Effectiveness of pneumatic reduction of ileocolic intussusception in children

Management of Intussusception in the Era of Ultrasound-Guided Hydrostatic Reduction: A 3-Year Experience from a Tertiary Care Center

Introduction:

Ultrasound-guided hydrostatic reduction (HSR) is currently the initial management tool in the treatment of intussusception. HSR is, however, confronted with failures besides there are still a number of patients who primarily undergo surgical intervention for the management of intussusception. We undertook this study to assess the efficacy of HSR and also to look for factors demanding the surgical exploration in patients with intussusception.

Materials and Methods:

A total of 215 patients with intussusception from June 2014 to June 2017 were prospectively studied. HSR was carried out in 203 patients, which was successful in 187 and unsuccessful in 16. These two groups were compared using the Student's t-test. Significance was set at P < 0.05. Twelve patients undergoing surgery primarily were also assessed for the factors affecting the decision-making.

Results:

HSR was successful in 187 and unsuccessful in 16. The failed group was more likely to have symptoms over 24 h, appearance of crescent, and ≥10-cm length on ultrasonography (USG). Two of these patients had ischemic bowel, two had ileoileal intussusception, and eight had pathological lead points, whereas no obvious cause could be identified in the rest of the four patients. Among the 12 patients who were primarily operated, four patients had peritonitis and other four patients were neonates. Laparoscopic reduction was done in four patients.

Conclusion:

HSR is a safe and effective treatment modality for intussusception. However, it is met with higher failure rates in patients with risk factors such as delayed presentation, appearance of crescent on USG, and length >10 cm. The role of HSR is also dubious in situations such as neonatal intussusception, small-bowel intussusception, and multiple intussusceptions and also in preventing the future recurrence. Such patients ought to be managed by laparotomy or where feasible by laparoscopy. Furthermore, before embarking on HSR, peritonitis and bowel ischemia should be ruled out clinically and radiologically. In the suspicious cases of bowel ischemia, USG Doppler may be helpful.

Operative indications in recurrent ileocolic intussusception

BACKGROUND

Air-contrast enema (ACE) is standard treatment for primary ileocolic intussusception. Management of recurrences is less clear. This study aimed to delineate appropriate therapy by quantifying the relationship between recurrence and need for bowel resection, pathologic lead points (PLP), and complication rates.

METHODS

After IRB approval, a single institution review of patients with ileocolic intussusception from 1997 to 2013 was performed, noting recurrences, outcomes, and complications. Fisher's exact and t-tests were used.

RESULTS

Of 716 intussusceptions, 666 were ileocecal. Forty-four underwent bowel resection, with 29 PLPs and 9 ischemia/perforation. Recurrence after ACE occurred in 96 (14%). Recurrence did not predict PLP (P=0.25). Recurrence (≥3) was associated with higher resection rate (P=0.03), but not ischemia/perforation (P=0.75). ACE-related complications occurred in 4 (0.5%) patients. Successful initial ACE had 98% negative predictive value for resection and PLP (e.g., after successful ACE, 2% had resections, 2% PLP). After failed initial ACE, 36% received resection, and 23% had PLP (P<0.001).

CONCLUSIONS

Recurrence is associated with a greater risk of resection but not PLP or ACE-complication. Failed ACE is associated with increased risk for harboring PLP and receiving resection. ACE should be the standard treatment in recurrent intussusception, regardless of number of recurrences.

Risk factors for surgery in pediatric intussusception in the era of pneumatic reduction

INTRODUCTION

Surgical treatment is still necessary for intussusception management in a subgroup of patients, despite advances in enema reduction techniques. Early identification of these patients should improve outcomes.

METHODS

The medical records of patients treated for intussusception at our institution from 2006 to 2011 were reviewed. Univariate and multivariate analyses, including stepwise logistic regression, were performed.

RESULTS

Overall, 379 patients were treated for intussusception, and 101 (26%) patients required operative management, with 34 undergoing intestinal resection. The post-operative complication rate was 8%. On multivariate analysis, failure of initial reduction (OR 9.9,p=0.001 95% CI, 4.6-21.2), a lead point (OR 18.5,p=0.001 95% CI, 6.6-51.8) or free/interloop fluid (OR 3.3,p=0.001 95% CI, 1.6-6.7) or bowel wall thickening on ultrasound (OR 3.3,p=0.001 95% CI, 1.1-10.1), age <1 year at reduction (OR 2.7,p=0.004, 95% CI, 1.4-5.9), and abdominal symptoms>2 days (OR 2.9,p=0.003, 95% CI, 1.4-5.9) were significantly associated with a requirement for surgery. Similarly, a lead point (OR 14.5, p=0.005 95% CI, 2.3-90.9) or free/interloop fluid on ultrasound (OR 19.8, p=0.001 95% CI, 3.4-117) and fever (OR 7.2, p=0.023 95% CI, 1.1-46) were significantly associated with the need for intestinal resection.

CONCLUSION

Abdominal symptoms>2 days, age<1 year, multiple ultrasound findings, and failure of initial enema reduction are significant predictors of operative treatment for intussusception. Patients with these findings should be considered for early surgical consultation or transfer to a hospital with pediatric surgical capabilities.

