298 Chapter 14 Based on these results we believe we can say that anastomotic complications are uncommon following primary anastomosis. This adds to our believe that a primary anastomosis could be preferred of enterostomy formation in case of doubt of the best treatment options. Identifying and using patient specific risk factors for anastomotic leakage could further aid the decision between these options. In our cohort, an ASA score of ≥III seems to be one of these pre-operatively known risk factors for anastomotic leakage, as is the case in adults.[11] Though patients treated for necrotizing enterocolitis were most at risk of a leakage, none of these patients with an ASA ≤ II developed a leakage. On the other hand, both patients with ASA score of III pre-operatively, treated for an incarcerated inguinal with the need of intestinal resection developed an anastomotic leakage. This is an example of how the ASA score seems to reflect anastomotic healing capacity by means of disease severity which could aid in selection of patients who are better of not being treated by primary anastomosis. Part IV During the analysis of the studies described in part III we noticed that being treated with an enterostomy was a significant risk factor for many different complications. Enterostomy creation can be necessary and lifesaving in case of diseases that have led to bowel obstruction, perforation or necrosis. In those patients’ complications like peritonitis or anastomotic leakage are believed to be prevented by enterostomy formation. However, to fairly compare the risks there has to be sufficient data on the risks of having an enterostomy. Therefore, in Part IV, we set out to evaluate the morbidity and effects on growth, related to enterostomy formation. Our results show that the burden of having an enterostomy can be high, with high chances of enterostomy related complications and negative effects on growth. Both these risks, and the long-term risks described in part III, should be taken into account when in doubt of creating an enterostomy or a primary anastomosis. We still agree that in really sick children, enterostomy formation might be the only option. However, in children who are less sick or infectious at the moment of surgery, a primary anastomosis might be the best long-term decision. To stress this, we evaluated our cohort of jejunoileal atresia patients to show the risks of complications comparing both treatment options. Though based on a retrospective cohort, these results show that primary anastomosis might result in less complications. In case an enterostomy is formed, many hospitals, like ours, perform a contrast enema before reversal in order to detect distal strictures. We evaluated the diagnostic accuracy for the contrast enema which suggests that this diagnostic should only be performed in patients treated for necrotizing enterocolitis.
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