Laparoscopic vs open surgical approach for intussusception requiring operative intervention

Case Report: An unusual case of wide ileoileal intussusception associated with intestinal volvulus in a 8-months-old infant

Introduction

Midgut volvulus and intussusception are prevalent paediatric abdominal emergencies. To the best of our knowledge, this is the first reported case of a connection between intestinal volvulus and a massive intussusception.

Case report

An 8-month-old male infant was brought to the emergency room with a history of abdominal pain and vomiting for <24 h. On physical examination, the child appeared restless and was found to have a circumferential hard mass of approximately 4 cm in diameter in the epigastric region. Upon admission, laboratory results showed a C-reactive protein level of 0.4 mg/dl, LDH level of 351 U/L, mild leukocytosis with a white blood cell count of 12 × 103 /µl, and 67% neutrophils. A physical exam was significant for abdominal distention, hyperresonance in percussion, and a palpable, painful epigastric mass. The findings of the operation included a dilated and ischemic intestinal loop, approximately 25 cm from the ileocecal valve, twisted upon itself for three turns. After de-rotation, an extensive occluding ileo-ileal invagination with an ischemic intestinal loop was identified, and a length of approximately 55-60 cm of the distal ileum, including the ischemic segment, was resected.

Discussion

This is the first reported case of a connection between intestinal volvulus and a massive intussusception. Currently, only two reported cases describe the connection between volvulus and intussusception, which are insufficient to establish a direct link between the two clinical conditions.

Laparoscopic versus Open Reduction of Intussusception in Infants and Children: A Systematic Review and Meta-analysis

We conducted a systematic review and meta-analysis to compare the efficacy and safety between laparoscopic reduction (LR) and open reduction (OR) of intussusception in infants and children. Literature searches were conducted to identify studies having compared LR and OR for children with intussusception failed to enema reduction. Parameters such as operative time, time to oral intake, length of hospital stay, overall postoperative complications, and recurrence were pooled and compared by meta-analysis. Among the 502 pediatric participants included in the 11 studies, 275 had received LR and 227 received OR. There were shorter length of hospital stays and time to oral intake with the LR approach compared with OR. However, no significant difference was found between LR and OR in the secondary outcome, such as the overall postoperative complications and recurrence. LR is a feasible, safe, and effective surgical procedure alternative to OR for pediatric intussusception. Compared with OR, LR has the advantage of shorter hospital stay and faster time to oral intake. Besides, the overall postoperative complications may be slightly lower in LR. We conclude that LR should be considered an acceptable option for children.

Laparoscopic versus Open Pediatric Surgery: Three Decades of Comparative Studies

INTRODUCTION

 Despite its wide acceptance, the superiority of laparoscopic versus open pediatric surgery has remained controversial. There is still a call for well-founded evidence. We reviewed the literature on studies published in the last three decades and dealing with advantages and disadvantages of laparoscopy compared to open surgery.

MATERIALS AND METHODS

 Studies comparing laparoscopic versus open abdominal procedures in children were searched in PubMed/MEDLINE. Reports on upper and lower gastrointestinal as hepatobiliary surgery and on surgery of pancreas and spleen were included. Advantages and disadvantages of laparoscopic surgery were analyzed for different types of procedures. Complications were categorized using the Clavien-Dindo classification.

RESULTS

 A total of 239 studies dealing with 19 types of procedures and outcomes in 929,157 patients were analyzed. We identified 26 randomized controlled trials (10.8%) and 213 comparative studies (89.2%). The most frequently reported advantage of laparoscopy was shorter hospital stay in 60.4% of studies. Longer operative time was the most frequently reported disadvantage of laparoscopy in 52.7% of studies. Clavien-Dindo grade I to III complications (mild-moderate) were less frequently identified in laparoscopic compared to open procedures (80.3% of studies). Grade-IV complications (severe) were less frequently reported after laparoscopic versus open appendectomy for perforated appendicitis and more frequently after laparoscopic Kasai's portoenterostomy. We identified a decreased frequency of reporting on advantages after laparoscopy and increased reporting on disadvantages for all surgery types over the decades.

CONCLUSION

 Laparoscopic compared with open pediatric surgery seems to be beneficial in most types of procedures. The number of randomized controlled trials (RCTs) remains limited. However, the number of reports on disadvantages increased during the past decades.

Laparoscopic and open surgery methods in managing surgical intussusceptions: A randomized clinical trial of postoperative complications

PURPOSE

To compare postoperative complications of laparoscopic surgery (LS) with open surgery (OS) in surgical intussusception patients.

