Optimal Closure Timing for Protective Jejunostomy in an Infant with Necrotizing Enterocolitis: A Case Report

Abstract

Patient: Female, 6-month-old

Final Diagnosis: Necrotizing enterocolitis

Symptoms: Abdomen distension • abdomin pain, fever and chills • leukocytosis • sepsis

Clinical Procedure: Protective jejunostomy

Specialty: Critical Care Medicine • Pediatrics and Neonatology • Pediatric Surgery

Objective: Unusual clinical course

Background

Necrotizing enterocolitis (NEC) is a prevalent, life-threatening gastrointestinal disease in premature neonates, characterized by intestinal inflammation, ischemia, and potential perforation. Protective measures such as ostomies of various types are a strategy to help patients during recovery from postoperative complications. Protective jejunostomy (PJ) in such cases aims to minimize intraluminal pressure and protect distal anastomoses or compromised bowel segments. However, the optimal timing for closure remains a matter of debate, between balancing bowel rest and avoiding complications associated with prolonged ostomies.

Case Report

We report an unusual case of a 6-month-old female patient, who presented with NEC and extensive intestinal compromise. Emergency laparotomy revealed multiple areas of bowel perforation and partial ischemia without perfusion. Surgical management included selective resection of non-viable bowel segments, primary closure of smaller perforations, creation of a PJ, and a distal ileostomy. The “clip and drop” technique was not used; instead, distal bowel patency was confirmed by a second intraoperative assessment and through intestinal saline solution injection on the tenth postoperative day due to high stoma output and persistent hydroelectrolyte imbalance. Postoperatively, the patient developed 2 new ileal perforations, requiring reoperation. Following the third surgical intervention, the patient demonstrated gradual recovery without major complications, followed by elective ileostomy closure after 6 months.

Conclusions

This case highlights the complexity of the surgical option and timing of PJ closure in complicated NEC in a 6-month-old female patient. Early closure can mitigate complications related to the stoma but carries the risk of compromising the fragile and recovering intestine. Decision-making must be careful and individualized, balancing the risks and benefits.

Introduction

Necrotizing enterocolitis (NEC) is one of the most serious neonatal gastrointestinal emergencies. The disease is characterized by bacterial invasion of the intestinal wall, leading to severe inflammation and necrosis at different points, which can rapidly progress to perforation, peritonitis, sepsis, and death if not treated early and adequately. Its etiopathogenesis is marked by the immune immaturity of the neonate associated with risk factors such as prematurity, low birth weight, and use of formula feeding as components that allow non-physiologic bacterial invasion, but the mechanism is still not fully understood [1–4]. NEC has a high mortality rate (30–50%), around 25–30% of cases need surgical approaches, and late complications are common, including short-bowel syndrome (15–25%) and intestinal stenosis (10–30%) [5,6]. Surgical interventions such as ileostomies and colostomies are the most commonly used in managing extensive NECs in severe cases. These ostomies allow the intestinal content to be diverted and the viability of the unaffected distal intestine to be preserved. The PJ is a temporary interruption of the intestinal transit that aims to decompress and facilitate the healing of the affected areas [7,8]. PJ is rarely performed due to anatomical and functional changes in gastrointestinal physiology, which are associated with a high risk of dehydration and electrolyte imbalances. The procedure diverts the enteric fluid from the jejunum, compromising the intestinal areas primarily responsible for the absorption of fluids and electrolytes, which can endanger the patient’s recovery and increase the complexity of clinical management [9]. We present a rare case of a full-term, 6-month-old female infant who spontaneously developed NEC, an unusual presentation given that the condition predominantly affects neonates [10]. This report aims to analyze the surgical rationale, indications, and timing considerations specific to the use of PJ in NEC, highlighting how PJ can serve as a bowel-preserving strategy in critically ill infants with extensive intestinal compromise and exploring the challenges encountered in balancing early closure against the risks of ongoing metabolic and structural complications.

