Portal venous air: The poor prognosis persists

Background/Purpose: The prognostic importance of portal vein air (PVA) in b abies with necrotizing enterocolitis (NEC) has been controversial. This stu dy compares the outcome in babies with NEC and PVA treated surgically versu s those with medical management. Methods: Forty neonates in the neonatal intensive care unit (NICU; 1995 thr ough 1999) had (PVA) during their hospitalization. Babies were analyzed for gestational age (GA), birth weight (BW), and survival after operative vers us medical management. Results: The average GA was 26 weeks, average BW was 1,173 g. Twenty-three patients (57.5%) tolerated full feedings and 8 (20%) partial feedings at di agnosis. All 40 babies required intubation at birth with 23 (57.5%) requiri ng reintubation with onset of PVA. In all cases, PVA was present within 24 hours of onset of abdominal distension, feeding intolerance, or heme-positi ve stools. Two cases of PVA "resolved" only to recur later in the patients' courses. Thirty-two patients (80%) manifested pneumatosis intestinalis on abdominal radiographs, and 8 (20%) had perforations. Acidosis was present i n 25 (63%) patients, and vasopressor support (dopamine) was required in 15 (38%), with 2 patients requiring support only preoperatively. Initial manag ement consisted of bowel rest, fluid resuscitation, orogastric decompressio n, and broad-spectrum antibiotics. Operation was performed in 31 (78%). Sev enteen underwent resection with ostomy formation with 6 deaths and 11 survi vors. Four underwent resection using the clip and drop back method, with on e death and 3 requiring an ostomy at second look laparotomy. Ten had NEC to talis and closure of the abdomen only. Overall operative mortality rate was 17 of 31 (54%). Nine seemingly stable patients were treated nonoperatively . Six had progressed disease and died before salvage laparotomy could be pe rformed, whereas 3 (33%) survived without further therapy. Conclusions: PVA has been a relative indication for operation. This view ha s been challenged by the survival of some patients without laparotomy. Alth ough nonoperative therapy seems appealing in hemodynamically stable patient s without acidosis, our data confirm the poor prognosis of infants with PVA and NEC. J Pediatr Surg 36:1143-1145. Copyright (C) 2001 by W.B. Saunders Company.