METHODS

From March 2015 to February 2018, infants between 6 to 24 months old had the clinical and sono-graphical signs of intussusception enrolled in this double-blind, randomized clinical trial. We divided surgical intussusception patients into two groups. In the LS group, we evaluated patients by direct laparoscopic observation, on-table hydrostatic enema, and mechanical reduction of intussusception. In the OS group, we performed the conventional technique. These patients were followed for 2 years after procedures for comparison of postoperative complications between the two groups.

RESULTS

We had 52 patients who needed surgical exploration (26 in each group). There were four (15%) and seven (27%) patients with self-reduced intussusception in LS and OS groups, respectively. The conversion rate was 31% (eight cases). Five cases (19%) in the LS group and four cases (15%) in the OS group needed bowel resections. Operating time was longer in the LS group (P ≤ 0.006), and the postoperative complication rate was higher in the OS group (P ≤ 0.021).

DISCUSSION

Laparoscopy is a screening tool to determine the need for OS in surgical intussusception patients. Laparoscopy reduces the incidence of OS and its complications.

Peter SD, Beres AL, Hu YY, Renaud EJ, Ricca R, Slidell MB, Taylor A, Smith CA, Miniati D, Sola JE, Valusek P, Berman L, Raval MV, Gosain A, Dellinger MB, Sømme S, Downard CD, McAteer JP, Kawaguchi A. Management of intussusception in children: A systematic review

OBJECTIVE

The goal of this systematic review by the American Pediatric Surgical Association Outcomes and Evidence-Based Practice Committee was to develop recommendations for the management of ileocolic intussusception in children.

METHODS

The ClinicalTrials.gov, Embase, PubMed, and Scopus databases were queried for literature from January 1988 through December 2018. Search terms were designed to address the following topics in intussusception: prophylactic antibiotic use, repeated enema reductions, outpatient management, and use of minimally invasive techniques for children with intussusception. The Preferred Reporting Items for Systematic reviews and Meta-Analyses (PRISMA) guidelines were followed. Consensus recommendations were derived based on the best available evidence.

RESULTS

A total of 83 articles were analyzed and included for review. Prophylactic antibiotic use does not decrease complications after radiologic reduction. Repeated enema reductions may be attempted when clinically appropriate. Patients can be safely observed in the emergency department following enema reduction of ileocolic intussusception, avoiding hospital admission. Laparoscopic reduction is often successful.

CONCLUSIONS

Regarding intussusception in hemodynamically stable children without critical illness, pre-reduction antibiotics are unnecessary, non-operative outpatient management should be maximized, and minimally invasive techniques may be used to avoid laparotomy.

LEVEL OF EVIDENCE

Level 3-5 (mainly level 3-4) TYPE OF STUDY: Systematic Review of level 1-4 studies.

Potential Therapeutic Approaches for the Intussusception Through a Side-to-Side Jejunojejunal Anastomosis After Laparoscopic Gastrectomy

We reviewed our experience with the management of intussusception presenting as a complication of laparoscopic gastrectomy (LG) and studied the feasibility of a laparoscopic intervention to treat or prevent this condition. We retrospectively analyzed the data of 12 patients diagnosed with intussusception, following gastrectomy, from 2008 to 2017, including clinical manifestations, incidence, post-LG time-interval before diagnosis, and treatment. Totally, 12/2300 gastrectomy patients (0.52%) developed intussusception. All 12 had undergone laparoscopic distal gastrectomy for gastric cancer (12/1250, 0.96%) and presented with intussusception through a side-to-side jejunojejunal anastomosis. The mean latency period was 423.8 (range: 86 to 1500) days. Four patients underwent emergent laparoscopic reduction of the efferent loop without bowel resection, along with fixation of the reduced jejunum to the afferent loop and the small bowel mesentery, to prevent a recurrence. One patient required open surgery with manual reduction and segmental resection of the gangrenous small bowel portion. All operated patients recovered without any complications. Intussusception resolved spontaneously in the remaining 7/12 patients. We found that a laparoscopic approach can be used for preventing or managing post-LG intussusception. We found that recurrence can be prevented or treated by anchoring and fixing the (reduced) efferent loop to the afferent loop and the small bowel mesentery.

A multicentre comparative study between laparoscopic and open surgery for intussusception in adults

AIM

Intussusception in adults is rare and requires surgery in most cases. While abdominal laparoscopic surgery (LS) is becoming more popular, there are few reports on the outcomes of adult intussusception treated with LS. This study compared the feasibility of LS vs open surgery (OS) for adult intussusception.

