International Comparison of Surgical Management Practices for Necrotizing Enterocolitis in Neonates: Insights from Cohorts in the Netherlands and Finland

Abstract

Introduction Surgical management of necrotizing enterocolitis (NEC) can result in significant morbidity and mortality. Surgical management varies in the absence of international evidence-based guidelines. We aimed to gain insight into practice variation between expert centers in the Netherlands and Finland. Materials and Methods Bicentric retrospective cohort study including all infants treated surgically for NEC (Bell’s stage ≥IIA) in two centers in the Netherlands and Finland between 2000 and 2021. Main outcomes were preoperative, intraoperative, and 3-month postoperative characteristics. Results We included 191 patients (122 Dutch and 69 Finnish). Median gestational age and birth weight were lower in Finnish patients (median [min.–max.]: 25 þ 4/7 [23 þ 0/7–39 þ 0/7] vs. 28 þ 2/7 [23 þ 6/7–41 þ 6/7], p < 0.001, and 795 g [545–4,000] vs. 1,103 g [420–3,065], p < 0.001). Indication for surgery was mostly pneumoperitoneum in Finnish patients (56.5% vs. 37.7%; p ¼ 0.02) versus clinical deterioration on conservative treatment in Dutch patients (51.6% vs. 23.2%; p < 0.001). A fixed-bowel loop was also more often an indication in Finland (20.3% vs. 3.3%; p < 0.001. Ostomy creation was more common in Finnish patients (92.8% vs. 53.3%; p < 0.001) and primary anastomosis in Dutch patients (29.5% vs. 4.4%; p < 0.001). Open-close procedures occurred in 13.9% of Dutch cases, versus 1.4% of Finnish cases (p ¼ 0.004). Mortality at 3 months was comparable when excluding open-close procedures (24.8% vs. 19.1%; p ¼ 0.46). Conclusions We observed varying populations, indications for surgery, and surgical approaches in NEC between the Netherlands and Finland. The occurrence of open-close procedures is 10-fold higher (13.9% vs. 1.4%) in the Netherlands compared to Finland. Long-term outcomes remain to be studied. These results point toward significant practice variation and strengthen the need for European management guidelines.