Necrotizing enterocolitis (NEC) can progress rapidly from intestinal inflammation to a life-threatening surgical emergency in premature infants, yet choosing when and how to operate remains one of the most challenging decisions in neonatal surgery. A comprehensive review published in the World Journal of Pediatric Surgery on June 2, 2026, synthesizes current evidence and offers a clinical framework to guide operative strategies, with a central message that surgery should do more than control immediate disease: it should preserve as much functional bowel as possible, reduce long-term complications, and support survival with better quality of life.
The review, led by researchers from the Department of Pediatric Surgery at Nationwide Children’s Hospital in Columbus, Ohio, addresses the high stakes of surgical NEC. Mortality is about 7% in medically managed disease but rises to roughly 20%–30% in surgical NEC. Survivors often face strictures, nutritional problems, intestinal failure from short bowel syndrome (SBS), and impaired neurodevelopment. Clinical decisions are complicated by the lack of a disease-specific biomarker, overlap with spontaneous intestinal perforation (SIP), and uncertainty about when a deteriorating infant has crossed from medical to surgical disease.
The authors compare the two primary operative approaches: peritoneal drainage (PD) and exploratory laparotomy. PD is less invasive and can be performed rapidly at the bedside, making it useful for extremely low-birth-weight infants who may not tolerate laparotomy, but failure to improve often requires rescue surgery. Exploratory laparotomy permits direct inspection and removal of necrotic bowel. Earlier randomized trials found broadly similar survival between the two approaches, but a more recent multicenter RCT found that among infants with a preoperative diagnosis of NEC, death or neurodevelopmental impairment occurred in 69% after laparotomy versus 85% after PD, with a 97% Bayesian probability that laparotomy was beneficial in this subgroup.
After resection, the choice between stoma creation and primary anastomosis depends on the infant’s stability and the viability of the remaining bowel. For extensive or multifocal disease, the review discusses damage control surgery, “clip and drop,” diverting jejunostomy, “patch, drain and wait,” and intraluminal stenting, all aimed at limiting unnecessary bowel loss. Emerging adjuncts such as indocyanine green fluorescence angiography (ICG-FA), direct peritoneal resuscitation (DPR), and mucous fistula refeeding may improve perfusion assessment, bowel preservation, or nutritional recovery, though the authors note that many of these techniques still rest on limited neonatal evidence and need stronger, well-controlled studies.
The review’s main lesson is that operative care for NEC cannot be reduced to a single preferred procedure. The best approach depends on how sick the infant is, whether the bowel is clearly non-viable, and how much intestine can safely be preserved. The authors emphasize that the immediate goal is survival, but long-term intestinal function, growth, and neurodevelopment also have to shape surgical decisions.
This framework could help neonatal and pediatric surgical teams structure multidisciplinary decisions around timing, operative risk, and bowel preservation rather than treating all surgical NEC in the same way. Risk scores such as the Neonatal Sequential Organ Failure Assessment (nSOFA), combined with imaging, laboratory findings, and the infant’s overall clinical trajectory, may support earlier recognition of high-risk cases. In the operating room, perfusion imaging and staged bowel-preserving approaches may reduce avoidable resection, while postoperative strategies such as mucous fistula refeeding may reduce dependence on total parenteral nutrition (TPN) and speed progression toward full feeds.
The review is available online with DOI: 10.1136/wjps-2026-001200. The World Journal of Pediatric Surgery is an open-access, peer-reviewed journal sponsored by Zhejiang University and Children’s Hospital, Zhejiang University School of Medicine, and published by BMJ Group.