METHOD

We reviewed retrospectively the medical records of adult patients with intussusception from three tertiary hospitals between 2000 and 2016. The patients were divided into LS and OS groups, and their surgical outcomes were compared.

RESULTS

Surgery was indicated in 71 patients with intussusception (41 LS and 30 OS). The median age of the patients was 49.0 and 51.5 years in the LS and OS groups, respectively (P = 0.930). Overall, nine (12.7%) patients had a negative laparotomy or laparoscopy with spontaneous reduction of the intussusception. Conversion to OS from LS was necessary in one patient (2.4%). The operative time and intra-operative and postoperative complication rates were not significantly different. However, there were more serious complications such as bowel perforation and major vessel injury in the LS group. The patients in the LS group had a shorter time to first food intake and hospital stay vs patients in the OS group (4.0 vs 6.0 days, P < 0.001, and 7.0 vs 10.5 days, P < 0.001, respectively).

CONCLUSION

LS may be feasible for adult intussusception; there may be more severe intra-operative complications than in OS.

Perforated gangrenous ileo-colic intussusception in a 9 month old Nigerian infant presenting at a private hospital: A case report

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The current case presented late with complication of gangrene and perforation because it was first managed as a case of gastroenteritis.

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Gastroenteritis is among the various differential diagnosis of intussusception a high index of suspicion is required for timely diagnosis.

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Being available, cheap and free of radiation, using ultrasound more often in infants can aid diagnosis.

Introduction

Intussusception is the process of invagination of a bowel segment into the adjoining intestinal lumen which may cause bowel obstruction and gangrene. It commonly occurs in infants at a mean age of 9-months with male preponderance. The condition has excellent prognosis if diagnosis is made early and appropriate treatment commenced and mortality rate from intussusception in children can be less than 1%. However, if diagnosis or treatments are delayed it can be fatal in a few days.

Presentation of case

We present a case of Ileo-colic perforated ileum due to delayed diagnosis. It was initially misdiagnosed as gastroenteritis at another hospital. The infant was resuscitated with intravenous fluid and had laparotomy. A signed consent was obtained before the surgery and media consent was signed for publication. A gangrenous terminal ileum was resected and ileo-colic anastomosis was done. Post-operative course was uncomplicated and the patient was discharged after 5days.

Discussion

The index case presented late with complication of gangrene and perforation because it was first managed as a case of gastroenteritis. Gastroenteritis is among the various differential diagnosis of intussusception. Complications have been reported to increase numbers of surgical treatment and sometimes mortality, but rarely occur with good diagnostic acumen.

Conclusion

We conclude that high clinical suspicion, interaction with senior surgeons and regular use of ultrasound in infants with gastrointestinal symptoms will aid diagnosis. Although surgery was performed in the index case, non-surgical reduction is a very efficient treatment modality in uncomplicated cases.

The incidence of negative intraoperative findings after unsuccessful hydrostatic reduction of ileocolic intussusception in children: A retrospective analysis

BACKGROUND

There is a lack of studies addressing the occurrence of negative intraoperative findings (that is the absence of intussusception) after an unsuccessful hydrostatic reduction of an ileocolic intussusception. The aim of this study is to determine the incidence of negative intraoperative findings after unsuccessful hydrostatic reduction of ileocolic intussusception.

METHODS

We conducted a multicentre retrospective study of all children aged 0-18 years treated for ileocolic intussusception from January 1, 2010 to December 31, 2015 in 9 Dutch hospitals. Primary outcome measure was the percentage of children without an intussusception during surgical exploration after unsuccessful hydrostatic reduction.

RESULTS

In the study period 436 patients were diagnosed with an ileocolic intussusception. Of these, 408 patients underwent hydrostatic reduction of an ileocolic intussusception. 112 patients (27.5%) underwent surgery after an unsuccessful hydrostatic reduction. In 13 (11.6%) patients no intraoperative evidence of intussusception was found. Patients who underwent surgical intervention after unsuccessful hydrostatic reduction were significantly younger than patients who had a successful hydrostatic reduction; there was no gender difference.

CONCLUSION

A substantial number of children (11.6%) underwent a laparotomy after unsuccessful hydrostatic reduction in whom no intussusception was found intraoperatively. We suggest initiating laparoscopy instead of laparotomy when surgery is necessary.

LEVEL OF EVIDENCE

Level II.

