Necessity of enterostomy at the initial operation in neonatal intestinal perforation: A nationwide matched study in Japan

Purpose: Neonatal intestinal perforation often necessitates urgent surgery, yet whether enterostomy is necessary or primary repair is preferable remains debated. We estimated the short-term effect of choosing enterostomy versus primary repair after adjustment for preoperative severity. Methods: We screened data from the National Clinical Database-Pediatric registry and enrolled neonates who underwent surgery for gastrointestinal perforation between 2017 and 2022. Patients were categorized into two initial operative strategies: enterostomy and non-enterostomy, defined as primary closure or resection with anastomosis without a stoma. Propensity score matching was performed to adjust for baseline characteristics. The primary outcomes were 30- and 90-day mortality and any unexpected complication within 30 days after the initial operation. Secondary outcomes included anastomotic leakage and unplanned reoperation within 30 days. Results: Of the 1297 identified cases, 914 met the inclusion criteria (enterostomy: 773 versus non-enterostomy: 141). The 30-day mortality rate was significantly higher in the enterostomy group (6.7 %, p = 0.047), without differences in the 90-day mortality or overall complication rates. In the propensity score matched cohort (all absolute standardized mean differences <0.15), mortality and overall complications did not differ between groups, whereas 30-day anastomotic leakage was lower in the enterostomy group (odds ratio, 0.13; 95 % CI, 0.03–0.6; p = 0.009). Conclusion: After severity adjustment, short-term outcomes after the initial operation were broadly comparable between enterostomy and primary repair. These findings suggest enterostomy is not universally required and primary repair may be reasonable in carefully selected infants. Longitudinal data are needed to assess cumulative morbidity, including stoma closure, beyond this registry snapshot.