Peritoneal Drainage in Spontaneous Intestinal Perforation: A 20-year single center review

Peritoneal Drainage in Spontaneous Intestinal Perforation: A 20-year single center review | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article Peritoneal Drainage in Spontaneous Intestinal Perforation: A 20-year single center review Goeto Dantes, Olivia Keane, Isabella Amaniera, Morgan Buchanan, and 3 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-7497221/v1 This work is licensed under a CC BY 4.0 License Status: Under Review Version 1 posted 10 You are reading this latest preprint version Abstract Purpose Spontaneous intestinal perforation (SIP) is a morbid condition of low-birth-weight neonates. Peritoneal drainage (PD), as opposed to upfront laparotomy (LP), is favored for SIP. However, PD management is neither standardized nor thoroughly understood. We reviewed our experience of PD in infants with SIP. Methods Neonates treated for SIP between 07/2004-03/2023 were reviewed. Patients with NEC or death immediately following PD were excluded. Patients treated with a PD that required LP within 30 days were considered salvage laparotomy (SL). Results A total of 235 neonates were included. The median gestational age and birth weight were 25.0 weeks (IQR: 24.1, 26.3) and 720 g (IQR: 620, 865). Ninety-three (39.6%) patients required SL at a median of 9 days (IQR: 5, 14) from PD. Indications for failure included recurrent pneumoperitoneum (52%), clinical deterioration (20%), and ongoing feculent drain output (14%). At SL, 8.1% of patients were found to have NEC. SL patients had twice the length of stay: 67 days (IQR: 38, 115) vs 113 days (IQR: 86, 153), p < 0.001. Conclusion PD is an important tool in the management of SIP, however SL is not uncommon (39%) and has clinical significance. Prospective data to improve PD management is needed. Figures Figure 1 Figure 2 Introduction Spontaneous intestinal perforation (SIP) is a highly morbid condition of infancy with a reported incidence rate of 1.6% in neonates less than 32-weeks gestational age and increased rates in very and extremely low birthweight (VLBW and ELBW) infants [ 1 , 2 ]. SIP is recognized as a distinct cause of neonatal intestinal perforation caused by a lack of bowel wall structural integrity that results in submucosal thinning and isolated/localized mucosal ulceration [ 3 – 5 ]. Thus, SIP can occur before initiation of feeds in low birthweight infants and is characterized by a single sub-centimeter perforation located on the anti-mesenteric border with healthy appearing adjacent bowel [ 3 – 5 ]. Laparotomy with resection or repair of the bowel perforation was the gold standard for treatment [ 6 ]. Alternatively, upfront peritoneal drain (PD) placement to control intra-abdominal sepsis while allowing bowel perforations to heal/seal without additional laparotomy, has been successful in up to 70% of neonates [ 7 ]. Neonates who fail initial PD either due to ongoing sepsis, re-accumulation of pneumoperitoneum or persistent stool leakage from the drain site, then undergo salvage laparotomy (SL) [ 7 , 8 ]. Previous research, most notably the Necrotizing Enterocolitis Surgery Trial (NEST) trial, has suggested that PD, as opposed to upfront laparotomy (LP), can be favorable in infants with SIP [ 9 ]. NEST found higher rates of death and neurodevelopment impairment were seen with upfront laparotomy compared to initial drainage that infants with the preoperative diagnosis of SIP [ 9 ]. Currently there are neither standardized guidelines for PD management or studies to answer questions such as: how long drains should remain in place, should drains be flushed, should a second drain be attempted, and what are discrete indications for salvage laparotomy. We also fall short in our understanding of why some drains are not successful. Necrotizing enterocolitis (NEC) is also a disease of low birthweight neonates that is characterized by ischemia causing full thickness hemorrhagic necrosis of the bowel wall thought to be primarily driven by initiation of feeds [ 6 , 10 , 11 ]. There can be significant overlap in clinical and abdominal radiographic findings in SIP and NEC and thus one presumed reason for peritoneal drain failure is preoperative misdiagnosis [ 6 , 12 ]. However, smaller studies have highlighted other possible risk factors including vasopressor requirement pre-intervention, lower birthweight, and later timing/day of life (DOL) of perforation [ 13 , 14 ]. As SL is associated with poor outcomes, understanding why certain neonates fail PD or identifying which subset of neonates with SIP are at increased risk of SL may improve outcomes [ 7 ]. Our institution published a retrospective review over a decade ago, attempting to answer some of these questions [ 7 ]. We now provide an updated review of our institutional data, investigating rates of PD failure in the treatment of SIP and reasons for failure. We sought to retrospectively compare clinical characteristics between those infants who fail peritoneal drainage and those treated successfully with drainage alone. Methods Study Design A retrospective cohort study of ELBW (< 1000g) and VLBW (< 1500g) neonates treated for pneumoperitoneum or suspected bowel perforation between July 2004 and March 2023 was conducted within a tertiary children’s healthcare system in a large urban setting. Neonates from 2004–2012 were previously reported on and were included in this updated review [ 7 ]. Patients with a pre-operative diagnosis of SIP who were treated with peritoneal drainage (PD) were included. Patients were admitted to one of two level IV neonatal intensive care units (NICUs) within the same health system. The cohort was built from extracting data from our institution’s electronic medical record (EMR). Patients with a pre-intervention diagnosis of NEC, incomplete charts, or death immediately following drainage, were excluded. Due to the nature of the study, a waiver for informed consent was obtained and approved by the institutional review board. Demographic factors of the patients collected from chart review of the electronic medical record, included: gestational age (weeks), race, ethnicity, biologic sex, birthweight (grams), and maternal age (years). Additional clinical factors including feeding history, laboratory/radiological findings, and surgical intervention/documentation were also reviewed and collected from the EMR. Some data points were compared before and after 2017, which was a rough division for when consistent data was available on included neonates. Preoperative diagnosis was obtained from procedural report documentation with cross-reference and verification with the pediatric surgery team consult and progress notes leading up to intervention for pneumoperitoneum. There are no standardized institutional protocols on the diagnosis or the management of infants with pneumoperitoneum and thus diagnosis and management decisions were entirely up to the pediatric surgery and neonatology teams. However, standard PD placement at our institution is performed with a quarter-inch Penrose drain placed in the right hemiabdomen via small open incision. This technique was utilized by all surgeons at our institution throughout the study period. Our surgical team does not employ percutaneous Seldinger technique with a pigtail catheter described at other institutions. 13 Infants treated with a PD that required LP for any reason within 30 days of PD were consider SL. Any laparotomy performed during their index admission was also recorded. Documented indication for SL and intraoperative diagnoses were obtained. “Clinical deterioration” was based on surgical team documentation of reasoning for SL and included signs and symptoms such as new or increasing pressor requirement, persistent lactic acidosis, worsening respiratory status, and/or ongoing/worsening thrombocytopenia/coagulopathy. Intraoperative diagnosis was obtained from the operative report documentation alone. This study followed the Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) reporting guidelines. Outcomes & Statistical Analysis Primary outcome of interest was reason cited for PD failure and operative indication. Descriptive statistics such as means (standard deviations) for continuous variables and counts (percentages) for categorical variables were provided for demographic and clinical characteristics. Comparison of clinical characteristics and outcomes of patients between those who failed PD vs those who were successfully treated with PD alone were done using Wilcoxon’s rank sum test for continuous variables, and Fisher’s exact test for categorical variables. All statistical tests were two-sided, and p < 0.05 were considered statistically significant. All statistical analyses were completed using R version 4.3.2. Results Overall, 301 neonates were treated for pneumoperitoneum with the preoperative diagnosis of SIP during the study timeframe. Of those with a preoperative diagnosis of SIP, 235 (78.1%) were treated with initial PD and were included in the analytic cohort. The median GA was 25.0 weeks (IQR: 24.1, 26.3) and median birthweight was 720 g (IQR: 625, 855). Of those initially treated with PD, 93 (39.6%) patients required SL. There was a median of 9 days (IQR: 5,14) from drain placement to salvage LP (Table 1 ). Figure 1 is a Kaplan-Meier curve demonstrating survival without SL or death. Table 1 Demographics and clinical characteristics N Observed Total Cohort N = 235 Peritoneal Drain N = 142 Salvage Laparotomy N = 93 p-value Birth Weight , grams (IQR) 235 720 (620, 865) 720 (625, 855) 726 (600, 900) 0.605 Gestational Age , weeks (IQR) 235 25.00 (24.14, 26.29) 25.00 (24.14, 26.00) 25.00 (24.00, 26.43) 0.921 Gender , Male (%) 235 156 (66%) 93 (65%) 63 (68%) 0.721 Race/Ethnicity , n (%) 234 0.730 Black 151 (65%) 87 (62%) 64 (69%) White 63 (27%) 40 (28%) 23 (25%) Asian 4 (1.7%) 2 (1.4%) 2 (2.2%) Hispanic or Latino 4 (1.7%) 3 (2.1%) 1 (1.1%) Pacific Islander, Native or American Indian 12 (5.1%) 9 (6.4%) 3 (3.2%) Apgar score 1 min , (IQR) 215 4 (2, 6) 4 (2, 6) 3 (2, 6) 0.852 Apgar score 5 min , (IQR) 217 7 (5, 8) 7 (5, 8) 7 (4, 8) 0.887 Chorioamnionitis , n (%) 224 17 (7.6%) 10 (7.6%) 7 (7.6%) 0.993 Mode of delivery 218 0.376 Vaginal 71 (33%) 39 (30%) 32 (36%) C-section 147 (67%) 90 (70%) 57 (64%) Birth date , n (%) 235 0.091 Before June 15th, 2017 142 (61%) 92 (65%) 50 (54%) After June 16th, 2017 93 (39%) 50 (35%) 43 (46%) Admission date , n (%) 235 < 0.001 Before Dec 2012 78 (33%) 59 (42%) 19 (20%) After Jan 2013 157 (67%) 83 (58%) 74 (80%) Died after 30 days of admission , n (%) 223 14 (6.3%) 14 (10%) 0 (0%) 0.003 Day of Life drain placement , (IQR) 233 7 (4, 10) 7 (5, 9) 7 (3.5, 11) 0.733 Character of drain , n (%) 211 0.450 Air only 11 (5.2%) 7 (5.1%) 4 (5.3%) Bile Stained Serous 22 (10%) 12 (8.8%) 10 (13%) Bloody, non-particulate 13 (6.2%) 6 (4.4%) 7 (9.3%) Meconium, Stool or Succus 109 (52%) 72 (53%) 37 (49%) Serous, non-particulate 56 (27%) 39 (29%) 17 (23%) Drain character , n (%) 211 1.000 Air only 11 (5.2%) 7 (5.1%) 4 (5.4%) Anything other than air 200 (95%) 