Management for intussusception in children

BACKGROUND

Intussusception is a common abdominal emergency in children with significant morbidity. Prompt diagnosis and management reduces associated risks and the need for surgical intervention. Despite widespread agreement on the use of contrast enema as opposed to surgery for initial management in most cases, debate persists on the appropriate contrast medium, imaging modality, pharmacological adjuvant, and protocol for delayed repeat enema, and on the best approach for surgical management for intussusception in children.

OBJECTIVES

To assess the safety and effectiveness of non-surgical and surgical approaches in the management of intussusception in children.

SEARCH METHODS

We searched the following electronic databases: Cochrane Central Register of Controlled Trials (CENTRAL; 2016, Issue 8) in the Cochrane Library; Ovid MEDLINE (1950 to September 2016); Ovid Embase (1974 to September 2016); Science Citation Index Expanded (via Web of Science) (1900 to September 2016); and BIOSIS Previews (1969 to September 2016).We examined the reference lists of all eligible trials to identify additional studies. To locate unpublished studies, we contacted content experts, searched the World Health Organization International Clinical Trials Registry Platform (ICTRP) and ClinicalTrials.gov (September 2016), and explored proceedings from meetings of the British Association of Paedatric Surgeons (BAPS), the American Soceity of Pediatric Surgery, and the World Congress of Pediatric Surgery.

SELECTION CRITERIA

We included all randomised controlled trials comparing contrast media, imaging modalities, pharmacological adjuvants, protocols for delayed repeat enema, and/or surgical approaches for the management of intussusception in children. We applied no language, publication date, or publication status restrictions.

DATA COLLECTION AND ANALYSIS

Two review authors independently conducted study selection and data extraction and assessed risk of bias using a standardised form. We resolved disagreements by consensus with a third review author when necessary. We reported dichotomous outcomes as risk ratios (RRs) with 95% confidence intervals (CIs). We analysed data on an intention-to-treat basis and evaluated the overall quality of evidence supporting the outcomes by using GRADE criteria.

MAIN RESULTS

We included six randomised controlled trials (RCTs) with a total of 822 participants. Two trials compared liquid enema reduction plus glucagon versus liquid enema alone. One trial compared liquid enema plus dexamethasone versus liquid enema alone. Another trial compared air enema plus dexamethasone versus air enema alone, and two trials compared use of liquid enema versus air enema. We identified three ongoing trials.We judged all included trials to be at risk of bias owing to omissions in reported methods. We judged five of six trials as having high risk of bias in at least one domain. Therefore, the quality of the evidence (GRADE) for outcomes was low. Interventions and data presentation varied greatly across trials; therefore meta-analysis was not possible for most review outcomes. Enema plus glucagon versus enema alone It is uncertain whether use of glucagon improves the rate of successful reduction of intussusception when compared with enema alone (reported in two trials, 218 participants; RR 1.09, 95% CI 0.94 to 1.26;low quality of evidence). No trials in this comparison reported on the number of children with bowel perforation(s) nor on the number of children with recurrent intussusception. Enema plus dexamethasone versus enema alone Use of the adjunct, dexamethasone, may be beneficial in reducing intussusception recurrence with liquid or air enema (two trials, 299 participants; RR 0.14, 95% CI 0.03 to 0.60; low quality of evidence). This equates to a number needed to treat for an additional beneficial outcome of 13 (95% CI 8 to 37). It is uncertain whether use of the adjunct, dexamethasone, improves the rate of successful reduction of intussusception when compared with enema alone (reported in two trials, 356 participants; RR 1.01, 95% CI 0.92 to 1.10;low quality of evidence). Air enema versus liquid enema Air enema may be more successful than liquid enema for reducing intussusception (two trials, 199 participants; RR 1.28, 95% CI 1.10 to 1.49; low quality of evidence). This equates to a number needed to treat for an additional beneficial outcome of 6 (95% CI 4 to 19). No trials in this comparison reported on the number of children with bowel perforation(s) or on the number of children with recurrent intussusception nor any intraoperative complications, such as bowel perforation, or other adverse effects. Only one trial reported postoperative complications, but owing to the method of reporting used, a quantitative analysis was not possible. We identified no studies that exclusively evaluated surgical interventions for management of intussusception.

