Abstract
OBJECTIVE: To delineate gestational age (GA)-dependent pathophysiology of necrotizing enterocolitis-associated intestinal perforation (NEC-IP) and establish precision management protocols. METHODS: A single-center retrospective cohort study (2013-2023) included 66 preterm (< 37 weeks) and 38 term (≥ 37 weeks) neonates with NEC-associated perforations. Outcomes included anatomical distribution, microbiological profiles, management disparities, and prognoses. RESULTS: Preterm infants exhibited significantly higher rates of twin gestation (43.9% vs 7.9%, p = 0.003), antenatal steroid exposure (43.9% vs 2.6%, p < 0.001), and preoperative fasting rate (33.3% vs 7.9%, p = 0.009) compared to term infants. Preterm infants demonstrated Gram-positive bacteremia (83.3%) with Gram-negative peritoneal predominance (83.9%), alongside significantly lower leukocyte counts (Stage 2:12.6 vs 14.9 × 10⁹/L, Stage 3: 9.1 vs 11.1 × 10⁹/L, both p < 0.05), platelet levels (all stage), and hemoglobin levels (Stage 1:125.1 vs 141.6 × 10(12)/L, p = 0.004). Term infants showed Gram-positive peritoneal dominance (76.2%) with classic peritonitis signs (hematochezia 68.4%, abdominal tenderness 55.3%). Lleal perforations predominated in preterms (69.7% vs 21.1%, p < 0.001), whereas colonic involvement was prevalent in terms (63.1%). Prolonged parenteral nutrition in preterms (27.0 vs 20.0 days, p = 0.009) correlating with prolonged hospitalization (38.4 ± 9.7 vs 23.5 ± 8.1 days; p < 0.001), achieved higher enteral tolerance (151.7 vs 134.2 ml/kg/d, p = 0.009). There was no case dead in initial admission. Rehospitalization and mortality rates in readmission were comparable (term 73.7 vs preterm 60.6%, p = 0.177;1% vs 2%; p = 0.653). Although weight at discharge in term group was higher compared to preterm infants (2.5 ± 0.4 vs 3.5 ± 0.6 kg; p < 0.001), while weight velocity was similar between two groups (18.3 ± 7.5 vs 16.6 ± 9.6 g.kg⁻(1)·d⁻(1); p = 0.312). CONCLUSION: GA-specific NEC-IP mechanisms mandate: (1) preterm-focused ileal exploration & Gram-negative coverage, (2) term-focused retroperitoneal debridement & Gram-positive control, and (3) GA-stratified diagnostic framework integrating clinical signs and imaging. This precision approach reduces missed perforations and surgical delays.