Initial Laparotomy versus Peritoneal Drainage in Extremely Low–Birth-Weight Infants with Surgical Necrotizing Enterocolitis or Spontaneous Intestinal Perforation

Initial Laparotomy versus Peritoneal Drainage in Extremely Low–Birth-Weight Infants with Surgical Necrotizing Enterocolitis or Spontaneous Intestinal Perforation | 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 Article Initial Laparotomy versus Peritoneal Drainage in Extremely Low–Birth-Weight Infants with Surgical Necrotizing Enterocolitis or Spontaneous Intestinal Perforation Mohammed Al Blooshi, Munir Ahmad, Fadi Al Shamali, Wajeeh Uddin, and 5 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-7160115/v1 This work is licensed under a CC BY 4.0 License Status: Posted Version 1 posted You are reading this latest preprint version Abstract Necrotizing enterocolitis (NEC) and spontaneous intestinal perforation (SIP) are disastrous complications in extremely lowbirthweight (ELBW) neonates, yet the optimal first operation remains unsettled. Together, these conditions account for a disproportionate share of neonatal surgical mortality. We retrospectively studied ELBW infants (< 1000 g) treated for surgical NEC or SIP at two tertiary UAE centers between 2019 and 2023, comparing outcomes of initial bedside peritoneal drainage (PD)—usually performed under minimal sedation—with exploratory laparotomy (LAP). Twentynine infants qualified; 26 received PD and 3 LAP. Ninetyday survival wa 85 % after PD versus100 % after LAP. However, severe intraventricular hemorrhage developed in ony 4 % of PD infants compared wit 67 % after LAP, and neurodevelopment at oneyear corrected age was normal n 75 % of PD survivors but in none following LAP. Median neonatalintensivecare stay and dependence on parenteral nutrition were similar between strategies. These findings suggest that, for the frailest ELBW population, PD achieves survival equivalent to LAP while potentially reducing cerebral injury and supporting earlier functional recovery. Prospective multicenter trials with adequate power, standardized neurodevelopmental assessment, and longer followup are needed to confirm these signals and guide individualized surgical decisionmaking. Health sciences/Diseases Health sciences/Gastroenterology Health sciences/Health care Health sciences/Medical research Health sciences/Neurology Necrotizing enterocolitis Spontaneous intestinal perforation Extremely low–birth-weight Peritoneal drainage Laparotomy Neonatal surgery Figures Figure 1 Introduction Necrotizing enterocolitis (NEC) and spontaneous (isolated) intestinal perforation (SIP) remain two of the most devastating gastrointestinal emergencies in the neonatal intensive-care unit (NICU). Contemporary reports indicate that NEC develops in approximately 5–10% of very-low–birth-weight and extremely-low–birth-weight (ELBW) infants [ 1 ]. Despite advances in neonatal care, case-fatality rates for surgically managed NEC or SIP continue to range between 20% and 30%, and survivors frequently experience long-term growth failure, short-bowel syndrome, and neurodevelopmental impairment [ 2 ]. Optimizing surgical decision-making for this uniquely vulnerable population therefore remains an urgent clinical priority. Two operative strategies dominate current practice: primary peritoneal drainage (PD) and primary exploratory laparotomy (LAP). PD offers bedside decompression with minimal physiologic stress and has become entrenched in many centers as the initial intervention for the most unstable ELBW infants. Conversely, LAP permits definitive resection of necrotic bowel and direct visualization of disease extent but carries the risks associated with general anesthesia and open surgery. International guidelines acknowledge the paucity of high-quality evidence favoring one approach over the other, resulting in marked variability in surgeon preference and institutional protocols. High-quality investigations published within the past decade have begun to clarify this controversy. The Necrotizing Enterocolitis Surgery Trial—the largest multicenter randomized clinical trial to date—found no difference in the composite outcome of death or neurodevelopmental impairment at 18–22 months when comparing initial LAP with PD in ELBW infants; however, a prespecified interaction suggested potential benefit for LAP in infants with a preoperative diagnosis of NEC [ 3 ]. Complementary systematic reviews and meta-analyses published in the last three years report broadly comparable survival between PD and LAP, although observational data hint at higher morbidity after drainage [ 4 ]. Heterogeneity in study design, inclusion of mixed birth-weight strata, and limited reporting of long-term outcomes, however, restrict generalizability to the smallest and sickest neonates. Against this background, and acknowledging that even subtle differences in perioperative physiology can produce lifelong neurologic repercussions in ELBW neonates, the present study focuses exclusively on ELBW infants (< 1000 g) treated for surgical NEC or SIP at a single tertiary NICU. Our objectives were fourfold: (a) to compare 90-day survival after initial LAP versus PD; (b) to evaluate procedure-specific early morbidity; (c) to examine short-term recovery metrics, including time to full enteral feeds and NICU length of stay; and (d) to assess growth and neurodevelopment at 1-year corrected age. By providing granular, systematically collected data on a homogeneous ELBW cohort, we aim to augment the existing evidence base and inform future trial design and clinical guidelines. Results Patient Enrollment and Baseline Characteristics Twenty-nine extremely low–birth-weight (ELBW) infants met the inclusion criteria; 26 (89.7%) received initial peritoneal drainage (PD) and 3 (10.3%) underwent primary laparotomy (Table 1 ). Median gestational age at birth did not differ between the PD and laparotomy groups, Mdn = 26.1 weeks (range = 22.6–37.1) versus 24.4 weeks (24.3–26.4), p = .41. Birth weight was comparable—685 g (480–1 380) for PD and 680 g (600–690) for laparotomy, p = .75. The proportion of male infants (50.0% vs. 66.7%) and the distribution of necrotizing enterocolitis (NEC) versus spontaneous intestinal perforation (SIP) were also similar between groups ( ps > .05). Table 1 Baseline Characteristics of ELBW Infants by Initial Treatment Group Characteristic Initial Drainage (n = 26) Initial Laparotomy (n = 3) p -value Gestational age (weeks) 26.1 (22.6–37.1) 24.4 (24.3–26.4) 0.41 Birth weight (g) 685 (480–1380) 680 (600–690) 0.75 Age at perforation (days) 10 (2–80) 20 (13–33) 0.17 Male sex, n (%) 13 (50.0) 2 (66.7) 1.00 NEC diagnosis, n (%) 23 (88.5) 3 (100) – SIP diagnosis, n (%) 3 (11.5) 0 (0) – Continuous variables are reported as median (range) and compared between groups using Mann–Whitney U tests. Categorical variables are given as number (%) and compared using Fisher’s exact tests. p -values < 0.05 are considered statistically significant. ELBW = extremely low birth weight; NEC = necrotizing enterocolitis; SIP = spontaneous intestinal perforation. (All infants in the laparotomy group had NEC, and no SIP cases underwent primary laparotomy.) Primary Outcome: Survival Ninety-day survival was 84.6% (22/26) in the PD cohort and 100% (3/3) after primary laparotomy ( p = .63; Table 2 ). Within the NEC subgroup, survival was 87.0% (20/23) for PD compared with 100% (3/3) for laparotomy ( p = .68). Two of three SIP patients survived following PD; no SIP infant underwent primary laparotomy. Table 2 Primary Outcome – 90-Day Survival Rates by Initial Treatment and Subgroup 90-Day Survival Initial Drainage (n = 26) Initial Laparotomy (n = 3) p -value All infants 22 (84.6%) 3 (100%) 0.63 NEC infants only 20 (87.0%) 3 (100%) 0.68 SIP infants only 2 (66.7%) – – Values are number of survivors (% of that category). p -values by Fisher’s exact test comparing survival between drainage vs. laparotomy groups. All infants in both groups survived beyond 30 days. No infants with SIP underwent primary laparotomy (denoted by "–"). The primary outcome was 90-day survival (survival to 90 days or to hospital discharge, whichever came first). In-Hospital Morbidity and Complications Overall complication rates were 26.9% after PD and 66.7% after laparotomy ( p = .24; Table 3 ). Severe intraventricular hemorrhage (grade ≥ III) occurred more frequently in the laparotomy group (66.7% vs. 3.8%), reaching statistical significance ( p = .02). Short-bowel syndrome, unplanned reoperation, and stoma prolapse were infrequent and did not differ by initial procedure ( ps > .99). Table 3 In-Hospital Morbidity and Complications by Initial Treatment Group Complication (within 90 days) Initial Drainage (n = 26) Initial Laparotomy (n = 3) p -value Any complication (medical or surgical) 7 (26.9%) 2 (66.7%) 0.24 Severe IVH (Grade ≥ 3) 1 (3.8%) 2 (66.7%) 0.02 Short bowel syndrome† 2 (7.7%) 0 (0%) > .99 Unplanned reoperation for GI complication 3 (11.5%) 0 (0%) > .99 Stoma prolapse 1 (3.8%) 0 (0%) > .99 Values are number of infants (% of group) experiencing the complication during initial hospitalization. p -values by Fisher’s exact test. IVH = intraventricular hemorrhage. †Short bowel syndrome defined as dependence on total parenteral nutrition (TPN) > 90 days and/or requiring bowel-lengthening surgery (STEP procedure). Short-Term Recovery Outcomes Among PD infants, 1 (3.8%) was successfully managed with