by Jessica Pasley
More than 20 years ago, Martin Blakely, MD, professor of Pediatric Surgery at Monroe Carell Jr. Children’s Hospital at Vanderbilt, asked what seemed to be a simple question that took nearly two decades to answer: What is the best treatment for two conditions commonly diagnosed among low birthweight newborns called necrotizing enterocolitis (NEC) or isolated intestinal perforation (IP)?
The question revolved around two surgical treatments that traditionally had unfavorable outcomes.
In an effort to improve survival and reduce the neurodevelopmental impairment of this patient population, Blakely led 20 centers across the United States in a study called Necrotizing Enterocolitis Surgery Trial (NEST).
The randomized neonatal surgery trial compared two surgical options — laparotomy versus peritoneal drainage — to determine which intervention was better for each condition.
“Very few of our neonatal surgical treatments have been studied properly and extensively. There has been much debate about these two treatments,” said Blakely.
“This is one of the very few randomized trials evaluating neonatal surgical treatment that met its required enrollment and followed the patient population beyond hospital discharge,” he said.
“We needed to engage in a scientifically rigorous, valid study design that might change practice. This level of study is extremely rare and almost never done.”
Results of the study were recently published in the Annals of Surgery.
NEST results showed that if a newborn has NEC, performing a laparotomy is the better option and leads to an approximately 20% lower death rate or impairment rate in those who survive. Alternatively, in newborns with isolated intestinal perforation, the findings leaned toward the use of peritoneal drainage, but questions still exist.
“The landmark finding was that diagnosis is key,” said Blakely. “After the study, the findings shine a light on the need to discriminate the two conditions prior to surgery. Prior trials did not take this into account and reported no difference in outcomes between the two surgical treatments.
“Now for the first time we have believable data showing the impact of the specific diagnosis on outcomes,” he said. “Moving forward we will do more studies in the IP population to confirm our initial findings because there was some uncertainty. Further research will improve the initial diagnostic accuracy of the two conditions.”
