Clinical features and management of post-necrotizing enterocolitis strictures in infants: A multicentre retrospective study

Abstract

To explore the clinical features and management of post-necrotizing enterocolitis strictures.Clinical data from 158 patients with post-necrotizing enterocolitis strictures were summarized retrospectively in 4 academic pediatric surgical centers between April 2014 and January 2019. All patients were treated conservatively in the internal medicine department. All patients underwent preoperative X-ray examinations, 146 patients underwent gastrointestinal contrast studies, and 138 patients underwent rectal mucosal biopsies. All of the patients were treated surgically.Of the 158 patients, 40 of them had necrotizing enterocolitis (NEC) Bell stage Ib, 104 had Bell stage IIa, and 14 had Bell stage IIb. In these patients, the clinical signs of intestinal strictures occurred at mean of 47.8 days after NEC. In 158 patients, 146 underwent barium enema examination, 116 demonstrated intestinal strictures, and 10 demonstrated microcolon and poor development. A total of 138 patients underwent rectal mucosal biopsies, and 5 patients had Hirschsprung disease. Intraoperative exploration showed that intestinal post-NEC strictures occurred in the ileal (17.7%, 28/158) and colon (82.3%, 130/158), including ascending colon, transverse colon and descending colon, and multiple strictures were detected in 36.1% (57/158) patients. Surgical resection of stricture segments in the intestine and primary end-to-end anastomosis were performed in 142 patients, and the remaining 16 patients underwent staged surgeries. In the 146 patients with complete follow-up data, 9 had postoperative adhesions: 4 of them received conservative treatment, and the others underwent a second operation. Fifteen patients were hospitalized 1 to 3 times for malnutrition and dehydration due to repeated diarrhea; these patients eventually recovered and were discharged smoothly. All the other patients had uneventful recoveries without stricture recurrence.Post-NEC strictures mostly occurred in the colon, and there were some cases of multiple strictures. A gastrointestinal contrast study was the preferred method of examination. Preoperative rectal mucosal biopsy resulted in a diagnosis of Hirschsprung disease, and then a reasonable treatment protocol was chosen. Surgical resection of stricture segments in the intestine and primary end-to-end anastomosis achieved good therapeutic effects with favorable prognoses in these patients.

Figure 1

Abdominal X-ray appearance of a post-NEC stricture. A: Intestinal expansion in a decubitus film. B: Intestinal expansion and liquid level in a stand-up film. C: Fluid and dilatation of the lower ileus in a lateral film.

Figure 2

Different types of intestinal strictures with barium enema examination. A: Stricture appearance, small lumens (black arrow) and dilatation of the proximal bowel in the stricture segment. B: Blind-end appearance (black arrow), contrast agents have difficulty passing through the stricture segments, dilated proximal intestinal canal. C: Fetal colon (black arrow), all colons were small and poorly developed.

Figure 3

CR immunohistochemistry of rectal suction biopsy. A: Normal expression of CR-immunoreactive ganglion cells (arrow) and nerve fibers in the myenteric plexus (×200) B. No positive CR-immunoreactive ganglion cells (arrow) in the myenteric plexus of HSCR tissues (×200).

Figure 4

H & E staining of the stricture segment (×200). Chronic inflammatory cell infiltration (blue arrow) and poorly developed nerve cells (black arrow) in the submucosa of the intestinal wall.