Predictors of failed enema reduction in children with intussusception: a systematic review and meta-analysis

Scoring System to Evaluate Risk of Nonoperative Management Failure in Children With Intussusception

INTRODUCTION

Typical first-line management of children with intussusception is enema reduction; however, failure necessitates surgical intervention. The number of attempts varies by clinician, and predictors of failed nonoperative management are not routinely considered in practice. The purpose of this study is to create a scoring system that predicts risk of nonoperative failure and need for surgical intervention.

METHODS

Children diagnosed with intussusception upon presentation to the emergency department of a tertiary children's hospital between 2019 and 2022 were retrospectively identified. Univariable logistic regression identified predictors of nonoperative failure used as starting covariates for multivariable logistic regression with final model determined by backwards elimination. Regression coefficients for final predictors were used to create the scoring system and optimal cut-points were delineated.

RESULTS

We identified 143 instances of ultrasound-documented intussusception of which 28 (19.6%) required operative intervention. Predictors of failed nonoperative management included age ≥4 y (odds ratio [OR] 32.83, 95% confidence interval [CI]: 1.91-564.23), ≥1 failed enema reduction attempts (OR 189.53, 95% CI: 19.07-1884.11), presenting heart rate ≥128 (OR 3.38, 95% CI: 0.74-15.36), presenting systolic blood pressure ≥115 mmHg (OR 6.59, 95% CI: 0.93-46.66), and trapped fluid between intussuscepted loops on ultrasound (OR 17.54, 95% CI: 0.77-397.51). Employing these factors, a novel risk scoring system was developed (area under the curve 0.96, 95% CI: 0.93-0.99). Scores range from 0 to 8; ≤2 have low (1.1%), 3-4 moderate (50.0%), and ≥5 high (100%) failure risk.

CONCLUSIONS

Using known risk factors for enema failure, we produced a risk scoring system with outstanding discriminate ability for children with intussusception necessitating surgical intervention. Prospective validation is warranted prior to clinical integration.

Impact of a 6-12-h delay between ileocolic intussusception diagnostic US and fluoroscopic reduction on patients' outcomes

BACKGROUND

Image-guided reduction of intussusception is considered a radiologic urgency requiring 24-h radiologist and technologist availability.

OBJECTIVE

To assess whether a delay of 6-12 h between US diagnosis and fluoroscopic reduction of ileocolic intussusception affects the success frequency of fluoroscopic reduction.

MATERIALS AND METHODS

Retrospective review of 0-5-year-olds undergoing fluoroscopic reduction for ileocolic intussusception from 2013 to 2023. Exclusions were small bowel intussusception, self-reduced intussusception, first fluoroscopic reduction attempt>12 h after US, prior bowel surgery, inpatient status, and patient transferred for recurrent intussusception. Data collected included demographics, symptoms, air/contrast enema selection, radiation dose, reduction failure, 48-h recurrence, surgery, length of stay, and complications. Comparisons between<6-h and 6-12-h delays after ultrasound diagnosis were made using chi-square, Fisher's exact test, and Mann-Whitney U tests (P< 0.05 considered significant).

RESULTS

Of 438 included patients, 387 (88.4%) were reduced in <6 h (median age 1.4 years) and 51 (11.7%) were reduced between 6 and 12 h (median age 2.05 years), with median reduction times of 1:42 and 7:07 h, respectively. There were no significant differences between the groups for reduction success (<6 h 87.3% vs. 6-12 h 94.1%; P-value = 0.16), need for surgery (<6 h 11.1% vs. 6-12 h 3.9%; P-value=0.112), recurrence of intussusception within 48 h after reduction (<6 h 9.3% vs. 6-12 h 15.7%; P-value=0.154), or length of hospitalization (<6 h 21:07 h vs. 6-12 h 20:03 h; P-value=0.662).

CONCLUSION

A delay of 6-12 h between diagnosis and fluoroscopic reduction of ileocolic intussusception is not associated with reduced fluoroscopic reduction success, need for surgical intervention after attempted reduction, recurrence of intussusception following successful reduction, or hospitalization duration after reduction.

