Idiopathic intussusception: the role of laparoscopy

BACKGROUND: The use of a barium enema affords both diagnostic confirmation and a chance for nonsurgical complete reduction of the intussusception, which must be proven by adequate reflux of barium into the distal ileum. If this does not occur, it is assumed that the intussusception has not been reduced, and the infant is taken straight to the operating room for laparotomy and surgical treatment. The aim of this study is to limit unnecessary surgical explorations by the diagnostic and the therapeutic policy of laparoscopy with assisted hydrostatic saline reduction under general anesthesia. METHODS: Over a period of 3 years, 90 patients with intussusception were treated. Twenty patients in whom hydrostatic reduction was contraindicated were treated initially by surgery. In the remaining 70 patients, hydrostatic reduction was successful in 50 (71%), and laparoscopy was performed in 20 patients before laparotomy. Hydrostatic saline reduction was used when there was failure of reduction seen by laparoscopy. RESULTS: In 20 patients, laparoscopy showed reduction of intussusception in eight patients (40%), and saline hydrostatic reduction was successful in six patients (30%), with failure of reduction in six patients (30%) necessitating laparotomy. CONCLUSION: The use of laparoscopy for diagnosis of failure of reduction of intussusception and the hydrostatic reduction by saline enema during laparoscopy saved 14 patients from unnecessary laparotomy.     

Enema reduction of intussusception by hydrostatic pressure under ultrasound guidance: a report of 377 cases

Three hundred seventy-seven pediatric intussusception patients were treated by normal saline hydrostatic enema under ultrasound guidance from October 1985 to April 1987. Before reduction, the rate of correct diagnosis by ultrasonography was 100%, and the rate of successful reduction was 95.5% in this group. With this technique there is no risk of x-ray exposure to the patient. The definite criteria for reduction are discussed. Clear echogram was shown during reduction and the ileo-ileo-coli intussusception can be diagnosed. Intestinal perforation, if any, can be accurately recognized at once. This technique is believed to be one of the most promising methods in nonoperative treatment of pediatric intussusception.     

Ultrasound guided hydrostatic reduction of intussusception in children by saline enema: our experience

Background

Intussusception is a common cause of acute intestinal obstruction with potentially serious complications. The treatment of choice is an attempt at initial non-operative treatment.

Aim

The purpose of the study was to evaluate the efficacy of the technique of hydrostatic reduction of intussusception using saline enema and ultrasound being practiced in our institute; the secondary goal was to identify patient subset in which it is more successful.

Material and Methods

The case records of all patients treated for intussusception in our institute from 1st January 2000 to 30th June 2007 were retrospectively analyzed to collect information. All patients with ultrasound diagnosed intussusception that were not having signs of shock or peritonitis were treated with normal saline enema under ultrasound guidance. Failure of three such attempts was an indication for operation.

Result and Conclusions

We found that this technique is easy, safe and extremely effective in treating intussusception in children. The success rate was 81.37% (83 out of 102 cases) and mortality rate was 1.2%. Ileoileocolic type of intussusception failed enema reduction more often (statistically significant; P value = 0.0032) while older patients (statistically significant, P value = 0.001) had higher success rates with the technique. Patients who had colocolic type of intussusception (P value = 0.29) and patients who present early (P value = 0.262) appear to have higher success rates but this was not statistically significant.     

Recurrent intussusception in children.

Twenty-eight children with 35 recurrent intussusceptions were collected and analyzed from a series of 600 intussusceptions over 17 yr. The overall recurrence rate in the entire series was 5% with 11% recurring after hydrostatic barium enema reduction, and 3% after operative reduction. Twenty-three children had one recurrence each, four children had two recurrences, and one child had four recurrent intussusceptions. More than two-thirds of the patients had a recurrence within 6 mo of their first intussusception, and half of these presented earlier and with fewer signs and symptoms than the previous attack had manifested. Twenty-one of 30 recurrences were reduced with barium enema. Sixteen were operated on, reducing nine manually and resecting four others. Only two leading points were found, and in both instances resection was required. All but two of the intussusceptions were ileocolic. The previous mode of reduction of each intussusception did not set a trend for future treatment of recurrent intussusceptions in the same child. While operative reduction diminishes the chances of a recurrent intussusception and ileocolic resection eliminates it, there does not seem to be any indication for surgery as long as barium enema reduction is successful. We have never observed the hydrostatic reduction of an intussusception caused by a leading point.     

