248 Chapter 11 Discussion In the presence of a stoma. the majority (61%) of the patients were declining on the growth chart. This resulted in severe malnourishment in 51% of the young children with a small bowel stoma, and in 16% of the patients with a colostomy at the time of stoma closure. After stoma closure the decline in Z-scores is reversed in most young children; 67% showed a positive trend on the growth chart within a year following stoma closure. The decline in growth during the treatment with a stoma is more profound in small bowel stomas compared to colostomies. Growth at stoma closure was significantly more impaired in those treated with a proximal small bowel stoma and those who received a stoma after major small bowel resection. Early closure did not significantly affect Z-scores at stoma closure although closure is realized at a significantly younger age. Within a year following closure, none of the evaluated factors had a significant influence on the Z-scores. Our results are in line with previous reports in small cohorts of infants treated with a stoma for multiple abdominal diseases and show that in the presence of both small and large bowel stomas a decline in growth can be expected.(14) Those treated with a small bowel stoma and specifically those treated with a proximal small bowel stoma or those undergoing major small bowel resection seem most at risk. Stoma excretion from the small bowel is higher in nutrients than excretion from colostomies which suggests that in the latter more nutrients are resorbed which might contribute to this difference in growth.(20) This could also explain why more patients treated with a small bowel stoma were in need of TPN following stoma formation compared to colostomies. This difference in functional proximal bowel might also explain why patients with more proximal stomas and those who underwent a major resection have significant lower Z-scores at stoma closure. Another explanation could be found in the differences in the types of disease which result in small bowel stomas, in our cohort mostly necrotizing enterocolitis. In patients treated for necrotizing enterocolitis, length of resected intestine and prolonged inflammation both negatively influence growth.(8, 21) It seems that stoma closure as soon as possible is a necessity for growth in all young patients which is in line with previous findings.(4) Even those at highest risk of growth impairment at the moment of stoma closure (patients treated by proximal ileostomy and those who underwent a major small bowel resection) show similar growth within a year following closure compared to patients with non-proximal small bowel stomas and those who did not underwent a major resection. This suggests that patients experience catch-up growth following stoma closure, even when there is less functional small bowel left, either due to resection or due to underdevelopment caused by disuse. Since stoma closure seems such an important condition for growth, this could be seen as an argument
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