Developing a Nomogram for Predicting Surgical Intervention in Pediatric Intussusception After Pneumatic Reduction: A Multicenter Study from China

Purpose

The objective of this study was to develop and validate a nomogram for predicting the need for surgical intervention in pediatric intussusception after pneumatic reduction.

Patients and Methods

This retrospective study analyzed the clinical data of children with acute intussusception admitted to four hospitals in China from January 2019 to January 2022. Based on the results of pneumatic reduction, the patients were divided into two groups: the successful reduction group (control group) and the failed reduction group (operation group). The total sample was randomly divided into a training set and a validation set in a 7:3 ratio. Logistic regression analysis was performed to establish a predictive model for surgical risk.

Results

A total of 1041 samples were included in this study, with 852 in the control group and 189 in the operation group. Among the total sample, 728 cases were used for training and 313 cases were used for validation. Logistic regression analysis of the training set identified age, time of abdominal pain, presence or absence of hematostoecia, C-reactive protein value from blood test on admission, and nested position indicated by B-ultrasound as independent predictors of intussusception intervention. Based on the five independent risk factors identified through multivariate logistic regression, a nomogram was successfully constructed to predict the failure of resetting by air enema under X-ray.

Conclusion

A nomogram was developed to predict the need for surgical intervention after intussusception pneumatic reduction in children. The nomogram was based on clinical risk factors including age, time of abdominal pain, presence or absence of blood in stool, value of C-reactive protein in blood test on admission, and nested position indicated by B-ultrasound. Our internal validation demonstrated that this nomogram can serve as a useful tool for identifying risk factors associated with failure of air enema in children with intussusception.

Predictors of Failure in Ultrasound-Guided Hydrostatic Reduction of Intussusception in Children: Retrospective Analysis in a Specialized Center in Ethiopia

Purpose

To identify factors predicting the failure of ultrasound-guided hydrostatic reduction of intussusception in children.

Patients and Methods

The medical records of 174 children who underwent ultrasound-guided hydrostatic reduction of intussusception over four years were reviewed at Tikur Anbessa Specialized Hospital. Patient's demography, clinical data, and sonography findings (type of intussusception, length of intussusception, presence of lead point, trapped fluid, lymph node, and free peritoneal fluid) were entered into SPSS 25 (IBM) and analyzed using logistic regression.

Results

The overall success rate of ultrasound-guided hydrostatic reduction was 81.6%. The sex, presence of abdominal cramps, vomiting, diarrhea, trapped lymph nodes on ultrasound, or history of upper respiratory tract infection had no association with hydrostatic reducibility. Currant jelly stool (OR 0.128; 95% CI, 0.27-0.616; P=0.01), Ileo-ileo colic intussusception (OR 0.055; 95% CI, 0.005-0.597; P=0.017), pathologic lead point (OR 0.66; 95% CI, 0.01-0.447; P=0.005) and abdominal distention (OR 0.209; 95% CI, 0.044-0.998; P=0.048) showed significant association with failed hydrostatic reduction.

Conclusion

The presence of currant jelly stool, ileo-ileo colic type intussusception, pathologic lead point, and abdominal distention are the most important predictors for failed ultrasound ultrasound-guided reduction intussusception in children.

Pushing Backwards: Evaluating Effectiveness of Conservative Treatment of Intestinal Intussusception

OBJECTIVE

Intestinal intussusception (II) is a common cause for acute abdomen in children, occurring in 0.33 to 0.71 per 1000 children per year. Early diagnosis and treatment are fundamental for prevention of irreversible intestinal damage. The first line of treatment is conservative, with saline reduction enema or air reduction enema. Our goal is to evaluate results with conservative treatment of II in children.

METHODS

A retrospective single-center review of all patients with diagnosis of II from January 2014 to December 2019 was performed. Demographics, clinical data, treatment option, and results were assessed.