Intussusception in infancy and childhood. Analysis of 385 cases

A consecutive series of 385 patients with intussusception treated between January 1, 1982 and December 31, 1987 was analysed. Male patients predominated over female by a ratio of 2.2:1. Seventy nine per cent of patients were under 12 months of age. There was no seasonal variation in the incidence of intussusception. Rectal bleeding was the most common symptom, followed closely by intermittent abdominal pain and vomiting. The duration of symptoms at the time of admission was less than 24 hours in 62%. Barium enema reduction was used initially in most patients. Successful reduction by barium enema alone was obtained in 66% of patients. Thirty two patients experienced recurrence of intussusception, six following operative reduction and 26 following barium enema reduction. Five patients experienced two recurrences each. Several factors including the age of the patients, the presence of a palpable mass, lethargy and abdominal distension were identified as influencing the success rate of barium enema reduction.     

超声引导下水压灌肠复位治疗小儿急性肠套叠

目的探讨超声引导下水压灌肠对小儿急性肠套叠复位的疗效。方法178例小儿诊断为急性肠套叠,其中174例采用B超下水压灌肠复位治疗。结果178例肠套叠患儿中,168例复位成功,复位成功率94．4％,其中2例5天内共水压灌肠5次,10例转为手术治疗。结论B超下水压灌肠复位治疗小儿肠套叠疗效满意．水压灌肠技术简易,安全可靠,值得推广。     

Intussusception: current management in infants and children

Intussusception remains a leading cause of bowel obstruction in early infancy and childhood. From 1970 to 1985, 83 patients with intussusception were treated. There were 51 boys and 32 girls ranging in age from 2 months to 22 years. Ten patients had a total of 14 separate recurrences; nine occurred during the initial hospitalization. Symptoms on presentation included abdominal pain (80%), palpable mass (60%), rectal bleeding (53%), and lethargy or sepsis (45%). Fifteen children underwent exploration without contrast studies based on duration of symptoms (greater than 5 days) and evidence of severe obstruction on plain abdominal x-ray films. In the remaining children, diagnosis was confirmed by barium enema and hydrostatic reduction was achieved in only 34 patients (42% success rate). Symptoms were present more than 48 hours in 55% of the reduction failures. At operation, five children had spontaneously reduced and an appendectomy was performed. Manual reduction was possible in 32 patients. The intussusception was irreducible in 26 patients, and 18 required temporary stomas. Pathologic lead points were found in 11 patients. Average length of hospitalization was 1.5 days after barium enema reduction, 9.6 days after manual reduction, and 13.8 days after bowel resection. There were no recurrences of intussusception after surgical reduction. A significant morbidity rate was observed with a delay in diagnosis. Adequate preoperative preparation and prompt surgical intervention are associated with 100% survival.     

Childhood intussusception: a comparative study of nonsurgical management

PURPOSE: A prospective study was conducted comparing air reduction, barium reduction under fluoroscopy, and saline reduction under ultrasound guidance for diagnosis and treatment of intussusception involved in 147 patients. METHODS: Fifty children received air reduction (AR group), 50 received barium enema reduction (BE group) and 47 received saline reduction under ultrasound guidance (US group). Nonoperative management was attempted if there was a history of less than 48 hours; absence of general or abdominal signs of toxicity, peritonism, or peritonitis, and reasonable blood electrolyte levels (K, 3 to 5 mmol/L; Na, 130 to 150 mmol/L). RESULTS: Group AR had successful outcome in 45 of 50 children (90%); BE had successful outcome in 35 of 50 children (70%), and US had successful outcome in 32 of 47 children (67%). This 20% to 23% success rate difference between air reduction and the other two techniques (BE and US) was statistically significant (P = .01). There was no significant difference between BE and US saline (P > or = .05). There were no perforations encountered in AR patients, three perforations in BE patients, and two perforations in US patients. There was no mortality. CONCLUSIONS: Air reduction seems to be associated with fewer complications and the highest success rate. Proper selection of patients is crucial to achieve a high success rate and to minimise complications.     