Case Report

A white 6-month-old female weighing 3.7 kg was admitted to the emergency room with signs of sepsis of unknown origin. The patient had abdominal distension with slight diffuse pain on palpation. Blood tests, urine culture, and blood culture were performed. The sepsis screening showed an infectious blood count with leukocytosis and a left shift. Abdominal X-rays and an abdominal ultrasound were carried out on the day of admission, and both revealed normal results. There were no signs of peritonitis.

Four days after admission, the patient’s condition worsened significantly, and she underwent oro-tracheal intubation, broad-spectrum antibiotic therapy, and vasoactive drugs. The abdominal distension worsened, and GI bleeding began. On the fifth day of hospitalization, a perianal ulcerative lesion was identified, which rapidly progressed to a deep, circumferential lesion in less than 12 hours. A blood culture was positive for Pseudomonas aeruginosa. Due to the risk of developing Fournier’s syndrome, the surgical team decided to perform a supra-umbilical transverse laparotomy to create a protective colostomy. After opening the abdominal cavity, a fecal obstruction was found in the terminal ileum and NEC with multiple lesions in part of the jejunum, ileum, and ascending and proximal transverse colon, with scattered areas of necrosis (Figure 1).

Figure 1.

Intraoperative image revealing areas of the patient’s bowel with a compromised, inflamed, and ischemic appearance, characteristic of NEC.

There were several scattered areas of thinning of the intestinal wall with segmental fragility, 2 visible perforations of the jejunum, and 3 visible perforations of the ileum. Given this mixed picture, the surgical team opted for selective resection of the 2 perforated jejunal segments while preserving the non-perforated but fragile areas to avoid excessive bowel loss and reduce the risk of short-bowel syndrome. During the procedure, the patient was hemodynamically unstable, and the anesthetist communicated that the patient was in severe septic shock, even with the use of vasoactive drugs. A double-barrel jejunostomy was performed in the most proximal perforation (the stoma was placed 15 cm from the duodenum-jejunal flexure) (Figure 2). An ileostomy in the most distal ileum perforation, and closure of all visible intestinal perforations with 4-0 Vicryl were performed. The cavity was drained with a Penrose drain. The circumferential anal lesion was sutured with 4-0 Vicryl.

Figure 2.

Diagram illustrating the anatomical positioning of an ileostomy, proximal jejunostomy, and distal jejunostomy.

Postoperatively, a nasogastric tube and open ostomies were maintained, as were broad-spectrum antibiotics, fasting, and parenteral nutrition. Vasoactive drugs were required for 4 days. There was a high output from the proximal jejunostomy, and the surgical team, despite the minimal drainage through the Penrose drain, decided to perform a second look in an open laparotomy on the 10^th postoperative day to avoid hydroelectrolyte disorders and check all intestinal lesions and anastomoses. The patency of the entire intestinal tract was checked intraoperatively with 0.9% sodium chloride solution, as is done in cases of intestinal atresia. The PJ was closed in 2 planes with Vicryl 4-0, and a new Penrose drain was inserted to drain the cavity. Two days after closing the PJ, the Penrose drain presented a moderate quantity of enteric fluid. The surgical team decided to reopen the supra-umbilical transverse laparotomy and found 2 new perforations (in previously healthy areas of the ileum). These were sutured in 2 planes with Vicryl 4-0. The PJ was reanalyzed and found to be intact, with no signs of a fistula. The cavity was again drained with a new Penrose drain.

The patient progressed well, with resolution of the infectious condition, and was initiated on an oral diet 5 days following the final procedure. She was discharged from the hospital in good general health. The normal sweat test ruled out the diagnosis of cystic fibrosis. The ileostomy was reversed 6 months after the initial surgery, resulting in the restoration of normal intestinal transit and full fecal continence, as confirmed during the late follow-up at 3 years of age.

