15 General introduction Chapter 1 (age rang 0-18 years) into account.[15, 16] These studies suggested that patients treated for necrotizing enterocolitis and infantile hypertrophic pyloric stenosis seem relatively most at risk of developing an incisional hernia. Additionally, having a history of enterostomy formation or surgery during the neonatal phase are suggested to be risk factors for hernia development. The strength of these conclusions is questionable because of low statistical power due to the inclusion of between 7 and 21 children with an incisional hernia. Additionally, most studies excluded laparoscopic surgeries, even though trocar site hernias in young children have been reported to complicate these procedures.[17] Furthermore, these studies included operation performed in children of wide age ranges extending from neonatal age up to 15 years of age, which decreases the generalizability of these results leaving room for speculation. 3.4. Intestinal anastomotic complications Aside from adhesions, mechanical obstructions are potentially caused by anastomotic stenosis occurring in newly formed intestinal anastomosis. This stenosis can occur shortly following surgery in case of technical error or tissue oedema, whereas strictures that form later during follow-up seem to be caused by chronic inflammation causing anastomotic scarring.[18] In both cases redo-surgery with redo-anastomosis is necessary in most patients. Currently, there is no uniformity in the technique used to create an intestinal anastomosis in order to minimize the risk of these complications.[18, 19] This is in one bit because studies evaluating different technical factors are lacking. The only advancement made in the recent years has shown that a single layer of sutures compared to a double layer seems to decrease the incidence of short-term stenosis without increasing the risks of leakage, leaving many other technical factors open for discussion.[20] Leakage of a newly formed intestinal anastomosis is seen as a grave complication which necessitates emergency surgery in most cases and could even result in mortality. Many surgeons believe this risk to be too high to safely create a primary anastomosis in young children with intestinal diseases. However, there is a lack of knowledge concerning the incidence of- and risk factors for anastomotic leakage as well as the rate of mortality associated to this complication. 4. Complications associated to enterostomy formation The creation of an enterostomy can be essential and lifesaving in young children with life threatening morbidity such as bowel perforations. [1, 2] Creation of an enterostomy is thought to be a relatively safe method to give the abdomen rest to recover. After recovery, when the inflammatory response has cooled off or after other congenital defects have settled, another operation is necessary to perform a secondary anastomosis. As stated
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