RESULTS

Thirty-eight cases were identified. The mean age was 26 months, and 68% were males. Most presented with abdominal pain (95%) and vomiting (66%), after an average of 30 hours. Rectal bleeding was present in 32% of patients. Abdominal ultrasound was performed in all patients for diagnosis. Conservative treatment was first option in 95% of patients, with a global effectiveness of 83% after 1 attempt. Saline reduction enema was more effective than air reduction enema (88% vs 70%), and patients with successful reduction were younger (24 vs 33 months), but neither reached statistical significance. Two patients had a subsequent II episode within 1 week after hospital discharge. Neither age, sex, symptoms and respective duration, rotavirus inoculation, intussuscepted bowel length, nor technique used was predictive of treatment failure or II relapse.

CONCLUSIONS

Conservative treatment in II is a safe and effective option, preventing invasive surgical procedures. Effectiveness of such treatments may be as high as 88% after 1 attempt, with rapid diet reintroduction. Same-day discharge after oral feeding toleration is safe.

Liberal surgical laparoscopy reduction for acute intussusception: experience from a tertiary pediatric institute

The optimal treatment for acute intussusception has not yet been defined. In this study, we explored whether employing a liberal laparoscopic intervention for intussusception could lead to favorable outcomes. We performed a historical control analysis to evaluate the outcomes associated with this liberal surgical management protocol. This liberal surgical management protocol were revised to incorporate a new protocol centered around the laparoscopic approach. In some cases of acute intussusception, liberal laparoscopic exploration and intervention were undertaken without initial hydrostatic or pneumatic reduction. During the study interval, a retrospective review was conducted on a total of 3086 patients. These were categorized into two groups: 1338 cases before May 2019 (pre-protocol group) and 1748 cases after May 2019 (post-protocol group). Surgical intervention rates in the pre-protoco and post-protocol period were 10.2% and 27.4% respectively (odds ratio [OR] = 0.30 [95% CI 0.25-0.37]; p < 0.001). No significant differences were observed in baseline clinical characteristics or demographic features between the two groups. The duration from admission to operation was longer for the pre-protocol group (p = 0.008) than for the post-protocol group. The post-protocol group demonstrated decreases in both intestinal resection (OR = 1.50 [95% CI 0.96-2.35]; p = 0.048) and total recurrent events (OR = 1.27 [95% CI 1.04-1.55]; p = 0.012) compared to the pre-protocol group. Liberal laparoscopic intervention for intussusception may effectively reduce the risk of intestinal resection and total recurrent events, thereby exhibiting promising outcomes for patients with intussusception.

Effects of sedatives on radiologic enema reduction in children with ileocolic intussusception: A systematic review and meta-analysis

BACKGROUND

In children with ileocolic intussusception, sedatives such as midazolam, ketamine and propofol may facilitate radiologic enema reduction, but studies on their separate and joint effects remain controversial.

OBJECTIVES

We aimed to systematically analyze studies for the effects of sedatives on the radiologic reduction of ileocolic intussusception in children.

METHODS

We searched PubMed, EMBASE, CINAHL, Scopus and Web of Science from database inception through March 2023 for articles that enrolled children with ileocolic intussusception who underwent non-operative pneumatic or hydrostatic enema reduction under ultrasound or fluoroscopic guidance with or without the use of sedatives. The primary and secondary outcomes were success rate in radiologic reduction of ileocolic intussusception and risk of perforation, respectively. Effect estimates from the individual studies were extracted and combined using the Hartung-Knapp-Sidik-Jonkman log-odds random-effects model. Heterogeneity between studies was checked using Cochran's Q test and the I2 statistic.

