Surgical Necrotising Enterocolitis (S-NEC): Where We Stand Today: A Narrative Review

Surgical necrotising enterocolitis (NEC) continues to carry significant morbidity and mortality in preterm and very-low-birth-weight infants. This review presents up-to-date evidence to guide the shift from medical to surgical treatment and to improve management during and after surgery. Need for surgery is best anticipated through dynamic clinical assessment, supported by laboratory markers of systemic inflammation or ischemia and targeted imaging, while pneumoperitoneum remains the sole absolute indication for immediate intervention. In infants without perforation, the timing of surgery remains challenging: delayed surgery after clinical deterioration worsens long-term outcomes, whereas very early surgery often reflects severe disease leading to greater bowel loss, highlighting the need for carefully timed intervention after brief stabilisation. Laparotomy remains the cornerstone of surgical management, with peritoneal drainage serving as a temporising option for the most unstable infants and laparoscopy emerging as a feasible adjunct. Long-term complications, including strictures, short bowel syndrome, neurodevelopmental impairment, bronchopulmonary dysplasia and severe retinopathy of prematurity highlight the need for better predictive tools, enhanced imaging of bowel viability, and rigorous nutritional support, while long-term quality-of-life outcomes remain insufficiently studied.