Risk factors for surgery in neonatal necrotizing enterocolitis without pneumoperitoneum: Bell stage IIb or higher

Identifying neonates with necrotizing enterocolitis (NEC) who may require surgery remains challenging in the absence of pneumoperitoneum. This study investigated factors associated with surgical intervention in neonates with Bell stage IIb or higher NEC without pneumoperitoneum. We retrospectively analyzed 171 neonates treated at the Maternal and Child Health Hospital of Guangxi Zhuang Autonomous Region between September 2019 and August 2024: 89 received conservative treatment and 82 underwent surgery. Multivariable Firth logistic regression identified associated factors, and robustness was assessed using 1,000 bootstrap resamples and sensitivity analyses. Intestinal obstruction on abdominal radiography (odds ratio [OR] 3.904, 95% confidence interval [CI] 1.687–9.441), ascites on ultrasound (OR 2.507, 95% CI 1.067–6.103), vasoactive drug use (OR 3.394, 95% CI 1.551–7.676), and higher blood lactate levels (OR 1.766, 95% CI 1.091–2.964) were associated with higher odds of surgery. Higher blood pH was associated with lower odds (OR 0.497 per 0.1-unit increase, 95% CI 0.273–0.867). Bootstrap 95% CIs for these five factors excluded 1, and sensitivity analyses generally supported the directions of association. Comprehensive assessment of imaging findings, vasoactive support requirements, tissue perfusion, and acid–base status may help identify neonates at increased risk of requiring surgery. These exploratory associations require confirmation in larger, multicenter studies.