129 (95%) 71 (95%) Drain character 2 , n (%) 211 0.616 Air and Serous/blood/bile stained 102 (48%) 64 (47%) 38 (51%) Meconium, stool or succus 109 (52%) 72 (53%) 37 (49%) Drain character 3 , n (%) 211 0.199 Meconium, stool or succus 109 (52%) 72 (53%) 37 (49%) Bile stained, Bloody 35 (17%) 18 (13%) 17 (23%) Serous or Air 67 (32%) 46 (34%) 21 (28%) Duration of first drain , days (IQR) 212 10 (7, 13) 11 (9, 14) 8 (5, 10) < 0.001 Indication for drain removal , n (%) 216 < 0.001 Purposeful Removal 138 (64%) 106 (83%) 32 (36%) During Surgery 50 (23%) 0 (0.0%) 49 (55%) Fell out prior to purposeful removal 28 (13%) 21 (16.5%) 8 (9%) Drain complication , n (%) 235 10 (4.3%) 4 (2.8%) 6 (6.5%) 0.200 Anatomic location of perforation , n (%) 98 0.691 Ileum 76 (78%) - 69 (78%) Jejunum 22 (22%) - 19 (22%) Surgery at any time during admission , n (%) 235 104 (44%) 11 (7.7%)** 93 (100%) < 0.001 Day of life surgery , (IQR) 108 18 (12, 27) 54 (42, 76)** 17 (12, 24) < 0.001 Days from drain placement to surgery , (IQR) 103 10 (5, 17) 56 (43, 72)** 9 (5, 14) < 0.001 Indication for surgery , n (%) 104 < 0.001 Persistent meconium/stool drainage 14 (13%) 1 (9.1%)** 13 (14%) Recurrent or persistent pneumoperitoneum 49 (47%) 1 (9.1%)** 48 (52%) Unimproved clinical status or clinical deterioration 19 (18%) 0 (0%) 19 (20%) Obstruction or stricture 14 (13%) 9 (81%)** 5 (5.4%) Other* 8 (7.7%) 0 (0%) 8 (8.6%) Final intraoperative diagnosis , n (%) 83 < 0.001 SIP 60 (72%) 1 (9.1%)** 59 (83%) NEC 9 (11%) 2 (18.2%)** 6 (8.4%) Stricture/bowel obstruction/abscess 14 (17%) 8 (73%)** 6 (8.4%) Length of stay , days (IQR) 235 97 (44, 130) 67 (38, 115) 113 (86, 153) < 0.001 Mortality , n (%) 235 0.583 Yes 26 (11%) 17 (12%) 9 (9.7%) No 209 (89%) 125 (88%) 84 (90%) *Other: Unknown, hemoperitoneum, drain complications **Outcomes and findings specific for neonates who required surgery/laparotomy beyond 30 days The most common indications for SL included: recurrent or persistent pneumoperitoneum (52%), clinical deterioration or non-improvement (20%), and ongoing drain output of meconium or stool (14%) (Table 1 ). Of those that underwent SL, 81% were noted to have an intraoperative diagnosis of SIP whereas 8.1% had stricture or bowel obstruction, and 8.1% had NEC (Table 1 ). An additional 11 neonates who did not require SL underwent surgery at some point during their index admission. Of these 11, 9 (81%) required surgery for strictures/bowel obstruction and 2 (18%) were found to have NEC. The total number of neonates with SIP treated with PD who required surgery at any point during index admission was 104 (44.2%). Ten (4.3%) of all neonates suffered drain complications including drain site evisceration/herniation, development of drain site enterocutaneous fistula or intra-abdominal hemorrhage. Rates of SL did appear to increase in the latter half of the study period (after June 2017) when compared to the earlier study period (before June 2017), 54% vs 46%, respectively, though this was not statistically significant (p = 0.091). Figure 2 demonstrates the daily rate of SL following PD. There was no difference in GA, BW, demographics, maternal/perinatal characteristics, character of drainage (air, meconium, etc.), or day of life PD placement between patients treated successfully with PD compared to those who required SL (Table 1 ). Duration of drain was longer in the cohort successfully treated with PD compared to those that failed PD; 11 days (IQR: 9, 14) vs 8 days (IQR: 5, 10) respectively (p < 0.001), Table 2 . Patients who required SL had a longer length of hospital stay: 67 days (IQR: 38, 115) vs 113 days (IQR: 86, 153) (p < 0.001). There was no difference in mortality between those who treated successfully with PD (12% mortality) compared to those that failed PD (9.7% mortality) (p = 0.583). Table 2 Comparison drain success rate between patients treated prior to June 15, 2017 to those patients treated on and after June 16, 2017 Characteristic N Obs. Total Cohort Before June 15, 2017 After June 16, 2017 P-value Drain Success* 235 0.011 Yes 130 (55%) 88 (62%) 42 (45%) No 105 (45%) 54 (38%) 51 (55%) Salvage laparotomy 235 0.091 Yes 93 (40%) 50 (35%) 43 (46%) No 142 (60%) 92 (65%) 50 (54%) Duration of first drain , days 212 10 (7, 13) 10 (7, 14) 9 (7, 11) 0.037 *Defined as no need for laparotomy during admission Discussion In this nearly 20-year single-center retrospective cohort study of over 200 infants with SIP we reported PD success in 61% of neonates. Of patients that required SL, most had an intraoperative diagnosis of SIP with only 8.1% diagnosed with NEC based on intraoperative findings. Another 11 neonates required laparotomy at some point during their index admission, most for bowel obstructions or strictures, and 10 neonates suffered drain complications. Neonates who required SL had twice the length of stay however otherwise there were no significant demographic or clinical differences between patients treated successfully with PD compared to those who required SL. There was no difference in mortality between those successfully treated with PD vs those requiring salvage laparotomy, meaning that those treated successfully with drains survive and do well. Overall, this data supports previous literature suggesting that PD can be highly successful in neonates with the preoperative diagnosis of SIP, however, does not elucidate risk factors for PD failure and does not offer insight into which subset of neonates with SIP are highest risk for SL. There can be significant overlaps in the clinical presentation between NEC and SIP making them difficult to distinguish preoperatively [ 12 , 15 , 16 ]. Both infants with either SIP or NEC may develop bloody stools, abdominal distension, and bilious emesis or nasogastric tube output [ 6 , 17 ]. Similarly, both NEC and SIP may present with pneumoperitoneum on abdominal radiographs. Though, classically NEC will be associated with bowel distension, pneumatosis intestinalis, or fixed bowel loops and SIP will typically demonstrate a paucity of bowel gas on abdominal radiographs [ 6 , 18 ]. Accurate initial diagnosis of SIP vs NEC is crucial as the recommended intervention varies between the two pathologies [ 9 ]. Studies have shown that most pediatric surgeons use preoperative SIP vs NEC diagnosis to guide decision-making within their practice, typically preferring drainage for SIP cases and laparotomy for NEC cases [ 7 , 19 – 21 ]. This surgeon decision-making has been supported by the reported results of the Necrotizing Enterocolitis Surgery Trial (NEST), a randomized controlled trial (RCT) comparing laparotomy to peritoneal drainage as first initial intervention in ELBW infants with SIP or NEC [ 9 ]. Despite well-established diagnostic challenges, we report 8.1% of infants who failed peritoneal drainage had an intraoperative diagnosis of NEC. As intraoperative diagnosis appears to be the gold standard in SIP and NEC, it is nearly impossible to know definitively if any of the neonates treated successfully with PD were misdiagnosed NEC as well. However, as previous literature has demonstrated the ongoing challenge of distinguishing SIP and NEC preoperatively, it is encouraging to see that only 8% of neonates were misdiagnosed for NEC in our cohort [ 9 , 12 ]. Meconium-related ileus, resulting from viscous meconium and poor intestinal motility, has increased in incidence as survival rates of low birthweight and premature infants has improved [ 22 – 24 ]. Early diagnosis is vital for success of conservative management such as meconium-softening enemas, and delays in diagnosis leads to increased risk of perforation [ 22 – 25 ]. While operative reports were thoroughly reviewed in a best attempt to elucidate the exact intraoperative diagnosis, there is a risk for misclassification of meconium-related ileus or NEC to the stricture/bowel obstruction group. Indeed, while stricture and bowel obstruction secondary to adhesive disease are known risks of neonatal perforation and subsequent interventions, rates reported in the literature are very low and overall data is sparse [ 26 – 28 ]. Our results highlight an area of potential improvement in better selection of patients for peritoneal drainage and support the need for appropriate imaging and work-up to detect possible meconium obstruction, which may include imaging using enteral contrast. For some pediatric surgeons, PD has evolved as the preferred first line strategy for the management of SIP especially in low birthweight infants [ 29 , 30 ]. However, there are no standardized guidelines on drain management and a lack of studies examining the appropriate duration of drain management to provide recommendations. Our study found no significant difference in character of drain (air, meconium, bile-stained, etc.) or the day of life of drain placement between those successfully treated with PD and those requiring laparotomy. However, we report that the duration of drain was significantly longer in the cohort successfully treated with PD compared to those that failed PD (median 11 vs. 8 days; p < 0.001). While this may seem counterintuitive, it may be an indication that those infants who will fail PD will declare themselves earlier and drain was removed during salvage LP. Keeping in mind the expected pathophysiology, if the goal is to allow the expected bowel perforation to seal, our results may support that patience is key while maintaining drains; given PD tolerance and resolution of sepsis. Indeed, a study by Jadhav et al. reported an even longer median drain duration of 13 days (IQR 9.5, 19.0) though the study was not only examining those successfully treated with PD alone [ 19 ]. On the other hand, 81% of neonates who failed in our study had SIP with a perforation that just had not (and likely would never) have sealed. In these scenarios, earlier identification of PD failure may help decrease days till SL and improve overall outcomes and LOS. Persistent or recurrent pneumoperitoneum was the most common reason for drain failure in our study. Indeed, Jadhav et al. reported a median time to resolution of pneumoperitoneum of 2 days (IQR 1.0, 3.3) [ 19 ]. Therefore, those that do not have resolution of pneumoperitoneum within the first few days post-drain placement may be at higher risk of drain failure. Future prospective studies are important to specifically understand this dilemma and clarify drain management. These studies may consider adjuncts to understanding drain failure such as ultrasound, diagnostic peritoneal lavage with markers for persistent entero-atmospheric fistulas or contrast studies. Defining the correct days of PD and indications for SL, may decrease unnecessary PD days, allow for family expectant counseling on need for salvage laparotomy, and improve outcomes. This study is not without limitations. We acknowledge the weaknesses inherent in a single-center retrospective review. As a single-center study, our results are limited to a racially diverse group of infants with a large Black (63%) population, which may limit the generalizability across all pediatric patient populations. Despite