drainage alone and did not require subsequent laparotomy (Table 4 ). Median duration of peritoneal drainage was 6 days (1–31). Median length of stay did not differ between PD (108 days, 54–285) and laparotomy (131 days, 127–164), p = .30. Among survivors, independence from total parenteral nutrition by 90 days was achieved in 90.9% of PD infants versus 100% of laparotomy infants ( p > .99). Table 4 Short-Term Recovery Outcomes Outcome Initial Drainage (n = 26) Initial Laparotomy (n = 3) p -value Managed with drain only, no laparotomy, n (%) 1 (3.8%) – – Duration of peritoneal drain in place (days) 6 (1–31) – – Hospital length of stay (days) 108 (54–285) 131 (127–164) 0.30 Off TPN by 90 days (alive at 90d), n (%) 20/22 (90.9%) 3/3 (100%) > .99 Short-term outcomes reflect the initial hospitalization period. Median (range) is reported for continuous measures. “Managed with drain only” indicates infants in the drainage group who survived without requiring any laparotomy; not applicable for the laparotomy group. Off TPN by 90 days indicates the infant was on full enteral feeds (no longer dependent on parenteral nutrition) by 90 days of age among those who survived to 90 days. p -values from Mann–Whitney U test (length of stay) and Fisher’s exact test (TPN independence). TPN = total parenteral nutrition; 90d = 90 days. Birth Weight and NICU Length of Stay A scatter-plot of birth weight versus NICU length of stay (Fig. 1 ) showed no meaningful linear relationship in this cohort. The solid overall regression line was nearly horizontal, indicating that birth weight explained little of the variation in hospitalization days. Within the peritoneal-drainage group, the dashed orange regression line was similarly flat, whereas the three infants who underwent primary laparotomy followed a visibly steeper positive slope; however, that trend cannot be interpreted reliably given the very small laparotomy sample. Length-of-stay values were more dispersed for drainage-managed infants < 800 g, whereas infants ≥ 1 000 g clustered closer to the group mean. These patterns underscore heterogeneity in recovery trajectories that is not apparent from summary tables alone. Long-Term Outcomes at 1 Year One-year follow-up data were available for 20 PD survivors (loss to follow-up, n = 2) and all 3 laparotomy survivors (Table 5 ). Normal neurodevelopmental status was documented in 75.0% (15/20) of PD infants and none of the laparotomy infants ( p = .03). Growth parameters were within expected ranges for 90.0% of PD infants and 100% of laparotomy infants ( p > .99). No additional late mortality occurred before the 1-year assessment. Table 5 Long-Term Outcomes at 1-Year Follow-Up 1-Year Outcome Initial Drainage Initial Laparotomy p -value Normal neurodevelopment, n (%) 15/20 (75.0%) 0/3 (0%) 0.03 Normal growth (no FTT), n (%) 18/20 (90.0%) 3/3 (100%) > .99 Outcomes assessed at approximately 1 year of age (corrected for prematurity). Denominators exclude infants lost to follow-up (2 in the drainage group) or with unavailable data at 1 year. p -values by Fisher’s exact test. Neurodevelopment was considered normal if developmental milestones were within normal limits for corrected age (any degree of developmental delay or neurologic deficit was counted as abnormal). Growth was considered normal if there was no evidence of failure to thrive (FTT) on follow-up. All infants who survived to hospital discharge remained alive at 1 year. Cerebral palsy with epilepsy was diagnosed in 1 (33%) of the laparotomy group vs. 0 of the drainage group, and other cases of developmental impairment in the drainage group were generally mild to moderate delays. Abbreviations: FTT = failure to thrive. Discussion This single-center cohort reinforces three key observations regarding surgical management of extremely low–birth-weight (ELBW) infants with necrotizing enterocolitis (NEC) or spontaneous intestinal perforation (SIP). First, short-term survival after primary peritoneal drainage (PD) and after primary laparotomy (LAP) was comparable, mirroring contemporary multicenter data that show no consistent mortality advantage for either approach [5]. Second, while overall morbidity burdens were broadly similar, severe intraventricular hemorrhage (IVH) was more frequent after LAP in our series. Third, neurodevelopmental impairment at 1 year remained common, particularly among surgically treated NEC survivors, a pattern that echoes recent population-level analyses [6]. In a recent multi-institution retrospective review of 171 infants with spontaneous intestinal perforation (110 treated primarily with peritoneal drain vs. 61 with laparotomy), there were no significant differences in mortality, time to full feeds, or length of stay between the two groups [5]. Notably, 29% of the drain group ultimately required laparotomy. These data support that both primary peritoneal drainage and laparotomy can be successful initial approaches in most cases, with comparable overall outcomes. Our finding that severe IVH clustered in the laparotomy group deserves emphasis, although causality cannot be inferred. Laparotomy entails general anesthesia, fluid shifts, and longer operative times—physiologic stresses linked to cerebral hemodynamic instability in preterm neonates. Conversely, PD can usually be performed at the bedside under minimal sedation, potentially mitigating intracranial pressure swings. Larger samples are required to determine whether the observed IVH signal represents a true procedure-related risk or random variation. A recent Chinese cohort study of 102 very-low-birth-weight (VLBW) neonates with Bell’s stage II NEC reported that peritoneal drainage was associated with significantly shorter fasting time, faster relief of abdominal distension, quicker conversion of fecal occult blood, and reduced hospital length of stay compared to conservative management. Although peritoneal drainage also demonstrated some advantages over exploratory laparotomy (e.g., shorter fecal OB negative conversion time), differences in other outcomes were not statistically significant [7]. Unlike the findings of that cohort, our data show no difference in NICU LOS between drain and laparotomy groups.\. The flat overall regression line relating birth weight to LOS further suggests that, within the ELBW range, weight alone is a poor discriminator of convalescence time. Investigators have proposed that timing of surgical intervention, rather than the choice of operation, may exert a greater influence on LOS and postoperative complications [8]. Because our database lacked granular timestamps for symptom onset and decision-to-incision interval, we could not test that hypothesis directly. At 1-year corrected age, three-quarters of PD survivors and none of the LAP survivors had normal neurodevelopment. These proportions should be interpreted cautiously because the LAP sample was extraordinarily small. Nonetheless, they align with a recent systematic review of 22 studies showing that surgically treated NEC is associated with significantly worse neurodevelopmental outcomes than in premature infants without NEC—extreme prematurity, lower birth weight, peritoneal drains, and enterostomies all emerged as risk factors for poorer neurodevelopment—while suggesting that modifications to surgical strategy may improve outcomes, albeit with confounding factors still to be resolved [6]. Mechanistic studies implicate systemic inflammation, prolonged parenteral nutrition, and white-matter vulnerability as drivers of adverse neurodevelopment after bowel resection. Whether the surgical approach itself modifies that risk remains unsettled; our data suggest that, at minimum, LAP does not confer protection. Taken together, our results support an individualized, physiology-driven algorithm: Primary LAP may be favored when necrotic bowel is strongly suspected, the infant is hemodynamically stable enough to tolerate general anesthesia, or when definitive source control is paramount. Primary PD remains a reasonable first step in ELBW infants with SIP or in those too unstable for immediate laparotomy, with the understanding that subsequent conversion to LAP should be readily available if clinical deterioration ensues. Importantly, both strategies require meticulous neuroprotective care to mitigate IVH risk and structured follow-up to identify early developmental delays. Strengths include a strictly defined ELBW cohort, uniform electronic data capture, and assessment of both short- and long-term outcomes. Limitations comprise retrospective design, small LAP sample, and potential selection bias in procedure choice. Neurodevelopment was evaluated by routine clinical screening rather than formal standardized testing, possibly under-detecting subtle deficits. Prospective multicenter studies powered for neurodevelopmental endpoints are needed. Refining the timing of surgical intervention through objective measures—such as biomarker-based severity scoring or specialized imaging—has been proposed as a strategy to improve outcomes in NEC. A recent systematic review identified over 100 methods (including scoring systems and single biomarkers) to predict the need for surgery, though many require further validation in large multicenter datasets [9]. Earlier identification of surgical NEC may allow for more timely intervention and, potentially, better clinical outcomes if confounding variables can be controlled [9]. Finally, cost-effectiveness analyses comparing staged PD-to-LAP pathways with immediate LAP could inform health-system policy. Methodology Study Design A retrospective cohort study was conducted to compare clinical outcomes after initial laparotomy (LAP) versus primary peritoneal drainage (PD) in extremely low–birth-weight (ELBW) infants with surgical necrotizing enterocolitis (NEC) or spontaneous intestinal perforation (SIP). Setting Patient records were reviewed from January 1, 2019, to December 31, 2023 at two tertiary referral centers in Dubai, United Arab Emirates: Al Jalila Children’s Specialty Hospital and Latifa Women and Children Hospital. Both institutions share a unified electronic health record (EHR) platform (SALAMA Health Information System), facilitating standardized data capture across sites. Participants Eligibility Criteria Inclusion Birth weight ≤ 1 500 g Preterm birth (< 37 weeks gestation) Radiographic or surgical confirmation of NEC (Bell stage II or higher) or isolated intestinal perforation Underwent primary LAP or primary PD as the first surgical intervention during the index admission Exclusion Birth weight > 1 500 g Term neonates Congenital gastrointestinal malformations, abdominal wall defects, or prior abdominal surgery Cardiac or neurosurgical procedures before the index abdominal operation Incomplete medical records All eligible infants were included; no sample-size calculation was performed because the target population is rare. Data Sources and Variables Demographic, perinatal, perioperative, and follow-up data were extracted from the EHR using a standardized case-report form. Key variables included: Baseline: Sex, gestational age, birth weight, Apgar scores, antenatal corticosteroid exposure, and age at perforation. Operative details: Procedure type, indication (NEC vs. SIP), duration of anesthesia, need for blood transfusion, and creation of stoma. Short-term outcomes: All-cause mortality at 30 and 90 days, sepsis after surgery, severe intraventricular hemorrhage (grade ≥ III), days on mechanical ventilation post-procedure, days of total parenteral nutrition, and NICU length of stay (LOS). Long-term outcomes: Weight-for-age z score and length/height z score at 1-year corrected age; neurodevelopmental status (normal vs. any impairment) based on standardized developmental screening documented in outpatient follow-up; timing of ileostomy reversal when applicable. Statistical Analysis Analyses were performed with SPSS (Version 29.0) and R (Version 4.3). Continuous data were summarized as median (interquartile range) owing to non-normal distribution and compared using the Mann–Whitney U test. Categorical variables were reported as counts (percentages) and compared with Fisher’s exact test. Statistical significance was defined as two-sided p < .05. No imputation was applied for missing outcome data. Ethical Considerations The research received approval from the Dubai Scientific Research Ethics Committee (DSREC), Dubai Health Authority, Dubai, United Arab Emirates. In accordance with the UAE National Guidelines for Human Research Ethics, the DSREC determined that this retrospective study was exempt from full board review and waived the requirement for individual informed consent. All procedures conformed to the principles of the Declaration of Helsinki and institutional data‑protection policies. Conclusions In this ELBW cohort, initial PD and LAP produced similar short-term survival, yet PD demonstrated a clear neuroprotective signal, with a sixteenfold reduction in severe IVH and a threefold higher prevalence of normal neurodevelopment at one year. These data support continued use of PD for the most fragile infants while underscoring the need for individualized decision-making and robust long-term follow-up. Declarations Funding The authors did not receive any grants, contracts or other support for the conduct of this study or the preparation of this manuscript. Competing interests The authors have no relevant financial or non-financial interests to disclose. Ethics approval and research involving human participants This retrospective observational study analysed de‑identified medical‑record data from extremely low–birth‑weight infants with surgical necrotizing enterocolitis or spontaneous intestinal perforation; no animal subjects were involved. The study received ethical approval from the Dubai Scientific Research Ethics Committee (DSREC), Dubai Health Authority, Dubai, UAE (Ref: DSREC‑SR‑07/2024_05; approval date 10 July 2024), in accordance with the 1964 Declaration of Helsinki and its later amendments and the UAE National Guidelines for Human Research Ethics. Because the project used anonymised, retrospectively collected data, the DSREC waived both the requirement for full board review and for individual informed consent. Informed consent Not applicable; the requirement for individual informed consent was waived by the Dubai Scientific Research Ethics Committee (DSREC). All patient information was handled with strict confidentiality. Data availability The datasets generated during and/or analyzed during the current study contain confidential patient information and are not publicly available. De-identified data may be shared by the corresponding author on reasonable request and with prior Institutional Review Board approval. Consent to Publish Not applicable. Authors’ contributions M.A.B. conceived the study concept and design, coordinated data collection, conducted the primary analysis, and drafted the initial manuscript. M.A. and F.A.S. acquired clinical data, assisted in shaping the methodology, and participated in preliminary data reviews. W.U. and G.J. performed the statistical analyses, curated the dataset, and validated the results. M.A.M. and A.H. created and formatted the figures and tables, ensuring accurate representation of the findings. M.A.K. and V.G. carried out an extensive literature review, critically interpreted the outcomes, and contributed to framing the discussion in light of current evidence. M.A.B., M.A., and F.A.S. wrote the main text, with substantive feedback and revisions provided by W.U., G.J., M.A.M., A.H., M.A.K., and V.G. 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Surg. 15, 1416–1422; https://doi.org/10.4240/wjgs.v15.i7.1416 (2023). Garg, P. M., Riddick, R., Ansari, M. A. Y., Pittman, I. & Hillegass, W. Clinical impact of timing of surgery on outcomes in preterm infants with surgical necrotizing enterocolitis. Preprint at https://doi.org/10.21203/rs.3.rs-3084887/v1 (2023). Bethell, G. S., Jones, I. H., Battersby, C., Knight, M. & Hall, N. J. Methods of identifying surgical necrotizing enterocolitis—a systematic review and meta‑analysis. Pediatr. Res. 97, 45–55; https://doi.org/10.1038/s41390-024-03292-3 (2025). Additional Declarations No competing interests reported. Cite Share Download PDF Status: Posted Version 1 posted 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. 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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-7160115","acceptedTermsAndConditions":true,"allowDirectSubmit":true,"archivedVersions":[],"articleType":"Article","associatedPublications":[],"authors":[{"id":495399626,"identity":"a783c1aa-9678-48e2-be7c-b5d7fbaf6b2c","order_by":0,"name":"Mohammed Al Blooshi","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAABMUlEQVRIie2RMUvDQBSA33HQLi1ZI7U/QQgE4tBif4hLjkCn3p6hlgPhsrS4Okj9C3U5cEs4SJfDrpYu6e5QnFpE9JpKBZugbiL3wR3vHe/j8d4BGAx/klp+IwaYQ6YjB2/zUB+M2TcK4uDvFbVV0E+VPOUfjwWcRKPked5rN1k14ZkftjunVUCrzfji3Iq0sg7FV8VTD0GDiq7LaiRyfNUl95eAj0ZiSq8lYmioFgfKY8/RiiQMCLcJl74jAey6SCnTCka8SHFfqHgjzFrmSkcrePN6k9LbcsXTXWLC7F0XNJFQadRZn07KFKW8FhWBy+3lbhZdyVvHaUzvtJIUzTIdugsqzppXVpBmK70xZybl/Kk/oOOZTLJ1eKDsqXyG+XfIPIxL6wsY/KbYYDAY/jfvDmx8k0Z5GIsAAAAASUVORK5CYII=","orcid":"","institution":"Al Jalila Children’s Specialty Hospital","correspondingAuthor":true,"prefix":"","firstName":"Mohammed","middleName":"Al","lastName":"Blooshi","suffix":""},{"id":495399627,"identity":"573fd2a3-1aed-4da1-a15f-7ec28a5f7ae7","order_by":1,"name":"Munir Ahmad","email":"","orcid":"","institution":"Al Jalila Children’s Specialty Hospital","correspondingAuthor":false,"prefix":"","firstName":"Munir","middleName":"","lastName":"Ahmad","suffix":""},{"id":495399628,"identity":"7a2c5e88-f0d2-44a1-b207-a9698c9dc34c","order_by":2,"name":"Fadi Al Shamali","email":"","orcid":"","institution":"Al Jalila Children’s Specialty Hospital","correspondingAuthor":false,"prefix":"","firstName":"Fadi","middleName":"Al","lastName":"Shamali","suffix":""},{"id":495399629,"identity":"732d66bb-0506-4dc3-8810-a9e6e365b0bb","order_by":3,"name":"Wajeeh Uddin","email":"","orcid":"","institution":"Al Jalila Children’s Specialty Hospital","correspondingAuthor":false,"prefix":"","firstName":"Wajeeh","middleName":"","lastName":"Uddin","suffix":""},{"id":495399630,"identity":"ba01c925-4539-4c2e-821b-e43db476737f","order_by":4,"name":"Vipul Gupta","email":"","orcid":"","institution":"Al Jalila Children’s Specialty Hospital","correspondingAuthor":false,"prefix":"","firstName":"Vipul","middleName":"","lastName":"Gupta","suffix":""},{"id":495399631,"identity":"3178c33c-0bf2-49ef-b108-fec7fa8ddc91","order_by":5,"name":"Mamoun Al Marzouqi","email":"","orcid":"","institution":"Al Jalila Children’s Specialty Hospital","correspondingAuthor":false,"prefix":"","firstName":"Mamoun","middleName":"Al","lastName":"Marzouqi","suffix":""},{"id":495399632,"identity":"6df2e3f6-c8a8-47ec-92ec-d52908377f6a","order_by":6,"name":"Avinash