RESULTS

A total of 17 studies with 2094 participants were included in the final review, of which 15 were included in the meta-analysis. Nine studies reported on the success rate of radiologic reduction performed under sedation in all participants, while six studies compared the success rate in two patient groups undergoing the procedure with or without sedation. The pooled success rate of non-operative reduction under sedation was 87 % (95 % CI: 80-95 %), P = 0.000 with considerable heterogeneity (I2 = 85 %). A higher success rate of 94 % (95 % CI: 88-99 %) and homogeneity (I2 = 12 %) were found in studies with pneumatic enema reduction. Among comparative studies, the odds of success of non-operative reduction were increased when the procedure was performed under sedation, with a pooled odds ratio of 2.41 (95 % CI: 1.27-4.57), P = 0.010 and moderate heterogeneity (I2 = 60 %). In a sensitivity analysis, homogeneity was found between analyzed studies when two outliers were excluded (I2 = 0.73 %). The risk of perforation was not significantly different (OR 1.52, 95 % CI: 0.09-23.34), P = 0.764 indicating small study effects. No publication, bias was detected on visual inspection of the funnel plots or the Begg's and Egger's bias tests. Most studies were categorized as having a low risk of bias using Joanna Briggs Institute checklists.

CONCLUSIONS

In selected patient groups, sedation can increase the success rate of radiologic enema reduction in children with ileocolic intussusception without evidence of increased risk of perforation. Systematic review protocol registration: PROSPERO CRD42023404887.

The Management of Intussusception: A Systematic Review

Intussusception (ISN) is a dangerous condition where a portion of the intestine slides into an adjacent area of the intestine. This telescoping motion frequently prevents liquids or food from flowing through. Developing management guidelines for ileocolic (IC) intussusception was the aim of this systematic study. Data sources were PubMed/Medical Literature Analysis and Retrieval System Online (MEDLINE), Scopus, and Embase databases. Our review investigated English-language articles (from 2010 to 2023) according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. Overall, there were 15 articles. Surveys and analyses of national databases were the most widely used methods (n=15). The search identified 561 studies; 15 were eligible for inclusion in the analysis. Further understanding of the management of intussusception may help improve evaluation and management in the future. The use of preventive antibiotics does not reduce problems following radiologic reduction. When clinically appropriate, repeated attempts at enema reduction may be made. After the enema reduction of ileocolic intussusception, patients can be safely watched in the emergency room (ER), thereby avoiding hospitalization. Success rates for laparoscopic reduction are high. When it comes to intussusception in children who are hemodynamically stable and do not have a serious illness, there is no need for pre-reduction antibiotics. Prioritizing nonoperative outpatient (OP) therapy is recommended as the primary approach, with the utilization of minimally invasive procedures to avoid the necessity for laparotomy. The management of colonic intussusception involves complete removal in one piece, while enteric intussusception can be addressed through reduction followed by resection. A targeted approach is recommended, recognizing the intermediate forms of intussusception that may exist between the colonic and enteric types. It is essential to note that the prevailing treatment for adult intussusception remains to be surgical intervention.

A deep-learning pipeline to diagnose pediatric intussusception and assess severity during ultrasound scanning: a multicenter retrospective-prospective study

Ileocolic intussusception is one of the common acute abdomens in children and is first diagnosed urgently using ultrasound. Manual diagnosis requires extensive experience and skill, and identifying surgical indications in assessing the disease severity is more challenging. We aimed to develop a real-time lesion visualization deep-learning pipeline to solve this problem. This multicenter retrospective-prospective study used 14,085 images in 8736 consecutive patients (median age, eight months) with ileocolic intussusception who underwent ultrasound at six hospitals to train, validate, and test the deep-learning pipeline. Subsequently, the algorithm was validated in an internal image test set and an external video dataset. Furthermore, the performances of junior, intermediate, senior, and junior sonographers with AI-assistance were prospectively compared in 242 volunteers using the DeLong test. This tool recognized 1,086 images with three ileocolic intussusception signs with an average of the area under the receiver operating characteristic curve (average-AUC) of 0.972. It diagnosed 184 patients with no intussusception, nonsurgical intussusception, and surgical intussusception in 184 ultrasound videos with an average-AUC of 0.956. In the prospective pilot study using 242 volunteers, junior sonographers' performances were significantly improved with AI-assistance (average-AUC: 0.966 vs. 0.857, P < 0.001; median scanning-time: 9.46 min vs. 3.66 min, P < 0.001), which were comparable to those of senior sonographers (average-AUC: 0.966 vs. 0.973, P = 0.600). Thus, here, we report that the deep-learning pipeline that guides lesions in real-time and is interpretable during ultrasound scanning could assist sonographers in improving the accuracy and efficiency of diagnosing intussusception and identifying surgical indications.

