667 - Predictors and Inter-center Variation in Post-Surgical NEC Strictures: A Report from the Children’s Hospitals Neonatal Consortium

Publication Number: 1644.667

Muralidhar H. Premkumar, Baylor College of Medicine, Houston, TX, United States; Irfan Ahmad, CHOC Children's Hospital of Orange County, Orange, CA, United States; Isabella Zaniletti, IZ Statistics LLC, Tampa, FL, United States; Toby Yanowitz, University of Pittsburgh School of Medicine, Pittsburgh, PA, United States; Kera M. McNelis, Emory University School of Medicine, Atlanta, GA, United States; Sujir P. Nayak, UTSW -Dallas, Dallas, TX, United States; Jae H.. Kim, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, United States; Julie Thai, Children's Hospital Los Angeles, Los Angeles, CA, United States; Parvesh Garg, Wake Forest School of Medicine of Wake Forest Baptist Medical Center, Winston Salem, NC, United States; Robert DiGeronimo, Seattle Children's, Seattle, WA, United States; Jotishna Sharma, Children's Mercy Kansas City, Kansas City, MO, United States; Mihai Puia-Dumitrescu, University of Washington School of Medicine, Seattle, WA, United States; Hala Chaaban, University of Oklahoma Health Campus, Oklahoma City, OK, United States; Sreekanth Viswanathan, Nemours Children's Hospital, ORLANDO, FL, United States; Jennifer A. Rumpel, University of Arkansas for Medical Sciences College of Medicine, Little Rock, AR, United States; Theresa Grover, University of Colorado School of Medicine, Aurora, CO, United States; Michael A.. Padula, Childrens Hospital of Philadelphia, Philadelphia, PA, United States; Karna Murthy, Ann & Robert H. Lurie Children's Hospital of Chicago, Chicago, IL, United States

Background: Surgical necrotizing enterocolitis (sNEC) remains a major cause of morbidity and mortality in preterm infants. Risk factors associated with post-sNEC intestinal stricture are poorly defined, and management heterogeneity likely contributes to wide inter-center variation in outcomes.

Objective: To estimate the associations between clinical and demographic factors and stricture formation in infants with sNEC and describe variability in stricture incidence across Level IV NICUs in the Children's Hospitals Neonatal Consortium (CHNC).

Design/Methods: Using data from the CHNC from 2010-24, we identified infants 34 weeks' gestational age (GA) with sNEC from 49 centers. Exclusions included patients with abdominal wall defects, NEC totalis, death within 30 days of NEC onset, and surgery prior to referral. The primary outcome was stricture formation defined as radiologic or operative evidence of stricture, OR bowel resection or adhesiolysis >30 days after initial surgery. Candidate predictors were analyzed using generalized liner mixed model with random intercept on hospitals. Significant predictors were retained using backward elimination (inclusion p< 0.2). Model discrimination was assessed using the area under the receiver operating characteristic (ROC) curve. Risk-standardized rates of stricture formation were calculated per center.

Results: Of 2,411 infants with sNEC, 810 (33.6 %) developed strictures. On bivariate analysis (Table 1), Hispanic ethnicity, cesarean delivery, multiple birth, ostomy creation at first surgery were associated with lower stricture risk. In comparison to initial laparotomy (LAP), infants with peritoneal drain followed by laparotomy (PD+LAP) had decreased stricture risk. In multivariable analysis (Table 2), older gestation, sNEC with perforation and PD+LAP were independently associated with lower risk (adjusted ORs < 1). The predictive model showed moderate discrimination (AUC 0.67). Across 49 hospitals, the mean risk-standardized rate for post-sNEC stricture was 31%, with substantial inter-center variation (24-38%, or 58% difference) (Fig. 1).

Conclusion(s): Multiple independent factors were associated with post-sNEC stricture in infants born  34 weeks GA who survived >30 days. While multivariable model showed limited discriminatory ability, striking inter-center variation suggests modifiable care practices. Collaborative benchmarking within the CHNC may identify strategies to reduce stricture formation and improve outcomes.

Figure 1. Comparison of adjusted OR for risk of strictures by center depicting inter-center variation in the risk of stricture
Eleven centers demonstrated increased risk, while 9 centers demonstrates decreased risk of stricture formation, referent to the overall mean.

Table 1. Bivariate analysis comparison of variables of infants with sNEC with and without strictures


Table 2. Multivariate analysis of variables of infants with sNEC with and without strictures.