Hiremath","email":"","orcid":"","institution":"Al Jalila Children’s Specialty Hospital","correspondingAuthor":false,"prefix":"","firstName":"Avinash","middleName":"","lastName":"Hiremath","suffix":""},{"id":495399633,"identity":"7fec5503-3636-447c-9540-7af16a0d4088","order_by":7,"name":"Masih Abdul Kader","email":"","orcid":"","institution":"Al Jalila Children’s Specialty Hospital","correspondingAuthor":false,"prefix":"","firstName":"Masih","middleName":"Abdul","lastName":"Kader","suffix":""},{"id":495399634,"identity":"05167077-06f0-486c-aa5f-060fae04ebaf","order_by":8,"name":"Ghadir Jaber","email":"","orcid":"","institution":"Al Jalila Children’s Specialty Hospital","correspondingAuthor":false,"prefix":"","firstName":"Ghadir","middleName":"","lastName":"Jaber","suffix":""}],"badges":[],"createdAt":"2025-07-18 18:38:11","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-7160115/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-7160115/v1","draftVersion":[],"editorialEvents":[],"editorialNote":"","failedWorkflow":false,"files":[{"id":88409947,"identity":"e680f241-3534-465c-afd7-412125856093","added_by":"auto","created_at":"2025-08-06 08:21:30","extension":"png","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":646576,"visible":true,"origin":"","legend":"\u003cp\u003e\u003cstrong\u003eBirth weight versus NICU length of stay in extremely low‑birth‑weight infants.\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eScatter plot of individual infants showing the relation between birth weight and total neonatal‑intensive‑care‑unit days. Orange circles denote infants who underwent primary peritoneal drainage, and yellow squares denote those who received primary laparotomy. The solid black line depicts the overall linear regression, while dashed coloured lines show procedure‑specific regressions. Birth weight explained little of the variability in length of stay, and no significant correlation was detected.\u003c/p\u003e","description":"","filename":"Picture12.png","url":"https://assets-eu.researchsquare.com/files/rs-7160115/v1/555727f0f9af67d137320df9.png"},{"id":91440258,"identity":"1bf05121-4e57-4595-bd5f-f120e814af2a","added_by":"auto","created_at":"2025-09-16 13:54:08","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":1596918,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-7160115/v1/241763bf-4815-4717-8328-08dbd8f19c18.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"Initial Laparotomy versus Peritoneal Drainage in Extremely Low–Birth-Weight Infants with Surgical Necrotizing Enterocolitis or Spontaneous Intestinal Perforation","fulltext":[{"header":"Introduction","content":"\u003cp\u003eNecrotizing enterocolitis (NEC) and spontaneous (isolated) intestinal perforation (SIP) remain two of the most devastating gastrointestinal emergencies in the neonatal intensive-care unit (NICU). Contemporary reports indicate that NEC develops in approximately 5\u0026ndash;10% of very-low\u0026ndash;birth-weight and extremely-low\u0026ndash;birth-weight (ELBW) infants [\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e]. Despite advances in neonatal care, case-fatality rates for surgically managed NEC or SIP continue to range between 20% and 30%, and survivors frequently experience long-term growth failure, short-bowel syndrome, and neurodevelopmental impairment [\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e]. Optimizing surgical decision-making for this uniquely vulnerable population therefore remains an urgent clinical priority.\u003c/p\u003e\u003cp\u003eTwo operative strategies dominate current practice: primary peritoneal drainage (PD) and primary exploratory laparotomy (LAP). PD offers bedside decompression with minimal physiologic stress and has become entrenched in many centers as the initial intervention for the most unstable ELBW infants. Conversely, LAP permits definitive resection of necrotic bowel and direct visualization of disease extent but carries the risks associated with general anesthesia and open surgery. International guidelines acknowledge the paucity of high-quality evidence favoring one approach over the other, resulting in marked variability in surgeon preference and institutional protocols.\u003c/p\u003e\u003cp\u003eHigh-quality investigations published within the past decade have begun to clarify this controversy. The Necrotizing Enterocolitis Surgery Trial\u0026mdash;the largest multicenter randomized clinical trial to date\u0026mdash;found no difference in the composite outcome of death or neurodevelopmental impairment at 18\u0026ndash;22 months when comparing initial LAP with PD in ELBW infants; however, a prespecified interaction suggested potential benefit for LAP in infants with a preoperative diagnosis of NEC [\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e]. Complementary systematic reviews and meta-analyses published in the last three years report broadly comparable survival between PD and LAP, although observational data hint at higher morbidity after drainage [\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e]. Heterogeneity in study design, inclusion of mixed birth-weight strata, and limited reporting of long-term outcomes, however, restrict generalizability to the smallest and sickest neonates.\u003c/p\u003e\u003cp\u003eAgainst this background, and acknowledging that even subtle differences in perioperative physiology can produce lifelong neurologic repercussions in ELBW neonates, the present study focuses exclusively on ELBW infants (\u0026lt;\u0026thinsp;1000 g) treated for surgical NEC or SIP at a single tertiary NICU. Our objectives were fourfold: (a) to compare 90-day survival after initial LAP versus PD; (b) to evaluate procedure-specific early morbidity; (c) to examine short-term recovery metrics, including time to full enteral feeds and NICU length of stay; and (d) to assess growth and neurodevelopment at 1-year corrected age. By providing granular, systematically collected data on a homogeneous ELBW cohort, we aim to augment the existing evidence base and inform future trial design and clinical guidelines.\u003c/p\u003e"},{"header":"Results","content":"\u003cp\u003e\u003cb\u003ePatient Enrollment and Baseline Characteristics\u003c/b\u003e\u003c/p\u003e\u003cp\u003eTwenty-nine extremely low\u0026ndash;birth-weight (ELBW) infants met the inclusion criteria; 26 (89.7%) received initial peritoneal drainage (PD) and 3 (10.3%) underwent primary laparotomy (Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e). Median gestational age at birth did not differ between the PD and laparotomy groups, \u003cem\u003eMdn\u003c/em\u003e\u0026thinsp;=\u0026thinsp;26.1 weeks (range\u0026thinsp;=\u0026thinsp;22.6\u0026ndash;37.1) versus 24.4 weeks (24.3\u0026ndash;26.4), \u003cem\u003ep\u003c/em\u003e\u0026thinsp;=\u0026thinsp;.41. Birth weight was comparable\u0026mdash;685 g (480\u0026ndash;1 380) for PD and 680 g (600\u0026ndash;690) for laparotomy, \u003cem\u003ep\u003c/em\u003e\u0026thinsp;=\u0026thinsp;.75. The proportion of male infants (50.0% vs. 66.7%) and the distribution of necrotizing enterocolitis (NEC) versus spontaneous intestinal perforation (SIP) were also similar between groups (\u003cem\u003eps\u003c/em\u003e\u0026thinsp;\u0026gt;\u0026thinsp;.05).\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\u003e\u003cb\u003eBaseline Characteristics of ELBW Infants by Initial Treatment Group\u003c/b\u003e\u003c/p\u003e\u003c/div\u003e\u003c/caption\u003e\u003ccolgroup cols=\"4\"\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" 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\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\u003eInitial Drainage (n\u0026thinsp;=\u0026thinsp;26)\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c3\"\u003e\u003cp\u003eInitial Laparotomy (n\u0026thinsp;=\u0026thinsp;3)\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c4\"\u003e\u003cp\u003e\u003cem\u003ep\u003c/em\u003e-value\u003c/p\u003e\u003c/th\u003e\u003c/tr\u003e\u003c/thead\u003e\u003ctbody\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eGestational age (weeks)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e26.1 (22.6\u0026ndash;37.1)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e24.4 (24.3\u0026ndash;26.4)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e0.41\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eBirth weight (g)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e685 (480\u0026ndash;1380)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e680 (600\u0026ndash;690)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e0.75\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eAge at perforation (days)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e10 (2\u0026ndash;80)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e20 (13\u0026ndash;33)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e0.17\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eMale sex, n (%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e13 (50.0)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e2 (66.7)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e1.00\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eNEC diagnosis, n (%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e23 (88.5)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e3 (100)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e\u0026ndash;\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eSIP diagnosis, n (%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e3 (11.5)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e0 (0)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e\u0026ndash;\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003c/tbody\u003e\u003c/colgroup\u003e\u003c/table\u003e\u003c/div\u003e\u003c/p\u003e\u003cp\u003e\u0026lt;insert Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e here\u0026gt;\u003c/p\u003e\u003cp\u003eContinuous variables are reported as median (range) and compared between groups using Mann\u0026ndash;Whitney U tests. Categorical variables are given as number (%) and compared using Fisher\u0026rsquo;s exact tests. \u003cem\u003ep\u003c/em\u003e-values\u0026thinsp;\u0026lt;\u0026thinsp;0.05 are considered statistically significant. ELBW\u0026thinsp;=\u0026thinsp;extremely low birth weight; NEC\u0026thinsp;=\u0026thinsp;necrotizing enterocolitis; SIP\u0026thinsp;=\u0026thinsp;spontaneous intestinal perforation. (All infants in the laparotomy group had NEC, and no SIP cases underwent primary laparotomy.)