the limitations of a single-center study, detailed pathologic and operative report information cannot be extracted from administrative databases that yield larger sample sizes of the greater pediatric population. The retrospective nature of this study limits our ability to understand how the surgeons came to their preoperative and intraoperative diagnoses or what clinical factors were used to make these diagnostic decisions. Though our institution does not have standardized protocols for differentiating or managing NEC vs SIP, being at a single center may have influenced surgeon practice patterns and how these surgeons decided upon the preoperative and intraoperative diagnoses. Additionally, our study spanned almost 20 years over which time our understanding of SIP and NEC and management has evolved, which may have influenced the results reported. Every attempt was made to thoroughly review operative reports and clarify the exact intraoperative diagnosis when not clearly stated. Any description of bowel necrosis or significant inflammation was assumed to be necrotizing enterocolitis and when available this was verified with review of pathology report findings. Feeding practices both prior to and following drain placement were not examined within this study and is an area for future study. Finally, this study is limited by the lack of standardized definition of drain “failure,” and thus it is unknown if certain patients waiting would have led to drain success as lone intervention. This study highlights the need for standardization in the definition of failure and timing of laparotomy as substantial variation of care exists. Conclusion Peritoneal drainage is an important tool in the management of SIP and is successful in most neonates undergoing PD. However, SL is not uncommon (41%) and patients who require SL suffer twice the length of stay. Improved differentiation between SIP and other causes of pneumoperitoneum as well as anticipation of PD failure may improve outcomes. Prospective studies are needed to define PD failure and guide drain management. Declarations Author Contribution GD and OK wrote the main manuscript, were involved with conceptualization and data curation. IA and MB were involved with data curation and manuscript editing. ZH was invovled with data analysis. HA and AB were invovled with conceptualization, and manuscript review. References Elgendy MM, Othman HF, Heis F, Qattea I, Aly H (2021) Spontaneous intestinal perforation in premature infants: a national study. J Perinatol 41:1122–1128 Swanson JR, Hair A, Clark RH, Gordon PV (2022) Spontaneous intestinal perforation (SIP) will soon become the most common form of surgical bowel disease in the extremely low birth weight (ELBW) infant. J Perinatol 42:423–429 Hwang H, Murphy JJ, Gow KW, Magee JF, Bekhit E, Jamieson D (2003) Are localized intestinal perforations distinct from necrotizing enterocolitis? 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Cite Share Download PDF Status: Under Review Version 1 posted Editorial decision: Revision requested 03 Mar, 2026 Reviews received at journal 26 Feb, 2026 Reviewers agreed at journal 09 Feb, 2026 Reviewers agreed at journal 08 Feb, 2026 Reviewers agreed at journal 11 Sep, 2025 Reviewers agreed at journal 07 Sep, 2025 Reviewers invited by journal 06 Sep, 2025 Editor assigned by journal 01 Sep, 2025 Submission checks completed at journal 01 Sep, 2025 First submitted to journal 30 Aug, 2025 You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. We do this by developing innovative software and high quality services for the global research community. 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Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-7497221","acceptedTermsAndConditions":true,"allowDirectSubmit":false,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":511489881,"identity":"9f6a0905-b07b-4cd8-8443-466290a3da54","order_by":0,"name":"Goeto Dantes","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAAAx0lEQVRIiWNgGAWjYFCCBDApB+MyNhCl5QADgzHpWhJhKglrkXdPfvb4Q0Vder/Y4WOfeRhsZDccIKDF8Mwzc4MDZw7nzpydljybhyHNmLCWGQlmEgfbDuRuuJ1jzMzDcDiRCC3p3yQO/qtLt4do+U9Yi7xEDtCWBuYEA2mwlgOEtRjwvCmTOHPssOGM22nJjHMMko1nErSlPX2bREVNnTz/7OTDDG8q7GT7CNqCrICJx4CAcrAtDUgcxh9E6BgFo2AUjIKRBwACrkVy2enj9QAAAABJRU5ErkJggg==","orcid":"","institution":"Emory University","correspondingAuthor":true,"prefix":"","firstName":"Goeto","middleName":"","lastName":"Dantes","suffix":""},{"id":511489882,"identity":"17a4eb48-6dfb-4d74-8614-6ebca0b04f1f","order_by":1,"name":"Olivia Keane","email":"","orcid":"","institution":"Emory University","correspondingAuthor":false,"prefix":"","firstName":"Olivia","middleName":"","lastName":"Keane","suffix":""},{"id":511489883,"identity":"6cbed7c2-dcf5-45d8-8045-3b7b6d78b532","order_by":2,"name":"Isabella Amaniera","email":"","orcid":"","institution":"Emory University School of Medicine, Emory University","correspondingAuthor":false,"prefix":"","firstName":"Isabella","middleName":"","lastName":"Amaniera","suffix":""},{"id":511489884,"identity":"ad68fe74-d173-4e37-91ca-1c6ba76d7104","order_by":3,"name":"Morgan Buchanan","email":"","orcid":"","institution":"Emory University School of Medicine, Emory University","correspondingAuthor":false,"prefix":"","firstName":"Morgan","middleName":"","lastName":"Buchanan","suffix":""},{"id":511489885,"identity":"2be14117-c15b-4ef7-84cc-718f50f330ef","order_by":4,"name":"Zhulin He","email":"","orcid":"","institution":"Emory University School of Medicine","correspondingAuthor":false,"prefix":"","firstName":"Zhulin","middleName":"","lastName":"He","suffix":""},{"id":511489886,"identity":"c7edd4bf-134d-45b9-b311-ba75d5d7ae79","order_by":5,"name":"Hanna Alemayehu","email":"","orcid":"","institution":"Emory University School of Medicine, Children's Healthcare of Atlanta","correspondingAuthor":false,"prefix":"","firstName":"Hanna","middleName":"","lastName":"Alemayehu","suffix":""},{"id":511489887,"identity":"e9adaac5-7ba9-4ac0-9ff6-d6b7cea12fad","order_by":6,"name":"Amina M. Bhatia","email":"","orcid":"","institution":"Emory University School of Medicine, Children's Healthcare of Atlanta","correspondingAuthor":false,"prefix":"","firstName":"Amina","middleName":"M.","lastName":"Bhatia","suffix":""}],"badges":[],"createdAt":"2025-08-30 19:53:11","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-7497221/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-7497221/v1","draftVersion":[],"editorialEvents":[],"editorialNote":"","failedWorkflow":false,"files":[{"id":91196085,"identity":"adea2721-85bd-4eb8-885a-99393b18fd84","added_by":"auto","created_at":"2025-09-12 15:01:25","extension":"png","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":59230,"visible":true,"origin":"","legend":"\u003cp\u003eKaplan Meier Curve demonstrating survival without Salvage Laparotomy or Death for 40 days.\u003c/p\u003e\n\u003cp\u003e*Solid line represents the salvage laparotomy probability, grey area means 95% confidence interval.\u003c/p\u003e","description":"","filename":"1.png","url":"https://assets-eu.researchsquare.com/files/rs-7497221/v1/054692166e6022d2e20270a2.png"},{"id":91196087,"identity":"ac2e6fa6-8b7d-4837-b067-9679b1e51ed3","added_by":"auto","created_at":"2025-09-12 15:01:25","extension":"png","order_by":2,"title":"Figure 2","display":"","copyAsset":false,"role":"figure","size":63149,"visible":true,"origin":"","legend":"\u003cp\u003eSalvage Laparotomy rate 30 days from peritoneal drain placement\u003c/p\u003e\n\u003cp\u003e*Rate calculated by number of salvage laparotomies on a given day divided by total number of patients\u003c/p\u003e","description":"","filename":"2.png","url":"https://assets-eu.researchsquare.com/files/rs-7497221/v1/a42faec8ad5dcfcaedd01015.png"},{"id":91198872,"identity":"1e8d99f8-2d5f-46f0-86c1-168fbcae9c53","added_by":"auto","created_at":"2025-09-12 15:17:25","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":1152583,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-7497221/v1/42b62d98-3330-43b5-a119-272878109d22.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"Peritoneal Drainage in Spontaneous Intestinal Perforation: A 20-year single center review","fulltext":[{"header":"Introduction","content":"\u003cp\u003eSpontaneous intestinal perforation (SIP) is a highly morbid condition of infancy with a reported incidence rate of 1.6% in neonates less than 32-weeks gestational age and increased rates in very and extremely low birthweight (VLBW and ELBW) infants [\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e, \u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e]. SIP is recognized as a distinct cause of neonatal intestinal perforation caused by a lack of bowel wall structural integrity that results in submucosal thinning and isolated/localized mucosal ulceration [\u003cspan additionalcitationids=\"CR4\" citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e]. Thus, SIP can occur before initiation of feeds in low birthweight infants and is characterized by a single sub-centimeter perforation located on the anti-mesenteric border with healthy appearing adjacent bowel [\u003cspan additionalcitationids=\"CR4\" citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e].\u003c/p\u003e\u003cp\u003eLaparotomy with resection or repair of the bowel perforation was the gold standard for treatment [\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e]. Alternatively, upfront peritoneal drain (PD) placement to control intra-abdominal sepsis while allowing bowel perforations to heal/seal without additional laparotomy, has been successful in up to 70% of neonates [\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e]. Neonates who fail initial PD either due to ongoing sepsis, re-accumulation of pneumoperitoneum or persistent stool leakage from the drain site, then undergo salvage laparotomy (SL) [\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e, \u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e]. Previous research, most notably the Necrotizing Enterocolitis Surgery Trial (NEST) trial, has suggested that PD, as opposed to upfront laparotomy (LP), can be favorable in infants with SIP [\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e]. NEST found higher rates of death and neurodevelopment impairment were seen with upfront laparotomy compared to initial drainage that infants with the preoperative diagnosis of SIP [\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e].