216 Chapter 9 As to ASA score, male sex seems to be associated with the occurrence of anastomotic leakage. Out of fifteen patients who developed a leakage in high-risk diseases (necrotizing enterocolitis, Hirschsprung’s disease and intestinal atresia), only one patient was female. Our results do not provide any insights on an explanation for this finding. The increased risk of anastomotic leakage related to gender is not fully clear, however it seems that females are better resistant to the damage occurring from ischemia-reperfusion-induced intestinal injury which occurs during surgery (20). Hirschsprung’s disease patients, which occurs predominantly in males, only reported three leakages in our cohort altough these patients made up 14% of our total cohort (21). If male sex is of key importance, we would have expected more leakages in this group. This suggests other factors should be of importance (21). Still, the factor gender seems of influence and might, in combination with other factors such as ASA score, be informative when deciding on type of treatment. Previous studies describe less complications, leakages as well as stenosis, in stapled compared to sutured anastomosis in young children (22, 23). These studies retrospectively included a diverse set of diseases including intestinal atresias, intussusception and necrotizing enterocolitis. In our cohort the majority of the stapled anastomosis was created as part of pouch formation in the treatment of Hirschsprung’s disease altough some intestinal atresia patients also received a stapled anastomosis. Although this is a selective group of patients and type of anastomosis, making comparison to the rest of the cohort difficult, no stenosis or leakages developed following these stapled anastomoses. Due to the retrospective nature of our analysis, we were limited to perioperative factors described in the patient’s files. Possibly other perioperative factors such as intestinal size discrepancy, infectious state of the patient or (faecal) peritonitis could influence the healing process of the anastomosis and thereby the occurrence of anastomotic stenosis and leakage (24). Moreover, the small number of anastomotic complications, especially for anastomotic stenosis, might have increased the chances of type II errors. Another result of the small number of cases was that we were unable to perform regression analysis on the outcome of anastomotic leakage. Therefore, we are unable to determine the strength of the association of male sex and high ASA score to the development of a leakage. Still, owing to our large cohort of young children receiving a primary anastomosis, we were able to determine that anastomotic stenosis seem to occur more often in colonic anastomosis and occurrence does not seem to be related to other technical features of anastomotic creation (other type of anastomosis, suture resorption time or mode of suturing). The occurrence of anastomotic leakage is associated with ASA score ≥III and male gender. Identifying more patient specific factors can result in better treatment selection which should not solely be based on type of disease.
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