When a Premature Baby Needs Surgery for NEC: Understanding the Choices

What the research says about the operations used to treat necrotizing enterocolitis — and why doctors sometimes reach different decisions

When medicine isn't enough

Necrotizing enterocolitis — NEC for short — is a serious bowel illness that mainly affects babies born very early. Most babies with NEC are treated without an operation, with rest for the bowel, antibiotics, and nutrition given through a vein. But in roughly one in three cases, the illness becomes severe enough that surgery is needed — usually because the bowel has developed a hole (a perforation) or because the baby is getting worse despite every other treatment [1]. Surgery for NEC is serious: these are tiny, fragile babies, and the risk to life and to long-term health is unfortunately real. If your baby is facing this, understanding the choices the surgical team weighs can make a frightening situation a little less bewildering. This article explains those choices and what the research shows about them.

The first choice: a drain or an operation

When the bowel perforates, the surgical team faces a first decision between two approaches. One is a full operation, called a laparotomy, in which the surgeon opens the abdomen, removes the damaged or dead bowel, and cleans the area. The other is much simpler: placing a small drain through the skin into the abdomen (called peritoneal drainage) to let out the fluid, air, and infection that have built up, in the hope that the bowel can settle and heal on its own. The drain can often be placed right at the bedside, without the baby needing to be moved to an operating room or put under full anaesthesia, which is why it has appealed as an option for the very sickest, most unstable babies — those who might not survive a major operation in the moment. The trade-off is that a drain does not let the surgeon see or remove any bowel that has already died; it relies on the body to heal itself or buys time until the baby is stronger.

For forty years, surgeons have debated which is better. The reassuring answer from the best research is that, on average, neither clearly beats the other for survival. Three carefully designed studies — in which babies were assigned at random to one approach or the other, the most reliable way to compare treatments — have tested this question. The first, in 2006, found almost identical survival with the two approaches [2]. The second, in 2008, found a difference in survival that was not large enough to be certain it wasn't due to chance — and importantly, about three-quarters of the babies who first got a drain ended up needing the full operation anyway [3]. The largest and most thorough, published in 2021 and known as the NEST trial, followed 310 babies and measured not just survival but also how the children were developing at around 18–22 months of age. It found nearly identical results: about 69–70% had died or had a developmental impairment in each group, with no meaningful difference between them [4]. A 2025 summary by the Cochrane organization, which independently reviews medical evidence, pulled these studies together and reached the same conclusion: neither approach is clearly superior [5].

The most useful clue: the baby's specific problem

The most interesting finding from the largest study wasn't the overall result but a detail within it. The babies' underlying problem fell into two types: NEC itself (where a section of bowel has become inflamed and died) and a different condition called isolated intestinal perforation (a hole in otherwise healthy bowel, which can happen in very premature babies without full-blown NEC). When the researchers looked at these two groups separately, they found that babies whose problem was NEC did somewhat better with the full operation, while babies with an isolated perforation did equally well with either approach [4].

This makes intuitive sense. If a piece of bowel has actually died, removing it and cleaning the area — something only the operation can do — is likely to help. If instead there's just a small hole in otherwise healthy bowel, a drain may give it the chance it needs to heal on its own. So rather than there being one "right" operation for every baby, the best choice may depend on what is actually wrong. This is why two excellent surgeons might reasonably make different choices for two different babies — and why the team's decision is tailored to your baby in particular. It is worth knowing that the two problems can be hard to tell apart before surgery, and sometimes the full picture only becomes clear during the operation itself; the team uses the baby's history, X-rays, and how the illness is behaving to make their best judgement, and they may adjust course as things become clearer.

Why older information can be misleading

You may come across claims that the full operation clearly leads to better survival than a drain. This comes from studies that simply looked back at what happened to many babies, rather than assigning treatments at random. The problem is that, in real life, surgeons tend to choose the simple bedside drain for the very smallest and sickest babies — the ones least able to withstand an operation [6]. So when those babies do worse, it is mostly because they were sicker to begin with, not because the drain itself was worse. When researchers account for this — or use the more reliable randomized studies — the apparent advantage largely disappears [7]. It's a good example of why the way a study is designed matters so much.

The second choice: rejoining the bowel or making a stoma

If the full operation is done and a damaged section of bowel is removed, the surgeon faces a second decision. They can either join the two healthy ends back together right away (called a primary anastomosis), or bring the end of the bowel out through an opening in the tummy wall (called a stoma), so that stool collects in a small bag outside the body until a later operation reconnects everything. Here the research used to be very limited, but it has recently improved. For years there were no high-quality trials comparing the two approaches, only studies looking back at what had happened to past patients [8]. Then, in 2024, the results of a study called the STAT trial were published — the first study to compare the two approaches by randomly assigning babies to one or the other (when the surgeon felt either was reasonable), which is the most reliable way to compare treatments. Across 80 babies in hospitals around the world, those whose bowel was rejoined right away were able to come off intravenous nutrition sooner and had fewer later bowel complications, with no difference in survival, compared with those who had a stoma [9]. A 2025 review combining 18 studies pointed the same way, linking rejoining the bowel to lower death rates in carefully chosen cases [10]. So the picture has shifted: for a reasonably stable baby whose damaged section can be cleanly removed, rejoining the bowel directly is now a well-supported choice that avoids a second operation and the challenges of living with a stoma. For the sickest babies, or when a lot of bowel is affected, a stoma is still often the safer choice [11]. A stoma means a second operation later to close it, which is a normal and expected part of the journey for many of these babies, not a sign that something has gone wrong. While a baby has a stoma, the team will keep a close eye on their fluids and growth, because stool leaving the body earlier than normal can affect how well nutrients are absorbed; nurses will also teach families how the stoma and its small bag are cared for, which can feel daunting at first but quickly becomes routine.