\u003c/p\u003e\u003cp\u003e Currently there are neither standardized guidelines for PD management or studies to answer questions such as: how long drains should remain in place, should drains be flushed, should a second drain be attempted, and what are discrete indications for salvage laparotomy. We also fall short in our understanding of why some drains are not successful. Necrotizing enterocolitis (NEC) is also a disease of low birthweight neonates that is characterized by ischemia causing full thickness hemorrhagic necrosis of the bowel wall thought to be primarily driven by initiation of feeds [\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e, \u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e, \u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e]. There can be significant overlap in clinical and abdominal radiographic findings in SIP and NEC and thus one presumed reason for peritoneal drain failure is preoperative misdiagnosis [\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e, \u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e]. However, smaller studies have highlighted other possible risk factors including vasopressor requirement pre-intervention, lower birthweight, and later timing/day of life (DOL) of perforation [\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e, \u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e].\u003c/p\u003e\u003cp\u003eAs SL is associated with poor outcomes, understanding why certain neonates fail PD or identifying which subset of neonates with SIP are at increased risk of SL may improve outcomes [\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e]. Our institution published a retrospective review over a decade ago, attempting to answer some of these questions [\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e]. We now provide an updated review of our institutional data, investigating rates of PD failure in the treatment of SIP and reasons for failure. We sought to retrospectively compare clinical characteristics between those infants who fail peritoneal drainage and those treated successfully with drainage alone.\u003c/p\u003e"},{"header":"Methods","content":"\u003cdiv id=\"Sec3\" class=\"Section2\"\u003e\u003ch2\u003eStudy Design\u003c/h2\u003e\u003cp\u003eA retrospective cohort study of ELBW (\u0026lt;\u0026thinsp;1000g) and VLBW (\u0026lt;\u0026thinsp;1500g) neonates treated for pneumoperitoneum or suspected bowel perforation between July 2004 and March 2023 was conducted within a tertiary children\u0026rsquo;s healthcare system in a large urban setting. Neonates from 2004\u0026ndash;2012 were previously reported on and were included in this updated review [\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e]. Patients with a pre-operative diagnosis of SIP who were treated with peritoneal drainage (PD) were included. Patients were admitted to one of two level IV neonatal intensive care units (NICUs) within the same health system. The cohort was built from extracting data from our institution\u0026rsquo;s electronic medical record (EMR). Patients with a pre-intervention diagnosis of NEC, incomplete charts, or death immediately following drainage, were excluded. Due to the nature of the study, a waiver for informed consent was obtained and approved by the institutional review board.\u003c/p\u003e\u003cp\u003e Demographic factors of the patients collected from chart review of the electronic medical record, included: gestational age (weeks), race, ethnicity, biologic sex, birthweight (grams), and maternal age (years). Additional clinical factors including feeding history, laboratory/radiological findings, and surgical intervention/documentation were also reviewed and collected from the EMR. Some data points were compared before and after 2017, which was a rough division for when consistent data was available on included neonates.\u003c/p\u003e\u003cp\u003ePreoperative diagnosis was obtained from procedural report documentation with cross-reference and verification with the pediatric surgery team consult and progress notes leading up to intervention for pneumoperitoneum. There are no standardized institutional protocols on the diagnosis or the management of infants with pneumoperitoneum and thus diagnosis and management decisions were entirely up to the pediatric surgery and neonatology teams. However, standard PD placement at our institution is performed with a quarter-inch Penrose drain placed in the right hemiabdomen via small open incision. This technique was utilized by all surgeons at our institution throughout the study period. Our surgical team does not employ percutaneous Seldinger technique with a pigtail catheter described at other institutions.\u003csup\u003e13\u003c/sup\u003e Infants treated with a PD that required LP for any reason within 30 days of PD were consider SL. Any laparotomy performed during their index admission was also recorded. Documented indication for SL and intraoperative diagnoses were obtained. \u0026ldquo;Clinical deterioration\u0026rdquo; was based on surgical team documentation of reasoning for SL and included signs and symptoms such as new or increasing pressor requirement, persistent lactic acidosis, worsening respiratory status, and/or ongoing/worsening thrombocytopenia/coagulopathy. Intraoperative diagnosis was obtained from the operative report documentation alone.\u003c/p\u003e\u003cp\u003e This study followed the Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) reporting guidelines.\u003c/p\u003e\u003c/div\u003e\n\u003ch3\u003eOutcomes \u0026 Statistical Analysis\u003c/h3\u003e\n\u003cp\u003ePrimary outcome of interest was reason cited for PD failure and operative indication. Descriptive statistics such as means (standard deviations) for continuous variables and counts (percentages) for categorical variables were provided for demographic and clinical characteristics. Comparison of clinical characteristics and outcomes of patients between those who failed PD vs those who were successfully treated with PD alone were done using Wilcoxon\u0026rsquo;s rank sum test for continuous variables, and Fisher\u0026rsquo;s exact test for categorical variables. All statistical tests were two-sided, and p\u0026thinsp;\u0026lt;\u0026thinsp;0.05 were considered statistically significant. All statistical analyses were completed using R version 4.3.2.\u003c/p\u003e"},{"header":"Results","content":"\u003cp\u003eOverall, 301 neonates were treated for pneumoperitoneum with the preoperative diagnosis of SIP during the study timeframe. Of those with a preoperative diagnosis of SIP, 235 (78.1%) were treated with initial PD and were included in the analytic cohort. The median GA was 25.0 weeks (IQR: 24.1, 26.3) and median birthweight was 720 g (IQR: 625, 855). Of those initially treated with PD, 93 (39.6%) patients required SL. There was a median of 9 days (IQR: 5,14) from drain placement to salvage LP (Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e). Figure\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003e is a Kaplan-Meier curve demonstrating survival without SL or death.\u003c/p\u003e\u003cp\u003e\u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab1\" border=\"1\"\u003e\u003ccaption language=\"En\"\u003e\u003cdiv class=\"CaptionNumber\"\u003eTable 1\u003c/div\u003e\u003cdiv class=\"CaptionContent\"\u003e\u003cp\u003eDemographics and clinical characteristics\u003c/p\u003e\u003c/div\u003e\u003c/caption\u003e\u003ccolgroup cols=\"6\"\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e\u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e\u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c6\" colnum=\"6\"\u003e\u003c/div\u003e\u003cthead\u003e\u003ctr\u003e\u003cth align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/th\u003e\u003cth align=\"left\" colname=\"c2\"\u003e\u003cp\u003eN Observed\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c3\"\u003e\u003cp\u003eTotal Cohort\u003c/p\u003e\u003cp\u003eN\u0026thinsp;=\u0026thinsp;235\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c4\"\u003e\u003cp\u003ePeritoneal Drain\u003c/p\u003e\u003cp\u003eN\u0026thinsp;=\u0026thinsp;142\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c5\"\u003e\u003cp\u003eSalvage Laparotomy\u003c/p\u003e\u003cp\u003eN\u0026thinsp;=\u0026thinsp;93\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c6\"\u003e\u003cp\u003ep-value\u003c/p\u003e\u003c/th\u003e\u003c/tr\u003e\u003c/thead\u003e\u003ctbody\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cb\u003eBirth Weight\u003c/b\u003e, grams (IQR)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e235\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e720 (620, 865)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e720 (625, 855)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e726 (600, 900)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e\u003cp\u003e0.605\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cb\u003eGestational Age\u003c/b\u003e, weeks (IQR)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e235\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e25.00 (24.14, 26.29)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e25.00 (24.14, 26.00)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e25.00 (24.00, 26.43)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e\u003cp\u003e0.921\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cb\u003eGender\u003c/b\u003e, Male (%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e235\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e156 (66%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e93 (65%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e63 (68%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e\u003cp\u003e0.721\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cb\u003eRace/Ethnicity\u003c/b\u003e, n (%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e234\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e\u003cp\u003e0.730\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eBlack\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e151 (65%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e87 (62%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e64 (69%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eWhite\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e63 (27%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e40 (28%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e23 (25%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eAsian\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e4 (1.7%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e2 (1.4%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e2 (2.2%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eHispanic or Latino\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e4 (1.7%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e3 (2.1%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e1 (1.1%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003ePacific Islander, Native or American Indian\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e12 (5.1%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e9 (6.4%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e3 (3.2%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cb\u003eApgar score 1 min\u003c/b\u003e, (IQR)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e215\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e4 (2, 6)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e4 (2, 6)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e3 (2, 6)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e\u003cp\u003e0.852\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cb\u003eApgar score 5 