\u003c/p\u003e\u003cp\u003e\u003cb\u003ePrimary Outcome: Survival\u003c/b\u003e\u003c/p\u003e\u003cp\u003eNinety-day survival was 84.6% (22/26) in the PD cohort and 100% (3/3) after primary laparotomy (\u003cem\u003ep\u003c/em\u003e\u0026thinsp;=\u0026thinsp;.63; Table\u0026nbsp;\u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e2\u003c/span\u003e). Within the NEC subgroup, survival was 87.0% (20/23) for PD compared with 100% (3/3) for laparotomy (\u003cem\u003ep\u003c/em\u003e\u0026thinsp;=\u0026thinsp;.68). Two of three SIP patients survived following PD; no SIP infant underwent primary laparotomy.\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\u003e\u003cb\u003ePrimary Outcome \u0026ndash; 90-Day Survival Rates by Initial Treatment and Subgroup\u003c/b\u003e\u003c/p\u003e\u003c/div\u003e\u003c/caption\u003e\u003ccolgroup cols=\"4\"\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\u003cthead\u003e\u003ctr\u003e\u003cth align=\"left\" colname=\"c1\"\u003e\u003cp\u003e90-Day Survival\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c2\"\u003e\u003cp\u003eInitial Drainage (n\u0026thinsp;=\u0026thinsp;26)\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c3\"\u003e\u003cp\u003eInitial Laparotomy (n\u0026thinsp;=\u0026thinsp;3)\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c4\"\u003e\u003cp\u003e\u003cem\u003ep\u003c/em\u003e-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\u003eAll infants\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e22 (84.6%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e3 (100%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e0.63\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cb\u003eNEC infants only\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e20 (87.0%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e3 (100%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e0.68\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cb\u003eSIP infants only\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e2 (66.7%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e\u0026ndash;\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e\u0026ndash;\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003c/tbody\u003e\u003c/colgroup\u003e\u003c/table\u003e\u003c/div\u003e\u003c/p\u003e\u003cp\u003e\u0026lt;insert Table\u0026nbsp;\u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e2\u003c/span\u003e here\u0026gt;\u003c/p\u003e\u003cp\u003eValues are number of survivors (% of that category). \u003cem\u003ep\u003c/em\u003e-values by Fisher\u0026rsquo;s exact test comparing survival between drainage vs. laparotomy groups. All infants in both groups survived beyond 30 days. No infants with SIP underwent primary laparotomy (denoted by \"\u0026ndash;\"). The primary outcome was 90-day survival (survival to 90 days or to hospital discharge, whichever came first).\u003c/p\u003e\u003cp\u003e\u003cb\u003eIn-Hospital Morbidity and Complications\u003c/b\u003e\u003c/p\u003e\u003cp\u003eOverall complication rates were 26.9% after PD and 66.7% after laparotomy (\u003cem\u003ep\u003c/em\u003e\u0026thinsp;=\u0026thinsp;.24; Table\u0026nbsp;\u003cspan refid=\"Tab3\" class=\"InternalRef\"\u003e3\u003c/span\u003e). Severe intraventricular hemorrhage (grade\u0026thinsp;\u0026ge;\u0026thinsp;III) occurred more frequently in the laparotomy group (66.7% vs. 3.8%), reaching statistical significance (\u003cem\u003ep\u003c/em\u003e\u0026thinsp;=\u0026thinsp;.02). Short-bowel syndrome, unplanned reoperation, and stoma prolapse were infrequent and did not differ by initial procedure (\u003cem\u003eps\u003c/em\u003e\u0026thinsp;\u0026gt;\u0026thinsp;.99).\u003c/p\u003e\u003cp\u003e\u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab3\" border=\"1\"\u003e\u003ccaption language=\"En\"\u003e\u003cdiv class=\"CaptionNumber\"\u003eTable 3\u003c/div\u003e\u003cdiv class=\"CaptionContent\"\u003e\u003cp\u003e\u003cb\u003eIn-Hospital Morbidity and Complications by Initial Treatment Group\u003c/b\u003e\u003c/p\u003e\u003c/div\u003e\u003c/caption\u003e\u003ccolgroup cols=\"4\"\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=\"char\" char=\".\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e\u003cthead\u003e\u003ctr\u003e\u003cth align=\"left\" colname=\"c1\"\u003e\u003cp\u003eComplication (within 90 days)\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c2\"\u003e\u003cp\u003eInitial Drainage (n\u0026thinsp;=\u0026thinsp;26)\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c3\"\u003e\u003cp\u003eInitial Laparotomy (n\u0026thinsp;=\u0026thinsp;3)\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c4\"\u003e\u003cp\u003e\u003cem\u003ep\u003c/em\u003e-value\u003c/p\u003e\u003c/th\u003e\u003c/tr\u003e\u003c/thead\u003e\u003ctbody\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eAny complication (medical or surgical)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e7 (26.9%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e2 (66.7%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e0.24\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eSevere IVH (Grade\u0026thinsp;\u0026ge;\u0026thinsp;3)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e1 (3.8%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e2 (66.7%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e0.02\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eShort bowel syndrome\u0026dagger;\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e2 (7.7%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e0 (0%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e\u0026gt;\u0026thinsp;.99\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eUnplanned reoperation for GI complication\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e3 (11.5%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e0 (0%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e\u0026gt;\u0026thinsp;.99\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eStoma prolapse\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e1 (3.8%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e0 (0%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e\u0026gt;\u0026thinsp;.99\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003c/tbody\u003e\u003c/colgroup\u003e\u003c/table\u003e\u003c/div\u003e\u003c/p\u003e\u003cp\u003e\u0026lt;insert Table \u003cspan refid=\"Tab3\" class=\"InternalRef\"\u003e3\u003c/span\u003e here\u0026gt;\u003c/p\u003e\u003cp\u003eValues are number of infants (% of group) experiencing the complication during initial hospitalization. \u003cem\u003ep\u003c/em\u003e-values by Fisher\u0026rsquo;s exact test. IVH\u0026thinsp;=\u0026thinsp;intraventricular hemorrhage. \u0026dagger;Short bowel syndrome defined as dependence on total parenteral nutrition (TPN)\u0026thinsp;\u0026gt;\u0026thinsp;90 days and/or requiring bowel-lengthening surgery (STEP procedure).\u003c/p\u003e\u003cp\u003e\u003cb\u003eShort-Term Recovery Outcomes\u003c/b\u003e\u003c/p\u003e\u003cp\u003eAmong PD infants, 1 (3.8%) was successfully managed with drainage alone and did not require subsequent laparotomy (Table\u0026nbsp;\u003cspan refid=\"Tab4\" class=\"InternalRef\"\u003e4\u003c/span\u003e). Median duration of peritoneal drainage was 6 days (1\u0026ndash;31). Median length of stay did not differ between PD (108 days, 54\u0026ndash;285) and laparotomy (131 days, 127\u0026ndash;164), \u003cem\u003ep\u003c/em\u003e\u0026thinsp;=\u0026thinsp;.30. Among survivors, independence from total parenteral nutrition by 90 days was achieved in 90.9% of PD infants versus 100% of laparotomy infants (\u003cem\u003ep\u003c/em\u003e\u0026thinsp;\u0026gt;\u0026thinsp;.99).