AUTHORS' CONCLUSIONS

This review identified a small number of trials that assessed a variety of interventions. All included trials provided evidence of low quality and were subject to serious concerns about imprecision, high risk of bias, or both. Air enema may be superior to liquid enema for successfully reducing intussusception in children; however, this finding is based on a few studies including small numbers of participants. Dexamethasone as an adjuvant may be more effective in reducing intussusception recurrence rates following air enema or liquid enema, but these results are also based on a few studies of small numbers of participants. This review highlights several points that need to be addressed in future studies, including reducing the risk of bias and including relevant outcomes. Specifically, surgical trials are lacking, and future research is needed to address this evidence gap.

Laparoscopic versus open reduction of intussusception in children: a retrospective review and meta-analysis

BACKGROUND

Intestinal intussusception is a frequent cause of bowel obstruction in children. Initial treatment involves pneumatic reduction. If this fails, operative reduction is indicated. There is controversy regarding use of the laparoscopic (LAP) versus the conventional open approach.

PATIENTS AND METHODS

We performed a retrospective review of all children with intussusception who required operative reduction at our institution over a 12-year time period. We also performed a meta-analysis to combine our data with the published literature.

RESULTS

We identified 28 patients requiring operative intervention for reduction of intussusception between January 2000 and April 2012. Five patients underwent LAP reduction, and 23 patients underwent open reduction. Operative times were not statistically different. The rate of overall complications was not statistically different, with 1 of 5 (20%) and 7 of 23 (30%) having complications in the LAP and open groups, respectively. Mean length of stay was 3.8±2.1 days in both the LAP and open groups, with no significant difference. Our meta-analysis identified five retrospective studies comparing LAP and open techniques for reduction of intussusception. We did not find a significant difference between groups with respect to operative time, overall complication rates, or re-operation rates. However, the length of hospital stay was significantly longer in the open group.

CONCLUSIONS

LAP reduction of intussusception is a safe and feasible alternative to the open approach. Length of stay may be shorter in the LAP group.

Laparoscopic treatment of intussusception

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The success of laparoscopic approach in children has encouraged the application of this technique in young (<2 years) children with non-complicated intussusception.

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The use of mini-laparoscopy in children (usually 2 mm instruments tools), described in processes such as acute appendicitis may be useful in the context of intussusception as well.

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Laparoscopic reduction of intussusception appears to be a safe procedure, in young children with uncomplicated intussusception.

Introduction

The success of laparoscopic approach in children has encouraged the application of this technique in young (<2 years) children with non-complicated intussusception.

Material and method

A retrospective analysis of our database provided a total of 4 patients who underwent laparoscopic reduction of intestinal intussusception between 8/2008 and 4/2013. A comprehensive review of each case was done including the video description of the laparoscopic technique of one of them.

Results

Four patients (2 boys) were treated by laparoscopy for intestinal intussusception. Mean age was 9 months (5–20 months). Delay time between initial symptoms and diagnosis and between diagnosis and surgery were 3.5 days and 6 h respectively. Mean operative time was 35 min. There were no conversions. There were no complications. Patients were discharged after 2.5 days (2–4 days). We herein report (video) the laparoscopic approach in a 5 month male child who suffered from a ileocecal intussusception. A 10 mm trocar was placed in the left lower quadrant and two 5 mm trocars were placed in the upper left quadrant and suprapubic just to the right midline. The cause of the intussusception was identified and the bowel was reduced. A concomitant appendectomy was performed.

Conclusion

Laparoscopic reduction of intussusception appears to be a safe procedure, in young children with uncomplicated intussusception.

Laparoscopy versus open surgery for idiopathic intussusception in children

PURPOSE

This study aims to compare the results of laparoscopy and open surgery for idiopathic intussusception in children as well as evaluate the efficacy of ileopexy.

METHODS AND MATERIALS

Between January 2007 and July 2013, children aged <18 years who were operated for intussusception in our institution were reviewed. Patients were classified into two groups, laparoscopy (LAP) and open (OPEN). Both groups were further divided into two subgroups, ileopexy (IP) and non-ileopexy (NIP). Parameters investigated included age, gender, operative indication, surgical procedure, type of intussusception, level of intussusceptum, presence of spontaneously reduced intussusception and pathologic lead points, operative time (OP time), time to oral intake (PO time), length of postoperative hospital stay (LOS), and surgical recurrence.