min\u003c/b\u003e, (IQR)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e217\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e7 (5, 8)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e7 (5, 8)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e7 (4, 8)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e\u003cp\u003e0.887\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cb\u003eChorioamnionitis\u003c/b\u003e, n (%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e224\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e17 (7.6%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e10 (7.6%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e7 (7.6%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e\u003cp\u003e0.993\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cb\u003eMode of delivery\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e218\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e\u003cp\u003e0.376\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eVaginal\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e71 (33%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e39 (30%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e32 (36%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eC-section\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e147 (67%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e90 (70%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e57 (64%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cb\u003eBirth date\u003c/b\u003e, n (%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e235\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e\u003cp\u003e0.091\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eBefore June 15th, 2017\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e142 (61%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e92 (65%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e50 (54%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eAfter June 16th, 2017\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e93 (39%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e50 (35%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e43 (46%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cb\u003eAdmission date\u003c/b\u003e, n (%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e235\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e\u003cp\u003e\u003cb\u003e\u0026lt;\u0026thinsp;0.001\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eBefore Dec 2012\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e78 (33%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e59 (42%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e19 (20%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eAfter Jan 2013\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e157 (67%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e83 (58%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e74 (80%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cb\u003eDied after 30 days of admission\u003c/b\u003e, n (%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e223\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e14 (6.3%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e14 (10%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e0 (0%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e\u003cp\u003e\u003cb\u003e0.003\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cb\u003eDay of Life drain placement\u003c/b\u003e, (IQR)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e233\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e7 (4, 10)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e7 (5, 9)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e7 (3.5, 11)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e\u003cp\u003e0.733\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cb\u003eCharacter of drain\u003c/b\u003e, n (%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e211\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e\u003cp\u003e0.450\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eAir only\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e11 (5.2%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e7 (5.1%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e4 (5.3%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eBile Stained Serous\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e22 (10%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e12 (8.8%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e10 (13%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eBloody, non-particulate\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e13 (6.2%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e6 (4.4%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e7 (9.3%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eMeconium, Stool or Succus\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e109 (52%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e72 (53%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e37 (49%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eSerous, non-particulate\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e56 (27%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e39 (29%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e17 (23%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cb\u003eDrain character\u003c/b\u003e, n (%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e211\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e\u003cp\u003e1.000\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eAir only\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e11 (5.2%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e7 (5.1%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e4 (5.4%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eAnything other than air\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e200 (95%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e129 (95%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e71 (95%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cb\u003eDrain character 2\u003c/b\u003e, n (%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e211\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e\u003cp\u003e0.616\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eAir and Serous/blood/bile stained\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e102 (48%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e64 (47%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e38 (51%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eMeconium, stool or succus\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e109 (52%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e72 (53%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e37 (49%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cb\u003eDrain character 3\u003c/b\u003e, n (%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e211\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e\u003cp\u003e0.199\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eMeconium, stool or succus\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e109 (52%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e72 (53%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e37 (49%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eBile stained, Bloody\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e35 (17%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e18 (13%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e17 (23%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eSerous or Air\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e67 (32%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e46 (34%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e21 (28%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cb\u003eDuration of first drain\u003c/b\u003e, days (IQR)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e212\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e10 (7, 13)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e11 (9, 14)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e8 (5, 10)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e\u003cp\u003e\u003cb\u003e\u0026lt;\u0026thinsp;0.001\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cb\u003eIndication for drain removal\u003c/b\u003e, n (%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e216\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e\u003cp\u003e\u003cb\u003e\u0026lt;\u0026thinsp;0.001\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003ePurposeful Removal\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e138 (64%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e106 (83%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e32 (36%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eDuring Surgery\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e50 (23%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e0 (0.0%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e49 (55%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eFell out prior to purposeful removal\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e28 (13%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e21 (16.5%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e8 (9%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cb\u003eDrain complication\u003c/b\u003e, n (%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e235\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e10 (4.3%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e4 (2.8%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e6 (6.5%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e\u003cp\u003e0.200\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cb\u003eAnatomic location of perforation\u003c/b\u003e, n (%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e98\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e\u003cp\u003e0.691\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eIleum\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e76 (78%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e-\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e69 (78%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eJejunum\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e22 (22%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e-\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e19 (22%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cb\u003eSurgery at any time during admission\u003c/b\u003e, n (%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e235\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e104 (44%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e11 (7.7%)**\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e93 (100%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e\u003cp\u003e\u003cb\u003e\u0026lt;\u0026thinsp;0.001\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cb\u003eDay of life surgery\u003c/b\u003e, (IQR)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e108\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e18 (12, 27)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e54 (42, 76)**\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e17 (12, 24)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e\u003cp\u003e\u003cb\u003e\u0026lt;\u0026thinsp;0.001\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cb\u003eDays from drain placement to surgery\u003c/b\u003e, (IQR)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e103\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e10 (5, 17)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e56 (43, 72)**\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e9 (5, 14)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e\u003cp\u003e\u003cb\u003e\u0026lt;\u0026thinsp;0.001\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cb\u003eIndication for surgery\u003c/b\u003e, n (%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e104\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e\u003cp\u003e\u003cb\u003e\u0026lt;\u0026thinsp;0.001\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003ePersistent meconium/stool drainage\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e14 (13%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e1 (9.1%)**\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e13 (14%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eRecurrent or persistent pneumoperitoneum\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e49 (47%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e1 (9.1%)**\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e48 (52%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eUnimproved clinical status or clinical deterioration\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e19 (18%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e0 (0%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e19 (20%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eObstruction or stricture\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e14 (13%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e9 (81%)**\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e5 (5.4%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eOther*\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e8 (7.7%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e0 (0%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e8 (8.6%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cb\u003eFinal intraoperative diagnosis\u003c/b\u003e, n (%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e83\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e\u003cp\u003e\u003cb\u003e\u0026lt;\u0026thinsp;0.001\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eSIP\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e60 (72%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e1 (9.1%)**\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e59 (83%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eNEC\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e9 (11%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e2 (18.2%)**\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e6 (8.4%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eStricture/bowel obstruction/abscess\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e14 (17%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e8 (73%)**\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e6 (8.4%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cb\u003eLength of stay\u003c/b\u003e, days (IQR)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e235\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e97 (44, 130)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e67 (38, 115)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e113 (86, 153)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e\u003cp\u003e\u003cb\u003e\u0026lt;\u0026thinsp;0.001\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cb\u003eMortality\u003c/b\u003e, n (%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e235\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e\u003cp\u003e0.583\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eYes\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e26 (11%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e17 (12%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e9 (9.7%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eNo\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e209 (89%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e125 (88%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e84 (90%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003c/tbody\u003e\u003c/colgroup\u003e\u003ctfoot\u003e\u003ctr\u003e\u003ctd colspan=\"6\"\u003e*Other: Unknown, hemoperitoneum, drain complications\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd colspan=\"6\"\u003e**Outcomes and findings specific for neonates who required surgery/laparotomy beyond 30 days\u003c/td\u003e\u003c/tr\u003e\u003c/tfoot\u003e\u003c/table\u003e\u003c/div\u003e\u003c/p\u003e\u003cp\u003eThe most common indications for SL included: recurrent or persistent pneumoperitoneum (52%), clinical deterioration or non-improvement (20%), and ongoing drain output of meconium or stool (14%) (Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e). Of those that underwent SL, 81% were noted to have an intraoperative diagnosis of SIP whereas 8.1% had stricture or bowel obstruction, and 8.1% had NEC (Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e). An additional 11 neonates who did not require SL underwent surgery at some point during their index admission. Of these 11, 9 (81%) required surgery for strictures/bowel obstruction and 2 (18%) were found to have NEC. The total number of neonates with SIP treated with PD who required surgery at any point during index admission was 104 (44.2%). Ten (4.3%) of all neonates suffered drain complications including drain site evisceration/herniation, development of drain site enterocutaneous fistula or intra-abdominal hemorrhage. Rates of SL did appear to increase in the latter half of the study period (after June 2017) when compared to the earlier study period (before June 2017), 54% vs 46%, respectively, though this was not statistically significant (p\u0026thinsp;=\u0026thinsp;0.091). Figure\u0026nbsp;\u003cspan refid=\"Fig2\" class=\"InternalRef\"\u003e2\u003c/span\u003e demonstrates the daily rate of SL following PD.\u003c/p\u003e\u003cp\u003eThere was no difference in GA, BW, demographics, maternal/perinatal characteristics, character of drainage (air, meconium, etc.), or day of life PD placement between patients treated successfully with PD compared to those who required SL (Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e). Duration of drain was longer in the cohort successfully treated with PD compared to those that failed PD; 11 days (IQR: 9, 14) vs 8 days (IQR: 5, 10) respectively (p\u0026thinsp;\u0026lt;\u0026thinsp;0.001), Table\u0026nbsp;\u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e2\u003c/span\u003e. Patients who required SL had a longer length of hospital stay: 67 days (IQR: 38, 115) vs 113 days (IQR: 86, 153) (p\u0026thinsp;\u0026lt;\u0026thinsp;0.001). There was no difference in mortality between those who treated successfully with PD (12% mortality) compared to those that failed PD (9.7% mortality) (p\u0026thinsp;=\u0026thinsp;0.583).\u003c/p\u003e\u003cp\u003e\u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab2\" border=\"1\"\u003e\u003ccaption language=\"En\"\u003e\u003cdiv class=\"CaptionNumber\"\u003eTable 2\u003c/div\u003e\u003cdiv class=\"CaptionContent\"\u003e\u003cp\u003eComparison drain success rate between patients treated prior to June 15, 2017 to those patients treated on and after June 16, 2017\u003c/p\u003e\u003c/div\u003e\u003c/caption\u003e\u003ccolgroup cols=\"6\"\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e\u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e\u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c6\" colnum=\"6\"\u003e\u003c/div\u003e\u003cthead\u003e\u003ctr\u003e\u003cth align=\"left\" colname=\"c1\"\u003e\u003cp\u003eCharacteristic\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c2\"\u003e\u003cp\u003eN Obs.\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c3\"\u003e\u003cp\u003eTotal Cohort\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c4\"\u003e\u003cp\u003eBefore June 15, 2017\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c5\"\u003e\u003cp\u003eAfter June 16, 2017\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c6\"\u003e\u003cp\u003eP-value\u003c/p\u003e\u003c/th\u003e\u003c/tr\u003e\u003c/thead\u003e\u003ctbody\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cb\u003eDrain Success*\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e235\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e\u003cp\u003e\u003cb\u003e0.011\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eYes\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e130 (55%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e88 (62%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e42 (45%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eNo\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e105 (45%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e54 (38%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e51 (55%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cb\u003eSalvage laparotomy\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e235\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e\u003cp\u003e0.091\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eYes\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e93 (40%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e50 (35%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e43 (46%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eNo\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e142 (60%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e92 (65%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e50 (54%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cb\u003eDuration of first drain\u003c/b\u003e, days\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e212\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e10 (7, 13)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e10 (7, 14)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e9 (7, 11)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e\u003cp\u003e\u003cb\u003e0.037\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003c/tbody\u003e\u003c/colgroup\u003e\u003ctfoot\u003e\u003ctr\u003e\u003ctd colspan=\"6\"\u003e*Defined as no need for laparotomy during admission\u003c/td\u003e\u003c/tr\u003e\u003c/tfoot\u003e\u003c/table\u003e\u003c/div\u003e\u003c/p\u003e"},{"header":"Discussion","content":"\u003cp\u003eIn this nearly 20-year single-center retrospective cohort study of over 200 infants with SIP we reported PD success in 61% of neonates. Of patients that required SL, most had an intraoperative diagnosis of SIP with only 8.1% diagnosed with NEC based on intraoperative findings. Another 11 neonates required laparotomy at some point during their index admission, most for bowel obstructions or strictures, and 10 neonates suffered drain complications. Neonates who required SL had twice the length of stay however otherwise there were no significant demographic or clinical differences between patients treated successfully with PD compared to those who required SL. There was no difference in mortality between those successfully treated with PD vs those requiring salvage laparotomy, meaning that those treated successfully with drains survive and do well. Overall, this data supports previous literature suggesting that PD can be highly successful in neonates with the preoperative diagnosis of SIP, however, does not elucidate risk factors for PD failure and does not offer insight into which subset of neonates with SIP are highest risk for SL.