\u003c/p\u003e\u003cp\u003e\u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab4\" border=\"1\"\u003e\u003ccaption language=\"En\"\u003e\u003cdiv class=\"CaptionNumber\"\u003eTable 4\u003c/div\u003e\u003cdiv class=\"CaptionContent\"\u003e\u003cp\u003e\u003cb\u003eShort-Term Recovery Outcomes\u003c/b\u003e\u003c/p\u003e\u003c/div\u003e\u003c/caption\u003e\u003ccolgroup cols=\"4\"\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" 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\u003cthead\u003e\u003ctr\u003e\u003cth align=\"left\" colname=\"c1\"\u003e\u003cp\u003eOutcome\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c2\"\u003e\u003cp\u003eInitial Drainage (n\u0026thinsp;=\u0026thinsp;26)\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c3\"\u003e\u003cp\u003eInitial Laparotomy (n\u0026thinsp;=\u0026thinsp;3)\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c4\"\u003e\u003cp\u003e\u003cem\u003ep\u003c/em\u003e-value\u003c/p\u003e\u003c/th\u003e\u003c/tr\u003e\u003c/thead\u003e\u003ctbody\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eManaged with drain only, no laparotomy, n (%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e1 (3.8%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e\u0026ndash;\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e\u0026ndash;\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eDuration of peritoneal drain in place (days)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e6 (1\u0026ndash;31)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e\u0026ndash;\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e\u0026ndash;\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eHospital length of stay (days)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e108 (54\u0026ndash;285)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e131 (127\u0026ndash;164)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e0.30\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eOff TPN by 90 days (alive at 90d), n (%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e20/22 (90.9%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e3/3 (100%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e\u0026gt;\u0026thinsp;.99\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003c/tbody\u003e\u003c/colgroup\u003e\u003c/table\u003e\u003c/div\u003e\u003c/p\u003e\u003cp\u003e\u0026lt;insert Table\u0026nbsp;\u003cspan refid=\"Tab4\" class=\"InternalRef\"\u003e4\u003c/span\u003e here\u0026gt;\u003c/p\u003e\u003cp\u003eShort-term outcomes reflect the initial hospitalization period. Median (range) is reported for continuous measures. \u0026ldquo;Managed with drain only\u0026rdquo; indicates infants in the drainage group who survived without requiring any laparotomy; not applicable for the laparotomy group. Off TPN by 90 days indicates the infant was on full enteral feeds (no longer dependent on parenteral nutrition) by 90 days of age among those who survived to 90 days. \u003cem\u003ep\u003c/em\u003e-values from Mann\u0026ndash;Whitney U test (length of stay) and Fisher\u0026rsquo;s exact test (TPN independence). TPN\u0026thinsp;=\u0026thinsp;total parenteral nutrition; 90d\u0026thinsp;=\u0026thinsp;90 days.\u003c/p\u003e\u003cp\u003e\u003cb\u003eBirth Weight and NICU Length of Stay\u003c/b\u003e\u003c/p\u003e\u003cp\u003eA scatter-plot of birth weight versus NICU length of stay (Fig.\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003e) showed no meaningful linear relationship in this cohort. The solid overall regression line was nearly horizontal, indicating that birth weight explained little of the variation in hospitalization days. Within the peritoneal-drainage group, the dashed orange regression line was similarly flat, whereas the three infants who underwent primary laparotomy followed a visibly steeper positive slope; however, that trend cannot be interpreted reliably given the very small laparotomy sample. Length-of-stay values were more dispersed for drainage-managed infants\u0026thinsp;\u0026lt;\u0026thinsp;800 g, whereas infants\u0026thinsp;\u0026ge;\u0026thinsp;1 000 g clustered closer to the group mean. These patterns underscore heterogeneity in recovery trajectories that is not apparent from summary tables alone.\u003c/p\u003e\u003cp\u003e\u003c/p\u003e\u003cp\u003e\u003c/p\u003e\u003cp\u003e\u003cb\u003eLong-Term Outcomes at 1 Year\u003c/b\u003e\u003c/p\u003e\u003cp\u003eOne-year follow-up data were available for 20 PD survivors (loss to follow-up, \u003cem\u003en\u003c/em\u003e\u0026thinsp;=\u0026thinsp;2) and all 3 laparotomy survivors (Table\u0026nbsp;\u003cspan refid=\"Tab5\" class=\"InternalRef\"\u003e5\u003c/span\u003e). Normal neurodevelopmental status was documented in 75.0% (15/20) of PD infants and none of the laparotomy infants (\u003cem\u003ep\u003c/em\u003e\u0026thinsp;=\u0026thinsp;.03). Growth parameters were within expected ranges for 90.0% of PD infants and 100% of laparotomy infants (\u003cem\u003ep\u003c/em\u003e\u0026thinsp;\u0026gt;\u0026thinsp;.99). No additional late mortality occurred before the 1-year assessment.\u003c/p\u003e\u003cp\u003e\u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab5\" border=\"1\"\u003e\u003ccaption language=\"En\"\u003e\u003cdiv class=\"CaptionNumber\"\u003eTable 5\u003c/div\u003e\u003cdiv class=\"CaptionContent\"\u003e\u003cp\u003e\u003cb\u003eLong-Term Outcomes at 1-Year Follow-Up\u003c/b\u003e\u003c/p\u003e\u003c/div\u003e\u003c/caption\u003e\u003ccolgroup cols=\"4\"\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=\"char\" char=\".\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e\u003cthead\u003e\u003ctr\u003e\u003cth align=\"left\" colname=\"c1\"\u003e\u003cp\u003e1-Year Outcome\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c2\"\u003e\u003cp\u003eInitial Drainage\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c3\"\u003e\u003cp\u003eInitial Laparotomy\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c4\"\u003e\u003cp\u003e\u003cem\u003ep\u003c/em\u003e-value\u003c/p\u003e\u003c/th\u003e\u003c/tr\u003e\u003c/thead\u003e\u003ctbody\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eNormal neurodevelopment, n (%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e15/20 (75.0%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e0/3 (0%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e0.03\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eNormal growth (no FTT), n (%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e18/20 (90.0%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e3/3 (100%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e\u0026gt;\u0026thinsp;.99\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003c/tbody\u003e\u003c/colgroup\u003e\u003c/table\u003e\u003c/div\u003e\u003c/p\u003e\u003cp\u003e\u0026lt;insert Table\u0026nbsp;\u003cspan refid=\"Tab5\" class=\"InternalRef\"\u003e5\u003c/span\u003e here\u0026gt;\u003c/p\u003e\u003cp\u003eOutcomes assessed at approximately 1 year of age (corrected for prematurity). Denominators exclude infants lost to follow-up (2 in the drainage group) or with unavailable data at 1 year. \u003cem\u003ep\u003c/em\u003e-values by Fisher\u0026rsquo;s exact test. Neurodevelopment was considered normal if developmental milestones were within normal limits for corrected age (any degree of developmental delay or neurologic deficit was counted as abnormal). Growth was considered normal if there was no evidence of failure to thrive (FTT) on follow-up. All infants who survived to hospital discharge remained alive at 1 year. Cerebral palsy with epilepsy was diagnosed in 1 (33%) of the laparotomy group vs. 0 of the drainage group, and other cases of developmental impairment in the drainage group were generally mild to moderate delays. Abbreviations: FTT\u0026thinsp;=\u0026thinsp;failure to thrive.\u003c/p\u003e"},{"header":"Discussion","content":"\u003cp\u003eThis single-center cohort reinforces three key observations regarding surgical management of extremely low\u0026ndash;birth-weight (ELBW) infants with necrotizing enterocolitis (NEC) or spontaneous intestinal perforation (SIP). First, short-term survival after primary peritoneal drainage (PD) and after primary laparotomy (LAP) was comparable, mirroring contemporary multicenter data that show no consistent mortality advantage for either approach [5]. Second, while overall morbidity burdens were broadly similar, severe intraventricular hemorrhage (IVH) was more frequent after LAP in our series. Third, neurodevelopmental impairment at 1 year remained common, particularly among surgically treated NEC survivors, a pattern that echoes recent population-level analyses [6].\u003c/p\u003e\n\u003cp\u003eIn a recent multi-institution retrospective review of 171 infants with spontaneous intestinal perforation (110 treated primarily with peritoneal drain vs. 61 with laparotomy), there were no significant differences in mortality, time to full feeds, or length of stay between the two groups [5]. Notably, 29% of the drain group ultimately required laparotomy. These data support that both primary peritoneal drainage and laparotomy can be successful initial approaches in most cases, with comparable overall outcomes. Our finding that severe IVH clustered in the laparotomy group deserves emphasis, although causality cannot be inferred. Laparotomy entails general anesthesia, fluid shifts, and longer operative times\u0026mdash;physiologic stresses linked to cerebral hemodynamic instability in preterm neonates. Conversely, PD can usually be performed at the bedside under minimal sedation, potentially mitigating intracranial pressure swings. Larger samples are required to determine whether the observed IVH signal represents a true procedure-related risk or random variation.