Discussion

This report presents a rare case of a full-term, 6-month-old female infant with spontaneous NEC who developed extensive intestinal necrosis, multiple perforations, and severe septic shock. Although the patient was not premature, the combination of fulminant Pseudomonas sepsis and aggressive soft-tissue infection likely acted as critical predisposing factors, triggering intestinal injury and precipitating the development of NEC in a full-term infant. The incidence of NEC among full-term infants is estimated at approximately 0.5 per 1000 live births, significantly lower than among neonates. It is often linked to distinct risk factors such as congenital heart disease, perinatal hypoxia, sepsis, polycythemia, or underlying genetic or metabolic conditions that compromise gut perfusion and integrity. In this patient, severe sepsis due to Pseudomonas aeruginosa bacteremia and rapidly progressing soft-tissue infection may have acted as the precipitating insult, creating an inflammatory and hypoxic environment that overwhelmed the intestinal mucosa’s protective capacity. This shows the importance of recognizing that NEC, although classically a disease of the premature gut, can arise in full-term infants under systemic conditions that disrupt gut perfusion, immunity, or microbial balance [11,12].

Given the lack of established management protocols for NEC in full-term infants, the surgical team had to apply individualized decision-making, as the case required urgent intervention. Suture of multiple intestinal perforations, the creation of a PJ, and a subsequent ileostomy were the most relevant [13,14].

The guiding approach used by the surgical team was the concept of ‘damage control surgery’, which prioritizes rapid clinical stabilization, containment of contamination, and minimization of operative stress so that definitive repairs can be executed later at a safer stage, as the the patient’s clinical condition limited the feasibility of multiple anastomoses, sutures, or other complex procedures due to the risks of intraoperative collapse, anastomotic failure, fistula formation, or short-bowel syndrome [15,16].

The surgical team selected a PJ with a distal ileostomy to divert intestinal flow, reduce intraluminal pressure, decompress the bowel, and preserve viable intestinal segments for recovery. Although various surgical techniques have been described – including drainage-based strategies in smaller neonates and “clip and drop” or staged resections in larger infants – no clear prospective evidence currently favors one approach over another. In this patient, while PJ carried known risks of high-output stoma leading to dehydration and electrolyte imbalance, due to bypassing the duodenum and proximal jejunum’s absorptive capacity, it was judged the best trade-off given the urgent need for stabilization and bowel salvage [17–19].

A major dilemma in managing PJ is determining the optimal timing for closure. Early closure can mitigate severe nutritional and electrolyte disturbances caused by the high-output stoma but carries the risk of stressing intestinal tissue that may still be inflamed or structurally weakened, increasing the likelihood of suture dehiscence or reperforation. In contrast, delayed closure allows more time for tissue recovery but prolongs exposure to dehydration, malnutrition, and fasting-induced mucosal compromise, with loss of antioxidant and anti-inflammatory functions. In this case, the surgical team opted for early closure on the tenth postoperative day due to persistent hydroelectrolytic imbalances and high stoma output [20–22].

Although early closure was chosen to mitigate nutritional and electrolyte disturbances, the patient developed 2 new perforations, not at previous suture sites, requiring reoperation. This outcome illustrates the delicate balancing of risk in NEC management and has broader lessons for surgical practice. Another consideration in managing cases like this is the potential use of distal stoma refeeding as an alternative to early jejunostomy closure. Instead of closing the proximal stoma to address high-output losses, refeeding proximal effluent into the distal stoma can help maintain nutrient absorption, stimulate distal mucosal integrity, and reduce electrolyte and fluid imbalances without exposing the fragile, recovering intestine to the mechanical stresses of early reconnection [23,24]. Although not employed in this case, distal refeeding may be a valuable bowel-preserving and metabolic-stabilizing strategy in select NEC patients, particularly when the intestine remains too compromised for safe closure. Having navigated the complex trade-offs between diversion, bowel preservation, and metabolic stabilization, our surgical team’s experience emphasizes the importance of careful, individualized decision-making, particularly in rare cases like full-term NEC, where the literature presents gaps.

Conclusions

Considering the patient’s critical condition and intestinal viability, the timing of PJ closure must be carefully evaluated to balance the risks of prolonged diversion against the dangers of premature reconnection. Early PJ closure addressed persistent nutritional and electrolyte disturbances caused by high-output stoma losses, but led to new perforations requiring reoperation, demonstrating that the intestine had not fully recovered. This outcome reinforces the importance of individualized, case-specific surgical strategies in managing a rare case of NEC in a full-term infant.