What this means for your family

If your baby needs surgery for NEC, the most important things to understand are these. The research shows that the major choices do not have a single right answer that applies to every baby — which is reassuring, because it means the team is not gambling between a clearly good and a clearly bad option, but tailoring a reasonable choice to your baby's specific situation. More than one operation is sometimes part of the plan from the start — for example, a drain first to stabilize a very sick baby, followed by a full operation when they are stronger, or a stoma that will later be closed. None of these steps mean something has gone wrong; they are a recognized path through a serious illness. And it is always reasonable to ask the team to explain why they are recommending a particular approach for your baby, what they found, and what they expect to happen next. These are hard decisions made by experienced people who are weighing your baby's size, stability, and specific problem, and who are drawing on decades of careful research about what does and does not change the outcome.

What researchers are working on next

Researchers want to confirm the promising finding that the baby's specific diagnosis should guide the choice of operation, and to build on the STAT trial with larger studies of rejoining the bowel versus making a stoma — STAT was relatively small and only included babies for whom surgeons judged either operation reasonable, so bigger studies would help confirm how widely its finding applies. The bigger hope, though, is to need these operations less often — by preventing NEC in the first place, and by developing new medical treatments for the damaged bowel. Among the most promising research directions are therapies based on stem cells, though these are still being studied in the laboratory and are not yet ready for babies [12]. For now, families can take some comfort in knowing that the choices their surgical team makes are guided by solid evidence about what does — and does not — make a difference, and that where the evidence is genuinely uncertain, the team is making a careful, individual judgement rather than guessing.

References

  1. Neu J, Walker WA. Necrotizing enterocolitis. New England Journal of Medicine. 2011;364(3):255–264. doi:10.1056/NEJMra1005408 ↩
  2. Moss RL, Dimmitt RA, Barnhart DC, et al. Laparotomy versus peritoneal drainage for necrotizing enterocolitis and perforation. New England Journal of Medicine. 2006;354(21):2225–2234. doi:10.1056/NEJMoa054605 ↩
  3. Rees CM, Eaton S, Kiely EM, Wade AM, McHugh K, Pierro A. Peritoneal drainage or laparotomy for neonatal bowel perforation? A randomized controlled trial. Annals of Surgery. 2008;248(1):44–51. doi:10.1097/SLA.0b013e318176bf81 ↩
  4. Blakely ML, Tyson JE, Lally KP, et al; Eunice Kennedy Shriver NICHD Neonatal Research Network. Initial laparotomy versus peritoneal drainage in extremely low birthweight infants with surgical necrotizing enterocolitis or isolated intestinal perforation: a multicenter randomized clinical trial. Annals of Surgery. 2021;274(4):e370–e380. doi:10.1097/SLA.0000000000005099 ↩
  5. Rath C, Samnakay N, Deshpande G, Sutyak KM, Basani L, Simmer K, Fiander M, Rao SC. Peritoneal drainage versus laparotomy as initial treatment for surgical necrotising enterocolitis or spontaneous intestinal perforation in preterm very low birth weight infants. Cochrane Database of Systematic Reviews. 2025;6(6):CD006182. doi:10.1002/14651858.CD006182.pub3 ↩
  6. Solis-Garcia G, Pierro A, Jasani B. Laparotomy versus peritoneal drainage as primary treatment for surgical necrotizing enterocolitis or spontaneous intestinal perforation in preterm neonates: a systematic review and meta-analysis. Children (Basel). 2023;10(7):1170. doi:10.3390/children10071170 ↩
  7. Li W, Tang J, Zhu Z, Tang W. Initial surgical treatment of necrotizing enterocolitis: a meta-analysis of peritoneal drainage versus laparotomy. European Journal of Pediatrics. 2022;181(7):2593–2601. doi:10.1007/s00431-022-04454-3 ↩
  8. Downard CD, Renaud E, St Peter SD, et al; American Pediatric Surgical Association Outcomes and Clinical Trials Committee. Treatment of necrotizing enterocolitis: an American Pediatric Surgical Association Outcomes and Clinical Trials Committee systematic review. Journal of Pediatric Surgery. 2012;47(11):2111–2122. doi:10.1016/j.jpedsurg.2012.08.011 ↩
  9. Eaton S, Ganji N, Thyoka M, et al. STAT trial: stoma or intestinal anastomosis for necrotizing enterocolitis: a multicentre randomized controlled trial. Pediatric Surgery International. 2024;40(1):279. doi:10.1007/s00383-024-05853-3 ↩
  10. Alansari AN, Mani S, Messaoud M, Altokhais T. Outcomes of primary intestinal anastomosis versus stoma in necrotizing enterocolitis: a systematic review and meta-analysis. Surgery in Practice and Science. 2025;23:100319. doi:10.1016/j.sipas.2025.100319 ↩
  11. Haricharan RN, Gallimore JP, Nasr A. Primary anastomosis or ostomy in necrotizing enterocolitis? Pediatric Surgery International. 2017;33(11):1139–1145. doi:10.1007/s00383-017-4126-z ↩
  12. Cavallaro G, et al. Bone marrow-derived mesenchymal stromal cells in necrotizing enterocolitis treatment: a narrative review. Frontiers in Pediatrics. 2025;13:1624236. doi:10.3389/fped.2025.1624236 ↩