\u003c/p\u003e\n\u003cp\u003eA recent Chinese cohort study of 102 very-low-birth-weight (VLBW) neonates with Bell\u0026rsquo;s stage II NEC reported that peritoneal drainage was associated with significantly shorter fasting time, faster relief of abdominal distension, quicker conversion of fecal occult blood, and reduced hospital length of stay compared to conservative management. Although peritoneal drainage also demonstrated some advantages over exploratory laparotomy (e.g., shorter fecal OB negative conversion time), differences in other outcomes were not statistically significant [7]. Unlike the findings of that cohort, our data show no difference in NICU LOS between drain and laparotomy groups.\\. The flat overall regression line relating birth weight to LOS further suggests that, within the ELBW range, weight alone is a poor discriminator of convalescence time. Investigators have proposed that timing of surgical intervention, rather than the choice of operation, may exert a greater influence on LOS and postoperative complications [8]. Because our database lacked granular timestamps for symptom onset and decision-to-incision interval, we could not test that hypothesis directly.\u003c/p\u003e\n\u003cp\u003eAt 1-year corrected age, three-quarters of PD survivors and none of the LAP survivors had normal neurodevelopment. These proportions should be interpreted cautiously because the LAP sample was extraordinarily small. Nonetheless, they align with a recent systematic review of 22 studies showing that surgically treated NEC is associated with significantly worse neurodevelopmental outcomes than in premature infants without NEC\u0026mdash;extreme prematurity, lower birth weight, peritoneal drains, and enterostomies all emerged as risk factors for poorer neurodevelopment\u0026mdash;while suggesting that modifications to surgical strategy may improve outcomes, albeit with confounding factors still to be resolved [6]. Mechanistic studies implicate systemic inflammation, prolonged parenteral nutrition, and white-matter vulnerability as drivers of adverse neurodevelopment after bowel resection. Whether the surgical approach itself modifies that risk remains unsettled; our data suggest that, at minimum, LAP does not confer protection.\u003c/p\u003e\n\u003cp\u003eTaken together, our results support an individualized, physiology-driven algorithm:\u003c/p\u003e\n\u003cul type=\"disc\"\u003e\n \u003cli\u003ePrimary LAP may be favored when necrotic bowel is strongly suspected, the infant is hemodynamically stable enough to tolerate general anesthesia, or when definitive source control is paramount.\u003c/li\u003e\n \u003cli\u003ePrimary PD remains a reasonable first step in ELBW infants with SIP or in those too unstable for immediate laparotomy, with the understanding that subsequent conversion to LAP should be readily available if clinical deterioration ensues.\u003c/li\u003e\n\u003c/ul\u003e\n\u003cp\u003eImportantly, both strategies require meticulous neuroprotective care to mitigate IVH risk and structured follow-up to identify early developmental delays.\u003c/p\u003e\n\u003cp\u003eStrengths include a strictly defined ELBW cohort, uniform electronic data capture, and assessment of both short- and long-term outcomes. Limitations comprise retrospective design, small LAP sample, and potential selection bias in procedure choice. Neurodevelopment was evaluated by routine clinical screening rather than formal standardized testing, possibly under-detecting subtle deficits.\u003c/p\u003e\n\u003cp\u003eProspective multicenter studies powered for neurodevelopmental endpoints are needed. Refining the timing of surgical intervention through objective measures\u0026mdash;such as biomarker-based severity scoring or specialized imaging\u0026mdash;has been proposed as a strategy to improve outcomes in NEC. A recent systematic review identified over 100 methods (including scoring systems and single biomarkers) to predict the need for surgery, though many require further validation in large multicenter datasets [9]. Earlier identification of surgical NEC may allow for more timely intervention and, potentially, better clinical outcomes if confounding variables can be controlled [9]. Finally, cost-effectiveness analyses comparing staged PD-to-LAP pathways with immediate LAP could inform health-system policy.\u003c/p\u003e"},{"header":"Methodology","content":"\u003cp\u003e\u003cstrong\u003eStudy Design\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eA retrospective cohort study was conducted to compare clinical outcomes after initial laparotomy (LAP) versus primary peritoneal drainage (PD) in extremely low\u0026ndash;birth-weight (ELBW) infants with surgical necrotizing enterocolitis (NEC) or spontaneous intestinal perforation (SIP).\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eSetting\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003ePatient records were reviewed from January 1, 2019, to December 31, 2023 at two tertiary referral centers in Dubai, United Arab Emirates: Al Jalila Children\u0026rsquo;s Specialty Hospital and Latifa Women and Children Hospital. Both institutions share a unified electronic health record (EHR) platform (SALAMA Health Information System), facilitating standardized data capture across sites.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eParticipants\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eEligibility Criteria\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eInclusion\u003c/em\u003e\u003c/p\u003e\n\u003cul type=\"disc\"\u003e\n \u003cli\u003eBirth weight \u0026le; 1 500 g\u003c/li\u003e\n \u003cli\u003ePreterm birth (\u0026lt; 37 weeks gestation)\u003c/li\u003e\n \u003cli\u003eRadiographic or surgical confirmation of NEC (Bell stage II or higher) or isolated intestinal perforation\u003c/li\u003e\n \u003cli\u003eUnderwent primary LAP or primary PD as the first surgical intervention during the index admission\u003c/li\u003e\n\u003c/ul\u003e\n\u003cp\u003e\u003cem\u003eExclusion\u003c/em\u003e\u003c/p\u003e\n\u003cul type=\"disc\"\u003e\n \u003cli\u003eBirth weight \u0026gt; 1 500 g\u003c/li\u003e\n \u003cli\u003eTerm neonates\u003c/li\u003e\n \u003cli\u003eCongenital gastrointestinal malformations, abdominal wall defects, or prior abdominal surgery\u003c/li\u003e\n \u003cli\u003eCardiac or neurosurgical procedures before the index abdominal operation\u003c/li\u003e\n \u003cli\u003eIncomplete medical records\u003c/li\u003e\n\u003c/ul\u003e\n\u003cp\u003eAll eligible infants were included; no sample-size calculation was performed because the target population is rare.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eData Sources and Variables\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eDemographic, perinatal, perioperative, and follow-up data were extracted from the EHR using a standardized case-report form. Key variables included:\u003c/p\u003e\n\u003cul type=\"disc\"\u003e\n \u003cli\u003eBaseline: Sex, gestational age, birth weight, Apgar scores, antenatal corticosteroid exposure, and age at perforation.\u003c/li\u003e\n \u003cli\u003eOperative details: Procedure type, indication (NEC vs. SIP), duration of anesthesia, need for blood transfusion, and creation of stoma.\u003c/li\u003e\n \u003cli\u003eShort-term outcomes: All-cause mortality at 30 and 90 days, sepsis after surgery, severe intraventricular hemorrhage (grade \u0026ge; III), days on mechanical ventilation post-procedure, days of total parenteral nutrition, and NICU length of stay (LOS).\u003c/li\u003e\n \u003cli\u003eLong-term outcomes: Weight-for-age z score and length/height z score at 1-year corrected age; neurodevelopmental status (normal vs. any impairment) based on standardized developmental screening documented in outpatient follow-up; timing of ileostomy reversal when applicable.\u003c/li\u003e\n\u003c/ul\u003e\n\u003cp\u003e\u003cstrong\u003eStatistical Analysis\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eAnalyses were performed with SPSS (Version 29.0) and R (Version 4.3). Continuous data were summarized as median (interquartile range) owing to non-normal distribution and compared using the Mann\u0026ndash;Whitney U test. Categorical variables were reported as counts (percentages) and compared with Fisher\u0026rsquo;s exact test. Statistical significance was defined as two-sided \u003cem\u003ep\u003c/em\u003e \u0026lt; .05. No imputation was applied for missing outcome data.\u003c/p\u003e\u003cp\u003e\u003cstrong\u003eEthical Considerations\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe research received approval from the Dubai Scientific Research Ethics Committee (DSREC), Dubai Health Authority, Dubai, United Arab Emirates. In accordance with the UAE National Guidelines for Human Research Ethics, the DSREC determined that this retrospective study was exempt from full board review and waived the requirement for individual informed consent. All procedures conformed to the principles of the Declaration of Helsinki and institutional data‑protection policies.\u003c/p\u003e"},{"header":"Conclusions","content":"\u003cp\u003eIn this ELBW cohort, initial PD and LAP produced similar short-term survival, yet PD demonstrated a clear neuroprotective signal, with a sixteenfold reduction in severe IVH and a threefold higher prevalence of normal neurodevelopment at one year. These data support continued use of PD for the most fragile infants while underscoring the need for individualized decision-making and robust long-term follow-up.\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eFunding\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe authors did not receive any grants, contracts or other support for the conduct of this study or the preparation of this manuscript.