71 The incidence of different forms of ileus following surgery for abdominal birth defects in infants Chapter 3 Early onset of an anastomotic stenosis is not widely reported and might even be overlooked in the infantile cohort. This review shows that early stenosis does occur and should be considered when conducting research into post-operative complications in the infantile cohort. Technical factors, such as suture reportion speed or mode of suturing, of influence during anastomotic creation should be evaluated to identify risk factors. Gastroschisis, and to a smaller extent intestinal atresias, were most at risk for late onset anastomotic stenosis. The process of anastomotic healing is to a great extent unclear. Most research has focussed on surgical innovations and techniques without the results leading to a conclusive resolution. Future research in the pathobiology at the cellular level might bring clarification on this matter [18]. This study has its limitations. Because of the variety in study designs and reported outcomes we were not able to look into risk factors which could have lowered heterogeneity. Although it must be noted that, by stratifying for birth defect, some outcomes had moderate to low heterogeneity. Another limitation was that because certain birth defects such as gastroschisis only occur in neonates, our stratification might have resulted in differences in mean age when comparing birth defects. This age difference could be an important reason why certain birth defects are more at risk of certain form of ileus. However, it is not the aim of this review to compare different birth defects but rather report an incidence for each individually. Thus, we believe that this age difference will not hinder the message of our review. If we had only included neonates in this review important birth defects, such as Hirschsprung’s disease, diagnosed beyond the neonatal period would have been excluded. Furthermore, it has to be stated that our results are based on retrospective cohorts available in the literature most of which did not have ileus as a primary outcome. This has undoubtedly increased the chances of occurrence of forms of bias such as selection, publication and reporting bias. Our risk of bias assessment showed most articles to have only fair quality mostly caused by the retrospective, observational nature of most included studies. Moreover, most studies did not have a strict definition of complications possibly resulting in observer bias. Lastly, only 57% of the included articles had a follow-up of at least half a year. Many other articles were unclear about the length of follow up. This lack of long-term follow-up might result in an underestimate of the real incidence of SBO and anastomotic stenosis. SBOs, for instance mostly arise within a year after surgery however episodes are reported 28 years after the initial laparotomy [210, 222, 278, 309-312]. Although these limitations might have influenced the pooled analyses, at this moment the presented data is the best available approximation of these complications in this cohort.
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