Journal of Pediatric Surgery VOL 35, NO 11 NOVEMBER 2000 Peritoneal Drainage as Definitive Treatment for Neonates With Isolated Intestinal Perforation By Darrell L. Cass, Mary L. Brandt, Dimple L. Patel, Jed G. Nuchtern, Paul K. Minifee, and David E. Wesson Houston, Texas Background/Purpose: To better define the indications for peritoneal drainage (PD) in premature babies with intestinal perforation, the authors reviewed their experience with this procedure in a tertiary neonatal intensive care setting. Methods: The charts of all neonates who underwent PD as initial treatment for intestinal perforation between 1996 and 1999 were reviewed. Those patients with pneumatosis intes- tinalis on abdominal radiograph had perforated necrotizing enterocolitis (NEC) diagnosed; whereas, those infants with no pneumatosis had isolated intestinal perforation diag- nosed. The clinical characteristics and outcomes of these 2 groups were compared. Results: Twenty-one premature neonates had primary PD between 1996 and 1999, 10 for isolated intestinal perforation and 11 for perforated NEC. Patients with isolated intestinal perforation had lower birth weights (708 v 949 g; P  .05), were less likely to have started feedings (30% v 91%, P  .05), and the perforation developed at an earlier age (10.6 v 28.0 d, P  .05) compared with the patients who had perforated NEC. Only 2 of 10 infants with isolated perforation required subsequent laparotomy (at 10 weeks for stricture and 12 weeks for a persistent fistula). For these patients, the long- term survival rate was 90%. In contrast, 8 of 11 infants with perforated NEC required laparotomy, and although the 30- day survival rate was 64%, the long-term survival rate was only 27%. Conclusions: Peritoneal drainage provides successful and definitive treatment for most premature babies with isolated intestinal perforation. For neonates with perforation caused by NEC, peritoneal drainage may provide temporary stabili- zation, but most of these infants require subsequent laparot- omy, and few survive. J Pediatr Surg 35:1531-1536. Copyright © 2000 by W.B. Saunders Company. INDEX WORDS: Peritoneal drainage, isolated intestinal per- foration, necrotizing enterocolitis, neonates. P ERITONEAL DRAINAGE (PD), achieved by the percutaneous placement of Penrose drains into the peritoneal cavity of neonates with intestinal perforation, was described originally over 25 years ago by Marshall 1 and Ein et al. 2 Initially, this procedure was recommended as a temporary measure for small, extremely ill infants with perforation caused by necrotizing enterocolitis (NEC). It was hoped that the drainage of air and stool would relieve symptoms of abdominal compartment syn- drome and sepsis and allow the infant to better tolerate subsequent laparotomy. Subsequently, it was observed that many of these infants required no further treatment. Unexpectedly, their outcomes were no worse, and pos- sibly better, than those who underwent immediate lapa- rotomy. 3,4 The use of PD gradually evolved such that some investigators now recommend PD for the initial management of all extremely low birth weight infants with perforated NEC. 5 However, the reported mortality using such an approach remains high. 6 Recently, clinicians have recognized a separate subset of premature neonates with bowel perforation in whom the perforation develops spontaneously and not in asso- ciation with NEC. This so-called, spontaneous, focal, idiopathic, indomethacin-associated, or isolated intesti- nal perforation tends to occur in extremely low birth weight infants, early in life, usually before feedings, and often in association with indomethacin therapy for patent ductus arteriosus. 7-16 These infants do not get pneuma- From the Department of Surgery, Texas Children’s Hospital and the Baylor College of Medicine, Houston, TX. Presented at the 33rd Annual Meeting of the Pacific Association of Pediatric Surgeons, Las Vegas, Nevada, May 15-19, 2000. Address reprint requests to David E. Wesson, MD, Division of Pediatric Surgery, Texas Children’s Hospital, 6621 Fannin, MC 3-2325, Houston, TX 77030-2399. Copyright © 2000 by W.B. Saunders Company 0022-3468/00/3511-0001$03.00/0 doi:10.1053/jpsu.2000.18299 1531 Journal of Pediatric Surgery, Vol 35, No 11 (November), 2000: pp 1531-1536