279 Routinecontrastenemapriortostomareversalseemsonlyrequiredfollowingtreatmentfornecrotizingenterocolitis:Anevaluationofthediagnosticaccuracyofthecontrastenema Chapter 13 Discussion In this study of 224 young children treated with an intestinal stoma the incidence of a stricture was 10%. Out of these strictures, 12% were missed during stoma reversal but found during redo-surgery in 1% of the overall cohort. Out of all patients who develop a stricture, 96% had a history of NEC. The contrast enema prior to stoma reversal, which was performed in 68% of all patients and 86% of the patients treated for NEC, detected 88% of these strictures. The diagnostic accuracy of the contrast enema in the overall cohort shows a sensitivity of 100%, specificity of 98%, a positive predictive value of 88% and a negative predictive value of 100% whilst the AUC was 0.98. The diagnostic accuracy of the contrast enema in NEC patients shows a sensitivity of 100%, specificity of 97%, a positive predictive value of 91% and a negative predictive value of 100% whilst the AUC was 0.98. Three patients reported a false positive enema making the false positive rate 13% in the overall cohort and 9% in patients treated for NEC. We and others show that the contrast enema is routinely used in many patients treated with a small bowel stoma although strictures are rarely identified (9). Moreover, our result suggest that the contrast enema is also regularly (58%) performed in patients treated with a colostomy, which has not been shown in previous studies. All but one patient who developed a stricture were previously treated for NEC. The only strictures in a patient not treated for NEC was found in a complicated case of duodenal atresia with multiple sights of intestinal ischemia due to a volvulus which was caused by an adhesion, which is a rare complication in these patients (12). Concluding from these results it seems that routine usage of a contrast enema in patients treated for meconium peritonitis, meconium ileus, Hirschsprung disease and focal intestinal perforation should not be recommended as it only increases exposure to ionizing radiation as well as costs. Since almost all strictures are found in patients treated for NEC, we would advise to only perform routine contrast enema prior to stoma reversal in all patients treated for NEC. We conclude this based on the high incidence of post-NEC strictures which develop in one in five patients as our results show. This incidence is similar to previous studies (5-8). With an AUC of 0.98 and zero false negative enemas, it seems that the enema has good diagnostic accuracy in detecting post-NEC strictures. There were two NEC patients who needed redo-surgery within days following stoma reversal due to a missed, but enema proven, stricture. This seems to suggest that these strictures can become symptomatic if not treated. However, it is questionable if all postNEC strictures identified on contrast enema would have become symptomatic if left untreated. This question can only truly be answered in a randomized controlled trial. Still, by looking at medically, nonsurgical, NEC patients, we might find an indication of
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