Necrotizing enterocolitis (NEC) is one of the most common conditions requiring emergency surgery in the neonatal intensive care unit and is associated with multi-organ dysfunction, multiple systemic morbidities and mortality. The resected bowel commonly shows evidence of coagulative necrosis, inflammation, interstitial hemorrhages, and reparative changes on the pathology examination. The severity of these pathological abnormalities may correlate with the disease's severity and pace of progression and may assist in the prediction of clinical outcomes. This review presents current evidence about the clinical utility of the intestinal pathology in bedside decision making, accurate diagnosing, prediction of outcomes, and in the prognostication of preterm infants with surgical NEC. Developing refined and validated noninvasive methods to diagnose the extent of bowel injury and monitoring of tissue repair throughout disease progression is paramount to mitigating the long-term morbidities in preterm infants with surgical NEC. Improved imaging methods such as targeted bowel ultrasound capable of assessing the inflammation and necrosis in real time will greatly advance care and provide focus for the temporal framework of surgical interventions.
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