Surgical Management of Necrotizing Enterocolitis and Isolated Intestinal Perforation in Premature Neonates Martin L. Blakely, MD,* Himesh Gupta, MD, † and Kevin P. Lally, MD* Necrotizing enterocolitis (NEC) and isolated intestinal perforation (IP) are two relatively common disease conditions that require neonatal surgical therapy. The early mortality rate approaches 50%, and survivors frequently have growth and neurodevelopmental impair- ment. Much discussion has occurred regarding whether initial drain placement alone or laparotomy with resection of diseased intestine should be the initial surgical therapy. Several recent prospective studies have shown that the early mortality rate is likely not significantly different after either of these surgical approaches. Major morbidity, especially the likelihood for neurodevelopmental impairment, may be different in the two treatment groups. Further prospective trials are needed to further explore this question and are planned. Studies focusing on prevention of NEC and IP and also on improved medical treatment are needed to allow a major advance in the outcomes of infants with NEC and IP. As these studies are being performed, trials evaluating existing medical and surgical therapies are also needed. Semin Perinatol 32:122-126 © 2008 Elsevier Inc. All rights reserved. KEYWORDS necrotizing enterocolitis (NEC), isolated intestinal perforation (IP), neonatal surgery N ecrotizing enterocolitis (NEC) and isolated intestinal perforation (IP) remain two of the most common con- ditions requiring emergency surgical therapy in premature neonates. NEC affects approximately 7% to 8% of extremely low birth weight (ELBW) infants, and 30% of those with NEC typically require surgical treatment. 1 IP is thought to be slightly less common, although the incidence rate for IP is not as well established as it is for NEC. Despite multiple improve- ments in intensive care of ELBW premature infants over the past decade, the diagnostic methods, medical and surgical management, and outcomes of infants with NEC or IP have not changed significantly. Multiple questions remain regard- ing the optimal care of infants with NEC or IP. One of the most controversial topics in the care of these patients is whether to perform a laparotomy with intestinal resection as needed or rather place a peritoneal drain as the initial oper- ation at the time that surgical treatment is thought to be needed. Although this controversy is the focus of multiple publications, it is likely that other areas should receive more attention to improve outcomes. For example, clarifying the indications for surgical therapy, developing methods for ear- lier diagnosis of NEC, understanding the pathogenesis of the disease, and of course, developing preventative strategies in high-risk neonates all would likely improve outcomes. The purpose of this report is to review some of these controversies and summarize the recent data regarding the use of laparot- omy versus drainage. In a recent NIH research planning workshop, it was stated that prevention of NEC is obviously the required event that would allow a major leap forward from the current poor results with treatment of this disease. 2 However, along with efforts aimed at development of preventive therapies, it is also obligatory to carefully study both medical and surgical treat- ment options that are currently used via the most rigorous clinical research methodology feasible. Diagnosis Practically, the methods used to establish the diagnosis of NEC have not changed dramatically within the past decade. Premature infants, especially ELBW infants who are known *Division of Pediatric Surgery, University of Tennessee Health Science Cen- ter, Memphis, TN. †Division of Pediatric Surgery, University of Texas Health Science Center, Houston, TX. Address reprint requests to Martin L. Blakely, MD, 777 Washington Avenue, Ste. P220, Memphis, TN 38105. E-mail: mblakely@utmem.edu 122 0146-0005/08/$-see front matter © 2008 Elsevier Inc. All rights reserved. doi:10.1053/j.semperi.2008.01.008