Primary Repair or Anastomosis Versus Enterostomy for Spontaneous Intestinal Perforation in Preterm Neonates: A Systematic Review.
Keywords:
spontaneous intestinal perforation; focal intestinal perforation; isolated intestinal perforation; preterm neonate; enterostomy; primary anastomosis; neonatal surgery.Abstract
Background: Spontaneous intestinal perforation (SIP) is a distinct gastrointestinal emergency of prematurity that predominantly affects very low birth weight and extremely low birth weight infants. It differs from necrotizing enterocolitis in pathogenesis, intraoperative findings, and postoperative course. The optimal operative strategy remains uncertain, particularly whether primary repair or primary anastomosis offers advantages over enterostomy in selected infants.
Methods: A systematic review was conducted in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) 2020 statement. PubMed/MEDLINE, Embase, Scopus, Web of Science, the Cochrane Library, and Google Scholar were searched from inception to 4 April 2026. Comparative studies of preterm neonates with SIP, including cohorts described as focal intestinal perforation or isolated intestinal perforation, were eligible if they compared primary repair or anastomosis with enterostomy. Mixed-population comparator studies involving isolated intestinal perforation and/or combined necrotizing enterocolitis-SIP cohorts were reviewed separately as supplementary evidence.
Results: Four SIP-specific retrospective comparative cohort studies formed the primary evidence base. Three studies provided directly verifiable sample sizes, comprising 105 infants in total. Across the studies with extractable numerical data, no consistent mortality advantage was demonstrated for either operative strategy. In Brisighelli et al., mortality was 23% after primary anastomosis and 33% after stoma formation. In Dübbers et al., mortality was 13.3% after primary anastomosis and 8.3% after enterostomy. Potential advantages of a non-stoma strategy were reported for discharge weight, length of hospital stay, parenteral nutrition duration, and number of procedures under general anesthesia. However, the evidence base was limited to retrospective studies and was vulnerable to confounding by indication [4-6,9].
Conclusions: Primary repair or primary anastomosis appears feasible in carefully selected preterm neonates with SIP, but current evidence does not establish superiority over enterostomy. The main potential advantages of a non-stoma strategy appear to relate to treatment burden and recovery rather than mortality. Better multicenter comparative studies are needed...
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