Predictors of failed enema reduction in childhood intussusception

BACKGROUND

Initial management of intussusception is enema reduction. Data are scarce on predicting which patients are unlikely to have a successful reduction. Therefore, we reviewed our experience to identify factors predictive of enema failure.

METHODS

A retrospective review of all episodes of intussusception over the past 10 years was conducted. Demographics, presentation variables, colonic extent of intussusceptions, and hospital course were collected. Extent of intussusception was classified as right, transverse, descending, and rectosigmoid. Episodes were grouped as success or failure of enema reduction and compared using the Student t test for continuous variables and χ(2) test for dichotomous variables. Significance was P less than .05.

RESULTS

We identified 405 episodes of intussusception and 371 attempts at enema reduction. There were 285 successful enema reductions. There was no difference between groups in age; sex; or the presence of emesis, fever, or abdominal mass. The failed enema group was more likely to have had symptoms over 24 hours before presentation (P = .006), bloody diarrhea (P < .001), and lethargy (P < .001). The chance of success diminished with colonic extent (right, 88%; transverse, 73%; left, 43%; colorectal, 29%; P < .001).

CONCLUSION

Predictors of failed enema reduction of intussusception include presence of symptoms over 24 hours, diarrhea, lethargy, and distal extent of intussusception.

Failure of enema reduction for ileocolic intussusception at a referring hospital does not preclude repeat attempts at a children's hospital

BACKGROUND

Some children with intussusception undergo attempted enema reduction at a hospital without pediatric radiology expertise and are transferred to a children's hospital (CH) if this is unsuccessful. We sought to determine whether a failed reduction (FR) at a referring hospital predicted failure of repeated attempts by a pediatric radiologist at a CH.

METHODS

A retrospective review of all children with ileocolic intussusception admitted to a large CH over 9 years was performed. Differences in outcome between those who initially presented to the CH and those who had a FR elsewhere before transfer (FR --> CH) were assessed.

RESULTS

A total of 152 subjects were identified. There was no difference in the frequency of successful enema reduction at the CH for those who initially presented at the CH (60.5%) and those who were transferred after a FR elsewhere (60.7%). The only predictor of successful reduction was anatomy, whereby 64% of intussusceptions proximal to the splenic flexure were reduced, but only 35% of those distal to that point (P < .01).

CONCLUSIONS

Children who are transferred to a CH after failed enema reduction elsewhere should undergo a repeat hydrostatic or pneumatic enema reduction in the absence of other contraindications.

Intussusception: the use of delayed, repeated reduction attempts and the management of intussusceptions due to pathologic lead points in pediatric patients

OBJECTIVE

The nonoperative management of intussusception continues to evolve and is the subject of ongoing debate. Our purpose was to assess our current enema reduction rate and to focus on two specific issues that have received little attention in the literature: first, the value and safety of using delayed, repeated reduction attempts and, second, the management of intussusceptions due to lead points.

MATERIALS AND METHODS

We performed a retrospective analysis of all intussusception cases seen at the Hospital for Sick Children, Toronto, Canada, a tertiary pediatric hospital, from May 1999 to December 2002.

RESULTS

There were 163 children with a total of 219 intussusceptions. Enema reduction was attempted in 211 (96%). Reduction rate with air enema was 90.2%. Delayed reduction attempts were used in 25 patients (15.3%) in 26 intussusceptions (12.3%) and were successful in 50% of the cases. Lead points were documented in 13 children (8%); sonography depicted the lead points in seven (53.8%) of the 13. The reduction rate of intussusceptions due to lead points was 63.6% (14/22).

CONCLUSION

Air enema associated with the use of delayed, repeated reduction attempts is a safe and effective approach for intussusception reduction with a high success rate. Delayed, repeated reduction attempts should be considered when the initial attempt manages to move the intussusceptum and the patient remains clinically stable. The management of intussusceptions due to lead points remains a challenge. Sonography does not depict all lead points, and the indication for other imaging studies should be tailored according to each particular patient. We recommend attempted enema reduction in all patients with lead points.

Air intussusception reduction: "the winds of change"

AIR is an excellent example of the application of the scientific process to the treatment of pediatric disease. For more than 40 years, pediatric radiologists in North America were comfortable with hydrostatic enemas for the diagnosis and treatment of intussusception. Initial clinical trials in the 1980s suggested the efficacy of AIR. Subsequent clinical studies demonstrated that fluoroscopy time and radiation are less, accurate pressure measurements are possible, and reduction rates are higher with AIR than with hydrostatic techniques. Questions regarding safety and types of perforation were answered in the laboratory with an animal model. Moreover, this experimental work clarified issues regarding maximum pressures and the importance of the Valsalva maneuver during AIR. Experimental data has been transferred to the radiological treatment of childhood intussusception. The "winds of change", generated by clinical and basic research, have now swept across North America. More and more radiologists are performing AIR. Many of the pediatric radiologists who still doubt the efficacy of AIR have had no experience with the technique. Air insufflation is safe and effective for the diagnosis and treatment of intussusception in infants and children. It is replacing the hydrostatic enema in an ever-increasing number of institutions. AIR is quicker, safer, and more effective than hydrostatic enemas. If you are using AIR, I hope this overview will further improve the radiological care of your pediatric patients. If you are not using AIR, I hope that these personal observations will stimulate your interest. "Try it; you'll like it!"