215 Should primary anastomosis be feared less? A retrospective analysis of anastomotic complications in young children Chapter 9 Previous studies have suggested that stenosis following Hirschsprung’s disease treatment could be prevented by routine dilatations during the first week post-surgery, although conflicting results on this method have been reported (17, 18). There is no consensus on how long the follow-up should be when conducting research into anastomotic stenosis in infants. The median time from operation to anastomotic stenosis was 44 days in our cohort, however stenosis developed both within ten days and up to 6 years after surgery. In our cohort, 80% of the stenoses developed within one year and 90% within two years. For this reason two years seems to be an acceptable cut-off as not to miss a significant amount of stenosis. An anastomotic leakage is a feared and unpredictable complication due the possible severe consequences. The most feared consequence of anastomotic leakage, mortality, occurred in two children in our cohort which is less than one percent. These fatalities show that when an anastomotic leakage occurs in vulnerable patients with multiple comorbidities the chances of mortality are high. However, if a leakage occurs in patients who are fit enough to undergo redo-surgery, most recover. Moreover, half of the patients with a leakage recover without an enterostomy. Enterostomy formation does not result in the prevention of complications, as previously described (5-7). Because of the associated complications of enterostomy formation, both short-term (e.g. high-output stoma, stoma prolapse, wound infections) and long-term (e.g. adhesive obstructions, incisional hernia, anastomotic stenosis), a primary anastomosis must be preferred (5, 6, 19). Because of these risks of enterostomy and the relatively low incidence of anastomotic leakage one could argue that it is unwise to decide on enterostomy creation in all patients with a high-risk diseases (i.e. necrotizing enterocolitis and intestinal atresia patients). Identifying patient related factors of those patients who are at increased risk of the development of anastomotic leakage could better help surgeons in the decision when not to perform a primary anastomosis. Although one should look for these factors within high-risk diseases we feel that the decision of treatment should not solely be based on type of disease. This is underlined by our results showing ASA score to be of more importance than type of disease. An ASA score of ≥III was significantly associated to the development of anastomotic leakage in our cohort, as is the case in adults (8). In necrotizing enterocolitis none of the twelve patients with a low ASA score (I or II) developed a leakage following primary anastomosis whilst two out of two patients with an incarcerated inguinal hernia warranting resection of the incarcerated intestine with primary anastomosis with an ASA score of III developed an anastomotic leakage. The ASA score seems to reflect disease severity pre-operatively and thereby possibly healing capacity of the anastomosis post-operatively.
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