281 Routinecontrastenemapriortostomareversalseemsonlyrequiredfollowingtreatmentfornecrotizingenterocolitis:Anevaluationofthediagnosticaccuracyofthecontrastenema Chapter 13 Inspection of the full intestinal tract would lengthen the duration of the surgery and increase the risk of iatrogenic damage to the intestine. Moreover, we show that at least in two patients the contrast enema did prove to show a stricture which, at stoma reversal, was not detected by our experienced pediatric surgeons whilst both strictures were found at the indicated sight during redo surgery. In case of a stricture that completely closes the lumen of the intestine, the full tract of the intestine cannot be visualized by using a one-way, antegrade or retrograde, enema. This could lead to missing a second stricture, as we show in one of our patients. Since this stricture was later found on retrograde enema, it could well be that if we had combined antegrade and retrograde enema in this patient we would not have missed the second stricture. In our cohort, eight patients, of which five treated for NEC, received a combined antegrade and retrograde enema due to uncertainty of full visualization of the intestinal tract. This resulted in the identification of three strictures, all in patients treated for NEC, which were all found and treated during stoma reversal. Therefore, it could be advisable to routinely combine these two enemas in case of incomplete or doubt of the visualisation of the intestinal tract. When evaluating the patients with a false positive contrast enema we noted that in all three patients the enema suggested a stricture at the splenic flexure. In adults, spasms at the in a healthy colon are described to mimic a fixed narrowing resulting in a pseudoobstruction at or near the splenic flexure (16). Although this might be an explanation of our finding, it is unclear if the same illusory image can occur in young children. Our advice only focusses on routinely performing contrast enema in all patients treated with a stoma, with the indication of detecting intestinal strictures prior to stoma reversal. The occurrence of certain complications, such as post-surgery enterocolitis following treatment for Hirschsprung’s disease, might increase the likelihood of stenosis development therefore leading to the decision to perform a contrast enema. Moreover, there can certainly be other indications for making a contrast enema such as to determine the transition zone in Hirschsprung disease, to clear impacted meconium in case of meconium ileus and to identify an intestinal atresia which was missed during stoma formation (17-20). This is specifically the case in patients with multiple atresias at different sights in the intestinal tract, which occur in up to 23% of the jejunoileal atresias (21). In our cohort, none of the patients treated for isolated jejunoileal intestinal atresia as for a combined jejunoileal atresia with a gastroschisis had a positive enema nor a missed atresia during surgery. This could indicate that visual identification of these multiple atresias during stoma formation is reliable which in turn could mean a contrast enema prior to reversal is unnecessary.
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