小儿肠套叠465例诊治体会

目的分析小儿肠套叠的临床特点、诊断及治疗。方法回顾性分析465例小儿肠套叠的临床表现、治疗效果。384例患儿空气灌肠治疗;81例手术治疗,并比较两种手术切口的愈合情况。结果465例小儿肠套叠的主要症状以腹痛、血便、呕吐和腹部肿块为主。空气灌肠法,操作简便,复位率可达82.58%以上;空气灌肠不能成功,需手术治疗,如能行麦氏切口较行腹直肌切口有优越性。结论小儿肠套叠早期诊断和治疗与预后相关。部分患儿手术可行麦氏切口。     

Ultrasound-guided hydrostatic reduction of intussusceptions by saline enema: a review of 5218 cases in 17 years

BACKGROUND: The aim of this study was to evaluate the results of ultrasound (US)-guided hydrostatic reduction (UGSED) of intussusceptions in pediatric patients by saline enema. METHODS: Five thousand two hundred eighteen pediatric patients with intussusceptions treated by UGSED from October 1985 to October 2002 were reviewed retrospectively. RESULTS: The success rate of reduction in 5218 patients was 95.5%. Two hundred thirty-seven patients (4.5%) underwent surgery. Colonic perforation occurred in 9 patients (0.17%). Two infants suffered from milk aspiration because of vomiting during the hydrostatic enema reduction. There was no mortality. CONCLUSIONS: UGSED of intussusceptions avoids radiation exposure. It is reliable and safe. It has high success rate and minimal complications. It is a perfect method for the nonoperative treatment of pediatric intussusception and can be widely used as routine therapy.     

Intussusception: the accuracy of ultrasound-guided saline enema and the usefulness of a delayed attempt at reduction.

BACKGROUND/PURPOSE: The aim of this study was to evaluate the therapeutic value of ultrasound (US)-guided saline enema for intussusception and the usefulness of a delayed attempt after at least 30 minutes when reduction has not been complete. METHODS: One hundred ninety-five cases of intussusception were diagnosed with ultrasonography. US-guided saline hydrostatic reduction was performed in 194 with an additional attempt after at least 30 minutes in those cases in which only partial resolution had been achieved. The method was changed (the volume of the reservoir bag and the caliber of the catheter were increased) so we analyze two different periods; 85 cases are included in the first period and 110 in the second. RESULTS: The global rate of successful reduction was 81.9% (159 of 194 cases), and it raised to 88.2% (97 of 110 cases) in the second period. In 15.5% cases (30 of 194) reduction was achieved in a delayed attempt at least 30 minutes after the initial partial resolution. The rate of recurrence was 9.7%. No perforation was seen. CONCLUSIONS: The accuracy of US-guided saline enema in achieving intussusception reduction is high, similar to other methods, avoiding radiation exposure. A delayed attempt after a period of rest increases the rate of reductions.     

Management of recurrent intussusception: nonoperative or operative reduction?

Purpose

The aim of this study was to determine how to manage children with recurrence of intussusception.

Methods

Medical records of patients treated for intussusception from 1976 to 2008 at the Queen Sirikit National Institute of Child Health were reviewed. Information on patients who developed recurrent intussusception was extracted to study patterns of recurrent attack and suitable management procedures. The statistical differences were analyzed by the χ² and the Student t test, with a P value < .05 considered significant.

Results

During the study period, 1340 patients were treated for 1448 episodes of intussusceptions, with an average of 40 cases per year. There were 108 episodes of recurrent intussusception in 75 patients (45 males and 30 females). The overall recurrence rate was 8%. Patient age at the first episode ranged from 3 months to 12 years (average, 14.9 months). The time interval before each recurrence ranged from 1 day to 3.2 years (average, 7.8 months). The number of recurrences ranged from 1 to 5 attacks. Recurrent intussusception occurred in 35 (15.8%) of 222 children following successful hydrostatic barium enema (BE) reduction and in 55 (11.4%) of 482 after successful pneumatic or air enema (AE) reduction. There was no statistical difference between the recurrence rates after the 2 nonoperative procedures (P = .08). Recurrent intussusception developed in 14 (3.0%) of 457 patients after operative manual reduction. Recurrence was not observed after intestinal resection for initial irreducible intussusception in 175 patients. The remaining 4 recurrent episodes occurred after spontaneous reduction. Of the 108 episodes of recurrence, BE and AE reductions were successful in 25 (96.2%) of 26 attempts and in 57 (92%) of 62 attempts, respectively. Seven patients had their first episode of intussusception treated surgically. All 7 when they recurred were successfully treated with either BE or AE reduction. Operative intervention was needed in 23 episodes of recurrent intussusception; 18 were reduced manually, and 5 required intestinal resection. Overall, 7 (9.3%) of the 75 recurrences had a pathologic lead point: colonic polyps in 4 cases and Meckel diverticulum in 3 cases. There were no deaths among the 75 patients with recurrent intussusception.