Ultrasound-guided hydrostatic reduction of intussusception: comparison of success rates between subspecialized pediatric radiologists and non-pediatric radiologists or radiology residents

Ileocolic intussusception is the most common cause of intestinal obstruction in children under two years of age. Treatment in most cases is radiologically guided reduction. In Slovenia, ultrasound (US)-guided hydrostatic reduction is currently the standard of care. The purpose of this study was to compare the success rate of US-guided hydrostatic reduction when performed by subspecialty-trained pediatric radiologists, non-pediatric radiologists, or radiology residents. We retrospectively analyzed medical records of patients with ileocolic intussusception who underwent US-guided hydrostatic intussusception reduction at University Medical Centre Ljubljana between January 2012 and December 2022 (n = 101). During regular daily working hours, the reduction was performed by pediatric radiologists. After hours (evenings and overnight), pediatric radiologists, non-pediatric radiologists, or radiology residents performed the reduction procedure. Patients were divided into three groups based on the operator performing the procedure. Data was analyzed using the chi-square test. Pediatric radiologists had thirty-seven (75.5%) successful first attempts, non-pediatric radiologists had nineteen (76.0%), and radiology residents had twenty (74.1%). There was no statistically significant difference in the success rate of ileocolic intussusception reduction depending on the operator who performed the procedure (p = 0.98). No perforation was observed in either group during the reduction attempts.  Conclusion: Our results demonstrate that US-guided hydrostatic reduction is a reliable and safe procedure that achieves good results even in the hands of less experienced, however appropriately trained, radiologists. The results should encourage more medical centers to consider the implementation of US-guided hydrostatic reduction of ileocolic intussusception. What is Known: • US-guided hydrostatic reduction is a well-established method of treatment for ileocolic intussusception in children. • The results regarding the influence of operator's experience with the procedure on its success rate are scarce and contradictory. What is New: • US-guided hydrostatic intussusception reduction is a reliable and safe technique that achieves similar success rates when performed by experienced subspecialized pediatric radiologists or less experienced but trained operators such as non-pediatric radiologists and radiology residents. • The implementation of US-guided hydrostatic reduction in general hospitals without subspecialized pediatric radiologists could improve patient care by increasing access to radiologically guided reduction and simultaneously decreasing the time to reduction attempts.

Development and evaluation of an artificial intelligence system for children intussusception diagnosis using ultrasound images

Accurate identification of intussusception in children is critical for timely non-surgical management. We propose an end-to-end artificial intelligence algorithm, the Children Intussusception Diagnosis Network (CIDNet) system, that utilizes ultrasound images to rapidly diagnose intussusception. 9999 ultrasound images of 4154 pediatric patients were divided into training, validation, test, and independent reader study datasets. The independent reader study cohort was used to compare the diagnostic performance of the CIDNet system to six radiologists. Performance was evaluated using, among others, balance accuracy (BACC) and area under the receiver operating characteristic curve (AUC). The CIDNet system performed the best in diagnosing intussusception with a BACC of 0.8464 and AUC of 0.9716 in the test dataset compared to other deep learning algorithms. The CIDNet system compared favorably with expert radiologists by outstanding identification performance and robustness (BACC:0.9297; AUC:0.9769). CIDNet is a stable and precise technological tool for identifying intussusception in ultrasound scans of children.

Is enema reduction in pediatric intussusception with a history of over 48 h safe: A retrospective cohort study

BACKGROUND

Intussusception is one of the most common acute abdominal diseases in children. Enema reduction is the first-line treatment for intussusception in good condition. Clinically, a history of disease over 48 h is usually listed as a contraindication for enema reduction. However, with the development of clinical experience and therapy, an increasing number of cases have shown that the prolongation of the clinical course of intussusception in children is not an absolute contraindication for enema treatment. This study aimed to analyze the safety and efficacy of enema reduction in children with a history of disease longer than 48 h.