\u003c/p\u003e\u003cp\u003eThere can be significant overlaps in the clinical presentation between NEC and SIP making them difficult to distinguish preoperatively [\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e, \u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e, \u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e]. Both infants with either SIP or NEC may develop bloody stools, abdominal distension, and bilious emesis or nasogastric tube output [\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e, \u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e]. Similarly, both NEC and SIP may present with pneumoperitoneum on abdominal radiographs. Though, classically NEC will be associated with bowel distension, pneumatosis intestinalis, or fixed bowel loops and SIP will typically demonstrate a paucity of bowel gas on abdominal radiographs [\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e, \u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e]. Accurate initial diagnosis of SIP vs NEC is crucial as the recommended intervention varies between the two pathologies [\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e]. Studies have shown that most pediatric surgeons use preoperative SIP vs NEC diagnosis to guide decision-making within their practice, typically preferring drainage for SIP cases and laparotomy for NEC cases [\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e, \u003cspan additionalcitationids=\"CR20\" citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e]. This surgeon decision-making has been supported by the reported results of the Necrotizing Enterocolitis Surgery Trial (NEST), a randomized controlled trial (RCT) comparing laparotomy to peritoneal drainage as first initial intervention in ELBW infants with SIP or NEC [\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e]. Despite well-established diagnostic challenges, we report 8.1% of infants who failed peritoneal drainage had an intraoperative diagnosis of NEC. As intraoperative diagnosis appears to be the gold standard in SIP and NEC, it is nearly impossible to know definitively if any of the neonates treated successfully with PD were misdiagnosed NEC as well. However, as previous literature has demonstrated the ongoing challenge of distinguishing SIP and NEC preoperatively, it is encouraging to see that only 8% of neonates were misdiagnosed for NEC in our cohort [\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e, \u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e].\u003c/p\u003e\u003cp\u003eMeconium-related ileus, resulting from viscous meconium and poor intestinal motility, has increased in incidence as survival rates of low birthweight and premature infants has improved [\u003cspan additionalcitationids=\"CR23\" citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e]. Early diagnosis is vital for success of conservative management such as meconium-softening enemas, and delays in diagnosis leads to increased risk of perforation [\u003cspan additionalcitationids=\"CR23 CR24\" citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e]. While operative reports were thoroughly reviewed in a best attempt to elucidate the exact intraoperative diagnosis, there is a risk for misclassification of meconium-related ileus or NEC to the stricture/bowel obstruction group. Indeed, while stricture and bowel obstruction secondary to adhesive disease are known risks of neonatal perforation and subsequent interventions, rates reported in the literature are very low and overall data is sparse [\u003cspan additionalcitationids=\"CR27\" citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR28\" class=\"CitationRef\"\u003e28\u003c/span\u003e]. Our results highlight an area of potential improvement in better selection of patients for peritoneal drainage and support the need for appropriate imaging and work-up to detect possible meconium obstruction, which may include imaging using enteral contrast.\u003c/p\u003e\u003cp\u003eFor some pediatric surgeons, PD has evolved as the preferred first line strategy for the management of SIP especially in low birthweight infants [\u003cspan citationid=\"CR29\" class=\"CitationRef\"\u003e29\u003c/span\u003e, \u003cspan citationid=\"CR30\" class=\"CitationRef\"\u003e30\u003c/span\u003e]. However, there are no standardized guidelines on drain management and a lack of studies examining the appropriate duration of drain management to provide recommendations. Our study found no significant difference in character of drain (air, meconium, bile-stained, etc.) or the day of life of drain placement between those successfully treated with PD and those requiring laparotomy. However, we report that the duration of drain was significantly longer in the cohort successfully treated with PD compared to those that failed PD (median 11 vs. 8 days; p\u0026thinsp;\u0026lt;\u0026thinsp;0.001). While this may seem counterintuitive, it may be an indication that those infants who will fail PD will declare themselves earlier and drain was removed during salvage LP. Keeping in mind the expected pathophysiology, if the goal is to allow the expected bowel perforation to seal, our results may support that patience is key while maintaining drains; given PD tolerance and resolution of sepsis. Indeed, a study by Jadhav et al. reported an even longer median drain duration of 13 days (IQR 9.5, 19.0) though the study was not only examining those successfully treated with PD alone [\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e]. On the other hand, 81% of neonates who failed in our study had SIP with a perforation that just had not (and likely would never) have sealed. In these scenarios, earlier identification of PD failure may help decrease days till SL and improve overall outcomes and LOS. Persistent or recurrent pneumoperitoneum was the most common reason for drain failure in our study. Indeed, Jadhav et al. reported a median time to resolution of pneumoperitoneum of 2 days (IQR 1.0, 3.3) [\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e]. Therefore, those that do not have resolution of pneumoperitoneum within the first few days post-drain placement may be at higher risk of drain failure. Future prospective studies are important to specifically understand this dilemma and clarify drain management. These studies may consider adjuncts to understanding drain failure such as ultrasound, diagnostic peritoneal lavage with markers for persistent entero-atmospheric fistulas or contrast studies. Defining the correct days of PD and indications for SL, may decrease unnecessary PD days, allow for family expectant counseling on need for salvage laparotomy, and improve outcomes.\u003c/p\u003e\u003cp\u003eThis study is not without limitations. We acknowledge the weaknesses inherent in a single-center retrospective review. As a single-center study, our results are limited to a racially diverse group of infants with a large Black (63%) population, which may limit the generalizability across all pediatric patient populations. Despite the limitations of a single-center study, detailed pathologic and operative report information cannot be extracted from administrative databases that yield larger sample sizes of the greater pediatric population. The retrospective nature of this study limits our ability to understand how the surgeons came to their preoperative and intraoperative diagnoses or what clinical factors were used to make these diagnostic decisions. Though our institution does not have standardized protocols for differentiating or managing NEC vs SIP, being at a single center may have influenced surgeon practice patterns and how these surgeons decided upon the preoperative and intraoperative diagnoses. Additionally, our study spanned almost 20 years over which time our understanding of SIP and NEC and management has evolved, which may have influenced the results reported. Every attempt was made to thoroughly review operative reports and clarify the exact intraoperative diagnosis when not clearly stated. Any description of bowel necrosis or significant inflammation was assumed to be necrotizing enterocolitis and when available this was verified with review of pathology report findings. Feeding practices both prior to and following drain placement were not examined within this study and is an area for future study. Finally, this study is limited by the lack of standardized definition of drain \u0026ldquo;failure,\u0026rdquo; and thus it is unknown if certain patients waiting would have led to drain success as lone intervention. This study highlights the need for standardization in the definition of failure and timing of laparotomy as substantial variation of care exists.\u003c/p\u003e"},{"header":"Conclusion","content":"\u003cp\u003ePeritoneal drainage is an important tool in the management of SIP and is successful in most neonates undergoing PD. However, SL is not uncommon (41%) and patients who require SL suffer twice the length of stay. Improved differentiation between SIP and other causes of pneumoperitoneum as well as anticipation of PD failure may improve outcomes. Prospective studies are needed to define PD failure and guide drain management.\u003c/p\u003e"},{"header":"Declarations","content":"\u003ch2\u003eAuthor Contribution\u003c/h2\u003e\u003cp\u003eGD and OK wrote the main manuscript, were involved with conceptualization and data curation. IA and MB were involved with data curation and manuscript editing. ZH was invovled with data analysis. HA and AB were invovled with conceptualization, and manuscript review.