16 Chapter 1 previously, many believe that by doing so the risk of anastomotic leakage is limited which seems one of the main arguments to pick stoma formation over primary anastomosis. In this view however, the stoma associated morbidity and the risk of complications following stoma reversal are mostly left out of the discussion. A reason for this blind spot might be the lack of studies published on this subject; over the last 30 years, only a few studies have focussed on young children with a stoma.(29, 30) 4.1. Stoma related growth impairment Whilst enterostomys can be lifesaving, it seems that having a stoma has a negative impact on a childs growth.[21] This growth impairment at young age in turn seems to have a negative impact on long-term development as well as increase the risk of stoma related complications.[22, 23] Having a stoma will cause loss of nutrients and sodium to some extend. If these losses result in sodium depletion, it can result in a failure to thrive. [24] This impaired growth in combination with sodium depeletion seems to occur even in children with adequate caloric intake.(31, 32) Following this insight, the suppletion of sodium in young children is now common practice at many institutions including ours. Yet adqueate guidelines are lacking resulting in differences in basic practice.(33) Since growth is such a multifactorial process it might well be that other patient specific factors are associated to growth impairment, however studies into this topic are lacking. 4.2. Major stoma related morbidity Set aside growth impairment, direct stoma related morbidity can occur during the time patients have the enterostomy. Examples are stoma necrosis, stenosis, prolapse or parastomal hernias, all of which could necessitate redo-surgery.[3] Moreover, stoma creation demands a timed reversal in most patients; which is mostly performed within 2-4 months following stoma creations. Stoma reversal, in some centres like ours, is commonly preceded by a contrast loopogram to evaluate the presence of distal strictures. Therefore, treatment by stoma demands at least two operations of a patient at a very young age as well as repeated exposure to radiation. When debating risks of primary anastomosis versus stoma formation, these risk are mostly left out. This is flawed since it is known that complications such as anastomotic leakage do also occur following stoma reversal. [2, 3, 6] In order to have an informed discussion about the best surgical treatment options for young children with intestinal defects it is important to approximate the true incidence of these stoma related complications as well as to identify risk factors. This could provide a basis for preventative strategies in the future, or might lead to changes in surgical approaches. Opening-up this discussion might result in a choice of treatment more suited to a specific patient rather than certain diseases in fear of complications.
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