280 Chapter 13 the clinical consequence of not treating post-NEC strictures before obstructive symptoms. In patients medically treated for NEC, no stoma is created, or contrast enema is performed so only those strictures that become symptomatic are detected and treated. Still, postNEC strictures are found in 20-30% of these patients, which is similar to surgically treated NEC patients (5, 6, 8). If the contrast enema would have detected many clinically insignificant strictures, one would expect the incidences to differ more profoundly. The strictures in medically treated NEC patients seem to become symptomatic at 2-3 months following initial NEC, which is approximately the moment of stoma reversal in surgically treated NEC patients. If not treated, patients suffering from post-NEC strictures are reported to have failure to thrive (5-8). Moreover, no complications of the treatment of post-NEC strictures have been reported, both in our cohort as in previous studies (6-8). We therefore conclude that it does not seem that contrast enemas lead to an overdiagnosis of post-NEC strictures and that stricture resection seems a relatively safe treatment which can prevent the patient from experiencing failure to thrive and undergoing a re-operation. Another hypothetically feasible way to evaluate the clinical relevance of a enema proven stenosis could be mucous fistula feeding. The idea of this procedure is that the introduction of proximal enterostomy excrete into the distal part of the stoma will mimic the route that normal intestinal content will go through. By doing so, the distal intestine is thought to undergo less atrophy otherwise caused by disuse. The clinical results of this procedure have been variable and complications, such as intestinal perforations caused by the refeeding catheter, have been described(13). However, other studies have suggested that mucous fistula feeding could result in less complications, such as short bowel syndrome and anastomotic leakage (14, 15). In case of a contrast enema proven stenosis, this procedure could might show if passage of stool is still possible. However, no study has evaluated if this is truly possible and since this procedure is not yet standard practice at our instate we have no further data about this topic. Our results are in contrast with the previous study which reported a post-NEC stricture incidence of only 5% and a high rate of false positive in these patients of 55% (N=5/9) (9). These figures resulted in a low predictive value of 44% in these patients. Since this study did not clearly describe the patients with a false negative enema, it is hard to conclude a reason for this difference. Yet the low incidence of post-NEC strictures will probably have had a large influence. Some surgeons might argue that most strictures can be detected during stoma reversal by clear examination without needing a contrast enema to indicate possible stenotic segments. However, during many stoma reversals the intestine is only partly observed.
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