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\n \u003cli\u003eElgendy MM, Othman HF, Heis F, Qattea I, Aly H (2021) Spontaneous intestinal perforation in premature infants: a national study. J Perinatol 41:1122\u0026ndash;1128\u003c/li\u003e\n \u003cli\u003eSwanson JR, Hair A, Clark RH, Gordon PV (2022) Spontaneous intestinal perforation (SIP) will soon become the most common form of surgical bowel disease in the extremely low birth weight (ELBW) infant. J Perinatol 42:423\u0026ndash;429\u003c/li\u003e\n \u003cli\u003eHwang H, Murphy JJ, Gow KW, Magee JF, Bekhit E, Jamieson D (2003) Are localized intestinal perforations distinct from necrotizing enterocolitis? J Pediatr Surg 38:763\u0026ndash;767\u003c/li\u003e\n \u003cli\u003ePumberger W, Mayr M, Kohlhauser C, Weninger M (2002) Spontaneous localized intestinal perforation in very-low-birth-weight infants: a distinct clinical entity different from necrotizing enterocolitis. J Am Coll Surg 195:796\u0026ndash;803\u003c/li\u003e\n \u003cli\u003eFatemizadeh R, Mandal S, Gollins L, Shah S, Premkumar M, Hair A (2021) Incidence of spontaneous intestinal perforations exceeds necrotizing enterocolitis in extremely low birth weight infants fed an exclusive human milk-based diet: A single center experience. J Pediatr Surg 56:1051\u0026ndash;1056\u003c/li\u003e\n \u003cli\u003eRausch LA, Hanna DN, Patel A, Blakely ML (2022) Review of Necrotizing Enterocolitis and Spontaneous Intestinal Perforation Clinical Presentation, Treatment, and Outcomes. Clin Perinatol 49:955\u0026ndash;964\u003c/li\u003e\n \u003cli\u003eJakaitis BM, Bhatia AM (2015) Definitive peritoneal drainage in the extremely low birth weight infant with spontaneous intestinal perforation: predictors and hospital outcomes. J Perinatol 35:607\u0026ndash;611\u003c/li\u003e\n \u003cli\u003eBlakely ML, Tyson JE, Lally KP, et al (2006) Laparotomy versus peritoneal drainage for necrotizing enterocolitis or isolated intestinal perforation in extremely low birth weight infants: outcomes through 18 months adjusted age. Pediatrics 117:e680-687\u003c/li\u003e\n \u003cli\u003eBlakely ML, Tyson JE, Lally KP, et al (2021) Initial Laparotomy versus Peritoneal Drainage in Extremely Low Birthweight Infants with Surgical Necrotizing Enterocolitis or Isolated Intestinal Perforation: A Multi center Randomized Clinical Trial. Ann Surg 274:e370\u0026ndash;e380\u003c/li\u003e\n \u003cli\u003eKim JH, Sampath V, Canvasser J (2020) Challenges in diagnosing necrotizing enterocolitis. Pediatr Res 88:16\u0026ndash;20\u003c/li\u003e\n \u003cli\u003eCaplan MS, Underwood MA, Modi N, et al (2019) Necrotizing Enterocolitis: Using Regulatory Science and Drug Development to Improve Outcomes. J Pediatr 212:208-215.e1\u003c/li\u003e\n \u003cli\u003eKeane OA, Dantes G, Dutreuil VL, Do L, Rumbika S, Sylvestre PB, Bhatia AM (2024) Comparison of preoperative and intraoperative surgeon diagnosis and pathologic findings in spontaneous intestinal perforation vs necrotizing enterocolitis. J Perinatol 44:568\u0026ndash;574\u003c/li\u003e\n \u003cli\u003eAhle S, Badru F, Damle R, et al (2020) Multicenter retrospective comparison of spontaneous intestinal perforation outcomes between primary peritoneal drain and primary laparotomy. J Pediatr Surg 55:1270\u0026ndash;1275\u003c/li\u003e\n \u003cli\u003eEmil S, Davis K, Ahmad I, Strauss A (2008) Factors associated with definitive peritoneal drainage for spontaneous intestinal perforation in extremely low birth weight neonates. Eur J Pediatr Surg 18:80\u0026ndash;85\u003c/li\u003e\n \u003cli\u003eRivero E, Javed F, Manzar S, Bhat R (2024) Laparotomy or peritoneal drainage in preterm infants with spontaneous intestinal perforation or surgical necrotizing enterocolitis? J Perinatol 44:146\u0026ndash;150\u003c/li\u003e\n \u003cli\u003eBuchheit JQ, Stewart DL (1994) Clinical comparison of localized intestinal perforation and necrotizing enterocolitis in neonates. Pediatrics 93:32\u0026ndash;36\u003c/li\u003e\n \u003cli\u003eMeyer CL, Payne NR, Roback SA (1991) Spontaneous, isolated intestinal perforations in neonates with birth weight less than 1,000 g not associated with necrotizing enterocolitis. J Pediatr Surg 26:714\u0026ndash;717\u003c/li\u003e\n \u003cli\u003ePatel RM, Ferguson J, McElroy SJ, Khashu M, Caplan MS (2020) Defining Necrotizing Enterocolitis: Current Difficulties and Future Opportunities. Pediatr Res 88:10\u0026ndash;15\u003c/li\u003e\n \u003cli\u003eJadhav P, Choi PM, Gollin G (2023) Percutaneous Pigtail Catheter Drainage of Spontaneous Intestinal Perforation in Premature Infants. J Surg Res 291:265\u0026ndash;269\u003c/li\u003e\n \u003cli\u003eApfeld JC, Kastenberg ZJ, Gibbons AT, Phibbs CS, Lee HC, Sylvester KG (2019) The disproportionate cost of operation and congenital anomalies in infancy. Surgery 165:1234\u0026ndash;1242\u003c/li\u003e\n \u003cli\u003eKirkby S, Greenspan JS, Kornhauser M, Schneiderman R (2007) Clinical outcomes and cost of the moderately preterm infant. Adv Neonatal Care 7:80\u0026ndash;87\u003c/li\u003e\n \u003cli\u003eAhle M, Ringertz HG, Rubesova E (2018) The role of imaging in the management of necrotising enterocolitis: a multispecialist survey and a review of the literature. Eur Radiol 28:3621\u0026ndash;3631\u003c/li\u003e\n \u003cli\u003eQuiroz HJ, Rao K, Brady A-C, Hogan AR, Thorson CM, Perez EA, Neville HL, Sola JE (2020) Protocol-Driven Surgical Care of Necrotizing Enterocolitis and Spontaneous Intestinal Perforation. J Surg Res 255:396\u0026ndash;404\u003c/li\u003e\n \u003cli\u003eLi W, Tang J, Zhu Z, Tang W (2022) Initial surgical treatment of necrotizing enterocolitis: a meta-analysis of peritoneal drainage versus laparotomy. Eur J Pediatr 181:2593\u0026ndash;2601\u003c/li\u003e\n \u003cli\u003eCass DL, Brandt ML, Patel DL, Nuchtern JG, Minifee PK, Wesson DE (2000) Peritoneal drainage as definitive treatment for neonates with isolated intestinal perforation. J Pediatr Surg 35:1531\u0026ndash;1536\u003c/li\u003e\n \u003cli\u003eParadiso VF, Briganti V, Oriolo L, Coletta R, Calisti A (2011) Meconium obstruction in absence of cystic fibrosis in low birth weight infants: an emerging challenge from increasing survival. Ital J Pediatr 37:55\u003c/li\u003e\n \u003cli\u003eMitani Y, Kubota A, Goda T, Kato H, Watanabe T, Riko M, Tsuno Y, Kumagai T, Yamaue H (2021) Optimum therapeutic strategy for meconium-related ileus in very-low-birth-weight infants. J Pediatr Surg 56:1117\u0026ndash;1120\u003c/li\u003e\n \u003cli\u003eOkuyama H, Ohfuji S, Hayakawa M, et al (2016) Risk factors for surgical intestinal disorders in VLBW infants: Case-control study. Pediatr Int 58:34\u0026ndash;39\u003c/li\u003e\n \u003cli\u003eByun J, Han J-W, Youn JK, Yang H-B, Shin SH, Kim E-K, Kim H-Y, Jung S-E (2020) Risk factors of meconium-related ileus in very low birth weight infants: patients-control study. Sci Rep 10:4674\u003c/li\u003e\n \u003cli\u003eDrewett MS, Burge DM (2007) Recurrent neonatal gastro-intestinal problems after spontaneous intestinal perforation. Pediatr Surg Int 23:1081\u0026ndash;1084\u003c/li\u003e\n\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":true,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"pediatric-surgery-international","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"pesi","sideBox":"Learn more about [Pediatric Surgery International](http://link.springer.com/journal/383)","snPcode":"383","submissionUrl":"https://submission.nature.com/new-submission/383/3","title":"Pediatric Surgery International","twitterHandle":"","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"em","reportingPortfolio":"Springer Hybrid","inReviewEnabled":true,"inReviewRevisionsEnabled":false},"keywords":"","lastPublishedDoi":"10.21203/rs.3.rs-7497221/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-7497221/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003ch2\u003ePurpose\u003c/h2\u003e\u003cp\u003eSpontaneous intestinal perforation (SIP) is a morbid condition of low-birth-weight neonates. Peritoneal drainage (PD), as opposed to upfront laparotomy (LP), is favored for SIP. However, PD management is neither standardized nor thoroughly understood. We reviewed our experience of PD in infants with SIP.\u003c/p\u003e\u003ch2\u003eMethods\u003c/h2\u003e\u003cp\u003eNeonates treated for SIP between 07/2004-03/2023 were reviewed. Patients with NEC or death immediately following PD were excluded. Patients treated with a PD that required LP within 30 days were considered salvage laparotomy (SL).\u003c/p\u003e\u003ch2\u003eResults\u003c/h2\u003e\u003cp\u003eA total of 235 neonates were included. The median gestational age and birth weight were 25.0 weeks (IQR: 24.1, 26.3) and 720 g (IQR: 620, 865). Ninety-three (39.6%) patients required SL at a median of 9 days (IQR: 5, 14) from PD. Indications for failure included recurrent pneumoperitoneum (52%), clinical deterioration (20%), and ongoing feculent drain output (14%). At SL, 8.1% of patients were found to have NEC. SL patients had twice the length of stay: 67 days (IQR: 38, 115) vs 113 days (IQR: 86, 153), p\u0026thinsp;\u0026lt;\u0026thinsp;0.001.\u003c/p\u003e\u003ch2\u003eConclusion\u003c/h2\u003e\u003cp\u003ePD is an important tool in the management of SIP, however SL is not uncommon (39%) and has clinical significance. Prospective data to improve PD management is needed.\u003c/p\u003e","manuscriptTitle":"Peritoneal Drainage in Spontaneous Intestinal Perforation: A 20-year single center review","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2025-09-12 15:01:20","doi":"10.21203/rs.3.rs-7497221/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"decision","content":"Revision requested","date":"2026-03-03T13:48:45+00:00","index":"","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2026-02-26T10:20:31+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"82091621969483412382245119306467294383","date":"2026-02-09T09:28:28+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"275514202199070408194660103689773786011","date":"2026-02-08T18:46:57+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"303633239957539236974371395336292033474","date":"2025-09-12T00:56:53+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"291166639000882066719822917802973044409","date":"2025-09-07T19:12:41+00:00","index":"hide","fulltext":""},{"type":"reviewersInvited","content":"","date":"2025-09-06T23:09:36+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2025-09-01T12:24:06+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2025-09-01T11:22:18+00:00","index":"","fulltext":""},{"type":"submitted","content":"Pediatric Surgery International","date":"2025-08-30T19:46:43+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"pediatric-surgery-international","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"pesi","sideBox":"Learn more about [Pediatric Surgery International](http://link.springer.com/journal/383)","snPcode":"383","submissionUrl":"https://submission.nature.com/new-submission/383/3","title":"Pediatric Surgery International","twitterHandle":"","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"em","reportingPortfolio":"Springer Hybrid","inReviewEnabled":true,"inReviewRevisionsEnabled":false}}],"origin":"","ownerIdentity":"d549165e-4520-43bf-849b-9f8a6b4a9ca5","owner":[],"postedDate":"September 12th, 2025","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"under-review","subjectAreas":[],"tags":[],"updatedAt":"2026-04-12T19:38:34+00:00","versionOfRecord":[],"versionCreatedAt":"2025-09-12 15:01:20","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-7497221","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-7497221","identity":"rs-7497221","version":["v1"]},"buildId":"XKTyCvWXoU3ODBz1xrDgd","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}