METHODS

We conducted a retrospective matched-pair cohort study of pediatric patients with acute intussusception between 2017 and 2021. All patients were treated with ultrasound-guided hydrostatic enema reduction. According to the length of history, the cases were classified into two groups: history <48 h (<48 h group) and history greater than or equal to 48 h (≧48 h group). We generated a 1:1 matched-pair cohort matched for sex, age, admission time, main symptoms, and concentric circle size on ultrasound. Clinical outcomes were compared between the two groups, including success, recurrence, and perforation rates.

RESULTS

From January 2016 to November 2021, 2701 patients with intussusception were admitted to the Shengjing Hospital of China Medical University. A total of 494 cases were included in the ≧48 h group, and 494 cases with a history of <48 h were selected for matched comparison in the <48 h group. The success rates of the ≧48 h and <48 h groups were 98.18% vs. 97.37% (p = 0.388), and the recurrence rates were 13.36% vs. 11.94% (p = 0.635), showing no difference according to the length of history. The perforation rate was 0.61% vs. 0%, respectively, with no significant difference (p = 0.247).The comparison of the different history groups showed that in patients with bloody stools, the length of history had no significant effect on the enema reduction outcome(94.90% vs. 86.76%, p = 0.064).

CONCLUSIONS

Ultrasound-guided hydrostatic enema reduction is safe and effective for pediatric idiopathic intussusception with a history of ≧48 h.

Current diagnosis and image-guided reduction for intussusception in children

Intussusception involves an invagination of the proximal bowel into the distal bowel, with ileocolic intussusception being the most common type. However, a diagnostic delay can lead to intestinal ischemia, bowel infarction, or even death; therefore, its early diagnosis and management are important. The primary role of abdominal radiography is to detect pneumoperitoneum or high-grade bowel obstruction in cases of suspected intussusception, and ultrasonography is the modality of choice for its diagnosis. Nonoperative enema reduction, the treatment of choice for childhood intussusception in cases without signs of perforation or peritonitis, can be safely performed with a success rate of 82%. Enema reduction can be performed in various ways according to image guidance method (fluoroscopy or ultrasonography) and reduction medium (liquid or air). Successful enema reduction is less likely to be achieved in children with a longer symptom duration, younger age, lethargy, fever, bloody diarrhea, unfavorable radiologic findings (small bowel obstruction, trapped fluid, ascites, absence of flow in the intussusception, intussusception in the left-sided colon), and pathological lead points. This review highlights the current concepts of intussusception diagnosis, nonsurgical enema reduction, success rates, predictors of failed enema reduction, complications, and recurrence to guide general pediatricians in the management of childhood intussusception.

Risk Factors of Nonsurgical Management Failure in Pediatric Intussusception Patients With Delayed Presentation

OBJECTIVES

The present study aimed to investigate the time-related predicting factors of the ultrasound-guided hydrostatic reduction (USGHR) failure in pediatric patients with ileocolic intussusception and delayed presentation.

METHODS

The present retrospective study included pediatric patients diagnosed with ileocolic intussusception who presented to our hospital with the related symptoms started 48 hours ago or greater duration during 2018-2020. The patients with spontaneous reduction were excluded from the study. Afterward, the participants with failed and successful USGHR were compared in terms of age, sex, symptom duration, and ultrasound findings using the χ 2 and logistic regression tests.

RESULTS

A total of 103 children were included in the present study. The mean symptom duration was 4.13 ± 2.39 days, with a range of 2-14 days. Moreover, 47.6% of the patients had a successful reduction. In addition, there was a significant relationship between failed USGHR and the factors of symptom duration, free peritoneal fluid, entrapped fluid between intussuscepted loops, the size of the invaginated segment, and malperfusion of the intussuscepted bowel loops detected using the Doppler ultrasound ( P < 0.05). However, there was no significant relationship between failed USGHR and the factors of the primary location of intussusception and the presence of intussuscepted lymph nodes ( P > 0.05).