Conclusions

Recurrent intussusception should be initially treated by nonoperative reduction. Laparotomy is needed in cases with failure of BE or AE reduction, in cases with suspicion of a pathologic lead point, and in selected cases with several episodes of recurrence. The treatment of recurrent intussusception, in general, should be similar to that of primary intussusception.     

Emergency department discharge following successful radiologic reduction of ileocolic intussusception in children: A protocol based prospective observational study

PurposePediatric intussusception's first line treatment consists of fluoroscopic guided air enema reduction. Postprocedure, these patients are usually admitted overnight for observation. The purpose of our study was to document the results of emergency department (ED) observation and discharge protocol after successful reduction of ileocolic intussusception.MethodsA prospective observational study was conducted after implementation of an ED protocol for ileocolic intussusception from 10/2014 to 7/2017 and compared these patients to a historical cohort immediately prior to protocol initiation (10/2011–9/2014). Data collected included demographics, total time in the ED and hospital, enema reduction, recurrence, and requirement for operative intervention. Results reported as means with standard deviation and medians reported with interquartile ranges (IQR).Results115 patients were treated with the prospective protocol and were compared to a 90 patient historical cohort. Reduction was successful in 84%–89% of cases. Median hospital time after enema was shorter in the protocol group [4.8 h (4.25, 14.97) versus 19.7 h (13.9, 33.45), p < 0.01]. Only 33% of patients were admitted following the protocol; the most common admission reason was persistent abdominal discomfort.ConclusionED observation and discharge after successful air enema reduction in children with ileocolic intussusception are safe, facilitate early discharge, and reduce hospital resource utilization.Level of evidenceIII.     

General anaesthesia may improve the success rate of hydrostatic reductions of intussusception

Intussusception is the most common cause of intestinal obstruction in young children. Hydrostatic enemas result in a successful reduction of intussusception in 50% to 80% of patients. Failure to achieve reduction with hydrostatic enema results in laparotomy, although a frequent finding upon exploration is complete reduction of the intussusception, presumably due to induction of general anaesthesia. Recent paediatric literature suggests that induction of general anaesthesia may improve the success rate of therapeutic hydrostatic enema. We report a difficult case of recurrent intussusception where the induction of general anaesthesia alone did not result in reduction of intussusception, but successful reduction by enema was achieved while the patient was anaesthetized.     

小儿肠套叠的影像诊断与空气灌肠整复失败的分析

目的：提高对小儿肠套叠的影像诊断与治疗的认识，方法：回顾性分析近15年来经空气灌肠证实的肠套叠患儿608例的影像学表现。其中550例经透视下行结肠注气整复成功，58例整复失败经手术复位。结果：空气灌肠整复失败58例中，术后病理证实有复杂型28例，器质性肠套叠2例，肠壁损伤21例，3例阑尾被套，4例肠坏死，其中回－回－结套24例，回结套24例，回回结结型4例，结论：透视下空气灌肠是诊断与治疗小儿肠套叠的最好方法，对于复杂型肠套叠及伴有肠管畸形，肠腔坏死等症，则应尽早采取手术治疗。     

The pattern of intussusception in Kuwait. A review of 244 cases

Two-hundred and thirty-three patients with 244 intussusceptions were treated in the Department of Paediatric Surgery, Ibn Sina Hospital, Kuwait, with only one death. Our incidence was around 25 per year. The age for idiopathic intussusception fits that reported in Western countries. Kuwaitis have a lower incidence of intussusception than other nationalities living in Kuwait. Diarrhea seems to precede intussusception in about 19.1% of cases; leading points were found in 8.2%, and recurrences in 4.5% of cases, most of them following barium reduction. Our complications were high, particularly in the operated group. Barium enema has become our first line of management and it has greatly reduced complications and shortened hospitalization times. Those who present early and late are more prone to operative treatment.     

