232 Chapter 10 contradicts the accepted preference of many surgeons to wait for a safe weight (e.g. >2.5kg) before considering stoma closure as to reduce the risk of surgery in a fragile patient.[10] Due to the negative effects of a stoma, some surgeons advocate for early closure within 6 to 8 weeks after creation.[4, 21] Until now there is no consensus on the optimal timing of stoma closure in young children. It seems that early closure or closure at a lower weight does not increase the risk of morbidity. Combining this with the finding of recent reports that early closure might result in early catch-up growth might imply the feasibility of early closure. [4, 21, 22] An argument against early closure is the presence of adhesions, potentially resulting in difficulties during stoma closure. Part of the adhesions might resolve in the first few weeks to months following index surgery, but this highly depends on the extensiveness of surgery and degree of inflammation with high inter-individual variability. Therefore, the perfect timing of early closure demands future research. Following stoma closure anastomotic leakage and stenosis were amongst the most common major complications within 30 days. With an overall incidence of 2% for anastomotic leakage and 6% for anastomotic stenosis, the occurrence in our cohort is similar to previous studies.[17] It shows that anastomotic morbidity, which seems the main reason not to perform a primary anastomosis, is not completely prevented by stoma formation. Previous studies have recommended construction of primary anastomosis in infantile disease like necrotizing enterocolitis and intestinal atresias.[23, 24] Although comparing both treatment options is beyond the scope of this study, the high risk of major stoma related morbidity should not be undervalued when considering both options. Incisional hernia and obstructive adhesions were most frequently observed after more than 30 days following surgery. Although the mortality rates of these forms of stoma related morbidity are lower than in adults, they still demand redo surgery, sometimes in an emergency setting.[3, 25] The development of new treatment strategies aiming at prevention of stoma formation could lower the risk burden relate to long-term morbidity. This has already been shown by the gradual change in treatment from a two staged (including a stoma) Rehbein’s procedure to a one staged pull through in Hirschsprung’s disease patients, which started around the new millennium. This change in surgical approach has seemingly lowered the incidence of adhesive obstructions from 10-20% to 4-5%.[25-28] The incidence of major stoma related morbidity did not differ between patients with an inflammatory and non-inflammatory disease, which underlines the high morbidity of stomas regardless of the underlying disease and inflammatory state of the patient which has been stated previously.[17, 29] Although a higher non-stoma related mortality following stoma formation is to be expected from diseases such as necrotizing enterocolitis, the survival following stoma closure does not differ between these two groups.[30]
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