CONCLUSIONS

The presence of entrapped fluid between the intussuscepted loops, free peritoneal fluid, and the length of the intussuscepted segments were all associated with USGHR failure in our study. Therefore, determining these predictors may help anticipate failure of reduction.

Clinical characteristics of pediatric intussusception and predictors of bowel resection in affected patients

Background

Surgery is required for the treatment of intussusception when enema reduction is unsuccessful, or when the patient develops peritonitis, bowel perforation, or intestinal damage. We aimed to evaluate the clinical and laboratory parameters that may be used to predict the need for bowel resection in children with intussusception.

Methods

This observational retrospective study included children who were admitted to the pediatric emergency department with intussusception. Univariate and multivariate logistic regression models were used to evaluate factors associated with bowel resection.

Results

In total, 584 children with intussusception were admitted to the pediatric emergency department; 129 of these children underwent surgery. Multivariate analysis revealed the following independent predictors of bowel resection for intussusception: symptoms for at least 2 days before surgery (OR = 6.863; p = 0.009), long intussusception (OR = 5.088; p = 0.014), pathological lead point (OR = 6.926; p = 0.003), and intensive care unit admission (OR = 11.777; p = 0.001) were factors independently associated with bowel resection.

Conclusion

Symptoms for at least 2 days before surgery, long intussusception, pathological lead, and intensive care unit admission were predictors of bowel resection in children with intussusception. These findings can be used to identify patients at high risk of needing surgery and bowel resection.

Temporal Validation of Chiang Mai University Intussusception Failed Reduction Score (CMUI)

This study aimed to validate the “Chiang Mai University Intussusception Failed Score (CMUI)” for intussusception non-operative reduction. Both a 2-year retrospective and a 5-year prospective consecutive review of patients with intussusception were conducted. Data were collected from January 2013 to December 2020. Related retrospective data of a developmental set from two centers from January 2006 to December 2012 were used. Ten prespecified prognostic factors for failed reduction were collected and from these a predictive score was calculated. The actual results of non-operative reduction were collected and set as a reference standard. Altogether, 195 episodes of intussusception were found. Twenty-two patients were excluded due to contraindications; therefore, a total of 173 episodes were included in the validation dataset. The development data set comprised 170 episodes. We found that no statistical significance was found from comparing the areas under the ROC of two datasets (p-value = 0.31), while specificity of the validation set was 93.8% (88.1–97.3). This temporal validation showed a high specificity and a high affinity for prediction of failed reduction as the development dataset despite being in an era of a higher successful reduction rate. The intensive reduction protocols might be introduced among patients with high-risk scores.

Development and Validation of a Nomogram for Predicting Pathological Intussusceptions in Children Prior to Surgical Intervention

PURPOSE

Establish and validate a nomogram to help predict the preoperative risk of a pathological intussusception.

METHODS

A primary cohort of patients who underwent surgery for an intussusception were enrolled from one center, while a validation cohort consisted of patients from another center. Multivariate logistic regression analysis was used to identify the variables to build the nomogram. A calibration curve accompanied by the Hosmer-Lemeshow test was used to assess the calibration of the nomogram. To quantify the discrimination of the nomogram, Harrell's C-index was calculated. The performance of the validated nomogram was tested in the external validation cohort. The logistic regression formulae created during the analysis of the primary cohort was applied to all patients in the external validation cohort, and the total points for each patient were calculated.

RESULTS

The primary cohort consisted of 368 patients and the validation cohort included 74. The LASSO logistic algorithm identified three (recurrence episodes, mass size, and infection history) out of 11 potential clinical variables as significantly predictive of a pathologic intussusception. The C-index for the predictive nomogram was 0.922 (95% CI, 0.885-0.959) for the primary cohort and 0.886 (95% CI, 0.809-0.962) for the validation cohort. The decision curve showed that if the threshold probability of a patient in the validation cohort was > 7%, then the nomogram was more beneficial than either indiscriminately treating all or none of the patients.

CONCLUSION

We developed a nomogram based on clinical risk factors that could be used to individually predict pathological intussusceptions in children prior to surgical intervention.