小儿急性肠套叠诊治回顾

目的　总结小儿急性肠套叠最有效的治疗方法。方法　对 1984年 8月～ 2 0 0 1年 8月在本院治疗的小儿急性肠套叠 2 3 45例总结回顾。结果　空气灌肠整复 2 2 2 8例 ,灌肠失败手术复位 117例 ,其中术中证实为特发性肠套叠者 79例 ,器质性病变伴肠套叠 3 8例。结论　空气灌肠是目前小儿急性肠套叠整复的最有效方法之一。     

Intussusception: barium or air?

At The Hospital For Sick Children, the use of air has recently replaced the use of barium in the reduction of intussusceptions. The purpose of this study was to review the results from 200 consecutive patients with intussusceptions, 100 patients treated with barium enema and 100 patients treated with air enema. The groups were similar with regard to sex, average and median ages, and presenting symptoms and signs. Successful reduction was achieved in 75% of episodes of intussusception treated with barium enema and 76% treated with air enema. Failure of either modality showed a high association with the presence of either a lead point or an ileoileal or ileoileocolic intussusception. Among those cases of unsuccessful reduction, operation was performed in all 59 cases; resection in 30 cases, manual reduction in 19, and spontaneous reduction was found in 10. There were three perforations during attempted reduction with barium and two with air. All perforations were treated by resection and primary anastomosis. There were 18 recurrent intussusceptions following barium enema reduction and nine following air enema reduction. Therefore, with the lower absorption of x-rays by air and the relatively inert nature of air (compared with barium in the event of a perforation), we feel that air enema is the treatment of choice in the initial management of intussusception.     

Endotoxin, cytokines and lipid peroxides in children with intussusception.

BACKGROUND: Intussusception is a relatively common paediatric surgical emergency. The aim of this study was to investigate selected inflammatory mediators in children with acute intussusception and to identify potentially useful plasma markers of clinical outcome. METHODS: Clinical, radiographic, operative and pathological details were recorded prospectively of all children presenting to a single institution with a confirmed diagnosis of acute intussusception during 1 year. Paired acute and convalescent venous blood samples were collected in a standard manner for blinded analysis of the following: malondialdehyde, C-reactive protein (CRP), interleukin (IL) 6, neopterin, tumour necrosis factor alpha, endotoxin, and immunoglobulin (Ig) G and IgM antiendotoxin core antibody (EndoCAb). RESULTS: Thirty-two consecutive children (23 boys, nine girls) with a median age of 4 months were studied. Acute ileocolic intussusception was managed by air enema reduction (n = 19), operative reduction (n = 8) or surgical resection (n = 5). Peripheral blood cultures were sterile. Acute levels of plasma IL-6, neopterin and CRP were significantly raised in comparison to both normal laboratory ranges and convalescent samples (P < 0.001). Using stepwise discriminant analysis, CRP was identified as the best variable at distinguishing between the three treatment groups (P < 0.001). IgM EndoCAb concentrations were significantly greater in the convalescent sera of all the patients (P < 0.001). CONCLUSION: Acute ileocolic intussusception in childhood is associated with endotoxinaemia and significantly raised levels of circulating inflammatory cytokines. Plasma CRP at diagnosis showed a statistically significant positive correlation with disease severity.     

改良空气灌肠法在小儿肠套叠的诊断和治疗的应用(附84例分析)

目的探讨改良空气灌肠法在诊治小儿肠套叠的临床应用价值。方法对我院在2000年1月至2006年12月采用改良空气灌肠法对84例小儿肠套叠的诊治资料进行回顾性分析。结果本组确诊为肠套叠84例,排除非肠套叠24例,明确诊断率为100%。复位成功79例,复位率为94.28%。复位未成功并手术治疗5例,其中3例是肠坏死1例为回回结肠型肠表叠,1例为Meckle憇室。复位后无并发症发生,然后随访有3例复发,其中1例复发4次,最后手术证实为Meckle憩室所致。本组在诊治过程无死亡病例发生。结论早期使用整复仪空气灌肠有助于提高肠套叠的诊断和复位率。采用中压、脉冲、间歇手术按摩改良法室气灌肠灌肠复位是种安全和有效的治疗措施。