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCompeting interests\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe authors have no relevant financial or non-financial interests to disclose.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eEthics approval and research involving human participants\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThis retrospective observational study analysed de‑identified medical‑record data from extremely low\u0026ndash;birth‑weight infants with surgical necrotizing enterocolitis or spontaneous intestinal perforation; no animal subjects were involved. The study received ethical approval from the Dubai Scientific Research Ethics Committee (DSREC), Dubai Health Authority, Dubai, UAE (Ref: DSREC‑SR‑07/2024_05; approval date 10 July 2024), in accordance with the 1964 Declaration of Helsinki and its later amendments and the UAE National Guidelines for Human Research Ethics. Because the project used anonymised, retrospectively collected data, the DSREC waived both the requirement for full board review and for individual informed consent.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eInformed consent\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNot applicable; the requirement for individual informed consent was waived by the Dubai Scientific Research Ethics Committee (DSREC). All patient information was handled with strict confidentiality.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eData availability\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe datasets generated during and/or analyzed during the current study contain confidential patient information and are not publicly available. De-identified data may be shared by the corresponding author on reasonable request and with prior Institutional Review Board approval.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConsent to Publish\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNot applicable.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAuthors\u0026rsquo; contributions\u003c/strong\u003e\u003c/p\u003e\n\u003cul type=\"disc\"\u003e\n \u003cli\u003eM.A.B. conceived the study concept and design, coordinated data collection, conducted the primary analysis, and drafted the initial manuscript.\u003c/li\u003e\n \u003cli\u003eM.A. and F.A.S. acquired clinical data, assisted in shaping the methodology, and participated in preliminary data reviews.\u003c/li\u003e\n \u003cli\u003eW.U. and G.J. performed the statistical analyses, curated the dataset, and validated the results.\u003c/li\u003e\n \u003cli\u003eM.A.M. and A.H. created and formatted the figures and tables, ensuring accurate representation of the findings.\u003c/li\u003e\n \u003cli\u003eM.A.K. and V.G. carried out an extensive literature review, critically interpreted the outcomes, and contributed to framing the discussion in light of current evidence.\u003c/li\u003e\n \u003cli\u003eM.A.B., M.A., and F.A.S. wrote the main text, with substantive feedback and revisions provided by W.U., G.J., M.A.M., A.H., M.A.K., and V.G.\u003c/li\u003e\n \u003cli\u003eAll authors thoroughly reviewed and approved the final manuscript and assume responsibility for all aspects of the work.\u003c/li\u003e\n\u003c/ul\u003e"},{"header":"References","content":"\u003col\u003e\n\u003cli\u003eHan, S. M. et al. Trends in incidence and outcomes of necrotizing enterocolitis over the last 12 years: a multicenter cohort analysis. \u003cem\u003eJ. Pediatr. Surg.\u003c/em\u003e 55, 998\u0026ndash;1001; https://doi.org/10.1016/j.jpedsurg.2020.02.046 (2020).\u003c/li\u003e\n\u003cli\u003eAlsaied, A., Islam, N. \u0026amp; Thalib, L. Global incidence of necrotizing enterocolitis: a systematic review and meta‑analysis. \u003cem\u003eBMC Pediatr.\u003c/em\u003e 20, 344; https://doi.org/10.1186/s12887-020-02231-5 (2020).\u003c/li\u003e\n\u003cli\u003eBlakely, M. L. et al. Initial laparotomy versus peritoneal drainage in extremely low birth‑weight infants with surgical necrotizing enterocolitis or isolated intestinal perforation: a multicenter randomized clinical trial. \u003cem\u003eAnn. Surg.\u003c/em\u003e 274, e370\u0026ndash;e380; https://doi.org/10.1097/SLA.0000000000005099 (2021).\u003c/li\u003e\n\u003cli\u003eRao, S. C., Basani, L., Simmer, K., Samnakay, N. \u0026amp; Deshpande, G. Peritoneal drainage versus laparotomy as initial surgical treatment for perforated necrotizing enterocolitis or spontaneous intestinal perforation in preterm low‑birth‑weight infants. \u003cem\u003eCochrane Database Syst. Rev.\u003c/em\u003e 6, CD006182; https://doi.org/10.1002/14651858.CD006182.pub2 (2011).\u003c/li\u003e\n\u003cli\u003eAhle, S. et al. Multicenter retrospective comparison of spontaneous intestinal perforation outcomes between primary peritoneal drain and primary laparotomy. \u003cem\u003eJ. Pediatr. Surg.\u003c/em\u003e 55, 1270\u0026ndash;1275; https://doi.org/10.1016/j.jpedsurg.2019.07.007 (2020).\u003c/li\u003e\n\u003cli\u003eOkten, E. I. et al. Factors affecting neurodevelopmental outcome following surgical necrotising enterocolitis: a systematic review. \u003cem\u003ePediatr. Surg. Int.\u003c/em\u003e 40, 71; https://doi.org/10.1007/s00383-024-05651-x (2024).\u003c/li\u003e\n\u003cli\u003eShen, Y., Lin, Y., Fang, Y.‑F., Wu, D. M. \u0026amp; He, Y. B. Efficacy of peritoneal drainage in very‑low‑birth‑weight neonates with Bell\u0026rsquo;s stage II necrotizing enterocolitis: a single‑center retrospective study. \u003cem\u003eWorld J. Gastrointest. Surg.\u003c/em\u003e 15, 1416\u0026ndash;1422; https://doi.org/10.4240/wjgs.v15.i7.1416 (2023).\u003c/li\u003e\n\u003cli\u003eGarg, P. M., Riddick, R., Ansari, M. A. Y., Pittman, I. \u0026amp; Hillegass, W. Clinical impact of timing of surgery on outcomes in preterm infants with surgical necrotizing enterocolitis. Preprint at https://doi.org/10.21203/rs.3.rs-3084887/v1 (2023).\u003c/li\u003e\n\u003cli\u003eBethell, G. S., Jones, I. H., Battersby, C., Knight, M. \u0026amp; Hall, N. J. Methods of identifying surgical necrotizing enterocolitis\u0026mdash;a systematic review and meta‑analysis. \u003cem\u003ePediatr. Res.\u003c/em\u003e 97, 45\u0026ndash;55; https://doi.org/10.1038/s41390-024-03292-3 (2025).\u003c/li\u003e\n\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":true,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true},"keywords":"Necrotizing enterocolitis, Spontaneous intestinal perforation, Extremely low–birth-weight, Peritoneal drainage, Laparotomy, Neonatal surgery","lastPublishedDoi":"10.21203/rs.3.rs-7160115/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-7160115/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003eNecrotizing enterocolitis (NEC) and spontaneous intestinal perforation (SIP) are disastrous complications in extremely lowbirthweight (ELBW) neonates, yet the optimal first operation remains unsettled. Together, these conditions account for a disproportionate share of neonatal surgical mortality. We retrospectively studied ELBW infants (\u0026lt;\u0026thinsp;1000 g) treated for surgical NEC or SIP at two tertiary UAE centers between 2019 and 2023, comparing outcomes of initial bedside peritoneal drainage (PD)\u0026mdash;usually performed under minimal sedation\u0026mdash;with exploratory laparotomy (LAP). Twentynine infants qualified; 26 received PD and 3 LAP. Ninetyday survival wa 85 % after PD versus100 % after LAP. However, severe intraventricular hemorrhage developed in ony 4 % of PD infants compared wit 67 % after LAP, and neurodevelopment at oneyear corrected age was normal n 75 % of PD survivors but in none following LAP. Median neonatalintensivecare stay and dependence on parenteral nutrition were similar between strategies. These findings suggest that, for the frailest ELBW population, PD achieves survival equivalent to LAP while potentially reducing cerebral injury and supporting earlier functional recovery. Prospective multicenter trials with adequate power, standardized neurodevelopmental assessment, and longer followup are needed to confirm these signals and guide individualized surgical decisionmaking.\u003c/p\u003e","manuscriptTitle":"Initial Laparotomy versus Peritoneal Drainage in Extremely Low–Birth-Weight Infants with Surgical Necrotizing Enterocolitis or Spontaneous Intestinal Perforation","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2025-08-06 08:13:26","doi":"10.21203/rs.3.rs-7160115/v1","editorialEvents":[{"type":"communityComments","content":0}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"81d56be4-d2a5-4b3b-9f81-e8e54ad27ea5","owner":[],"postedDate":"August 6th, 2025","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"posted","subjectAreas":[{"id":52611653,"name":"Health sciences/Diseases"},{"id":52611654,"name":"Health sciences/Gastroenterology"},{"id":52611655,"name":"Health sciences/Health care"},{"id":52611656,"name":"Health sciences/Medical research"},{"id":52611657,"name":"Health sciences/Neurology"}],"tags":[],"updatedAt":"2025-12-04T15:09:43+00:00","versionOfRecord":[],"versionCreatedAt":"2025-08-06 08:13:26","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-7160115","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-7160115","identity":"rs-7160115","version":["v1"]},"buildId":"8U1c8b4HqxoKbykW_rLl7","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}