dr. Gómez Dovigo is a general abdominal surgeon, Quiron Hospital A, Coruña, Spain. Dr. Miguez Fortes is a pediatric surgeon-in-training; Dr. Dargallo Carbonell is a pediatric surgeon and Head of the Department of Pediatric Surgery; Dr. Pita-Fernández is a researcher in the Clinical Epidemiology and Biostatistics Research Group; and Dr. Caramés Bouzán is a pediatric surgeon, Department of Pediatric Surgery, University Hospital A, Coruña, Spain. Please address correspondence to: Miriam García González, Complejo Hospitalario Universitario de A Coruña, As Xubias de abajo s/n. 15006 A Coruña, Spain; email: Miriam.firstname.lastname@example.org.