Peritoneal drainage versus primary laparotomy in premature newborns with intestinal perforation: a retrospective cohort study evaluating an etiology-driven surgical approach

The surgical management of intestinal perforation in extremely low birth weight (ELBW) infants, stemming from necrotizing enterocolitis (NEC) or spontaneous intestinal perforation (SIP), is a subject of enduring debate. The comparative effectiveness of initial bedside peritoneal drainage (PD) versus formal primary laparotomy (PL) on mortality and major morbidity is not fully resolved.

To compare 90-day mortality and comprehensive morbidity outcomes between PD-first and PL-first strategies in a homogeneous cohort of preterm infants with intestinal perforation, with rigorous subgroup analysis based on disease etiology (NEC vs. SIP).

A single-center retrospective cohort study (2010–2023) included infants with gestational age < 32 weeks and/or birth weight < 1500 g undergoing surgery for pneumoperitoneum. Propensity score matching (PSM) with comprehensive illness severity covariates was used to balance baseline characteristics. Primary outcome was 90-day all-cause mortality, with secondary analysis of attributable versus non-attributable deaths. Secondary outcomes included short-term surgical morbidity, nutritional independence, long-term gastrointestinal outcomes, and incidence of short-bowel syndrome (SBS). Sensitivity analyses addressed temporal bias and confounding by non-GI comorbidities.

Of 126 eligible infants, 66 underwent PD-first and 60 PL-first. After PSM with 15 covariates (n = 94), overall mortality was comparable (PD: 34.0% vs. PL: 36.2%, p = 0.81; p-for-interaction between treatment and etiology = 0.02). In the SIP cohort (n = 41), PD was associated with significantly lower mortality (15.8% vs. 45.5%, p = 0.03; adjusted HR 0.32, 95% CI 0.11–0.91) and fewer major surgical complications (21.1% vs. 54.5%, p = 0.03). Among 14 SIP patients managed definitively with PD alone, median 24-month follow-up revealed no cases of intestinal obstruction or stricture. In the NEC cohort (n = 53), PL was associated with a non-significant trend towards lower mortality (38.5% vs. 55.6%, p = 0.24) but a significantly higher rate of surgical complications (57.7% vs. 29.6%, p = 0.04). Time to full enteral feeds was shorter in the PD group overall (median 42 vs. 55 days, p = 0.02), a finding that persisted after excluding patients with non-GI comorbidities. Sensitivity analyses restricted to 2015–2023 confirmed main findings.

The observed association between initial surgical strategy and survival is contingent upon underlying etiology. PD appears advantageous for SIP, was associated with lower mortality and morbidity with acceptable long-term outcomes. For NEC, PL may offer a survival trend advantage despite higher immediate surgical morbidity, likely due to definitive source control. These findings strongly advocate for an etiology-driven surgical decision-making paradigm.