RESULTS

There were 23 and 35 patients in LAP and OPEN group, respectively. No significant difference was found on age, operative indication, surgical procedure, type of intussusception, level of intussusceptum, and presence of spontaneously reduced intussusception between both groups. In LAP group, mean OP time was significantly longer; mean PO time and LOS were significantly shorter. One surgical recurrence occurred in each group (p = 0.76). In comparison of LAP-IP (n = 15) and LAP-NIP (n = 8), OP time, PO time, and LOS were similar in both subgroups. One recurrence was noted in LAP-IP (p = 0.46). The overall conversion rate was 13.0 % (6.8 vs. 25 %, p = 0.21). Compared to patients with intussusceptum to ascending colon, the conversion rate was significantly higher in patients with intussusceptum to transverse and descending colon. With the exclusion of conversion, OP time was significantly shorter in LAP-NIP (p = 0.01).

CONCLUSION

Laparoscopy should be considered the primary modality for radiologically irreducible or recurrent idiopathic intussusception in children. Ileopexy provides no benefit on recurrence prevention but contributes to longer OP time.

Laparoscopic treatment of intussusception in children: a systematic review

BACKGROUND

Idiopathic intussusception is one of the most common causes of small bowel obstruction in children. In the event of failed radiological reduction, laparotomy remains the treatment of choice. There is still no agreement in pediatric surgery about safety and effectiveness of the use of minimally invasive surgery in this common pediatric condition. By reviewing available data we aimed to establish whether laparoscopy should be the primary technique in the surgical reduction of intussusception.

METHODS

A systematic review of all publications on the laparoscopic treatment of pediatric intussusception from January 1990 to April 2012 was performed. The following variables were analyzed: age, laparoscopic success rate, reason for conversion, enterotomy rate, operative time, complications, and length of stay (LOS).

RESULTS

Ten retrospective studies treating 276 cases of laparoscopically reduced intussusception were identified. A total of 80 conversions corresponded to a 71.0% laparoscopic success rate. Only one case of intraoperative iatrogenic intestinal perforation was reported (0.4%). Postoperative complications occurred in 8 patients (2.9%), and adhesive small bowel obstruction was reported in 1 case (0.4%). Recurrence rate after laparoscopy was 3.6%. Three of 10 papers compared results between laparoscopic and open reduction of intussusception showing a shorter mean LOS in the former group (4.0 vs. 7.1 days, p<0.01).

CONCLUSION

Laparoscopy is safe and effective in the treatment of pediatric intussusception. Tertiary centers with adequate minimally invasive skills should establish laparoscopy as the primary surgical technique in the treatment of this condition.

Laparoscopic versus open reduction of intussusception in children: experience over a decade

BACKGROUND

Intussusception is a common cause of bowel obstruction in children, which sometimes necessitates operative reduction and or resection. We report our series of patients with intussusception who were treated laparoscopically (LAP group) compared with exploratory laparotomy (OPEN group).

SUBJECTS AND METHODS

After institutional review board approval, a retrospective review was performed evaluating outcomes for patients requiring surgical reduction of intussusception over a 10-year period. Analysis was based on intent to treat, and technique of exploration was surgeon's choice. Data were analyzed with the Wilcoxon rank sum test and chi-squared test where appropriate. P≤.05 was considered significant.

RESULTS

During the time period studied, there were 92 patients treated surgically for intussusception: 65 LAP and 27 OPEN. Conversion to the open procedure was required for 21 patients in the LAP group, and of those, 6 required bowel resection. Seven of the patients who were started in the OPEN group ultimately required bowel resection. Operative time, length of hospital stay, time to full feeds, and total days of narcotics were all significantly shorter for the LAP group compared with the OPEN group (P=.003, P=.001, P=.001, and P=.004, respectively). A pathologic lead point was found in 14% of LAP and 15% of OPEN cases. In a subset analysis, 33% of patients who were converted from the LAP group to the open procedure had a pathologic lead point. Complication rates between the LAP and OPEN groups were comparable.

CONCLUSIONS

Laparoscopy appears to be a safe and effective technique for reducing intussusception in children. The laparoscopic cases had shorter operative time, shorter time to full feeds, lower requirement for intravenous narcotics, and earlier discharges.

Japanese guidelines for the management of intussusception in children, 2011

BACKGROUND

The Japanese Society of Emergency Pediatrics has formulated evidence-based guidelines for the management of intussusception in children in order to diagnose intussusceptions promptly, to initiate appropriate treatment as early as possible, and to protect intussuscepted children from death.

METHODS

Literature was collected systematically via the Internet using the key words "intussusception" and "children." The evidence level of each paper was rated in accordance with the levels of evidence of the Oxford Center for Evidence-based Medicine. The guidelines consisted of 50 clinical questions and the answers. Grades of recommendation were added to the procedures recommended on the basis of the strength of evidence levels.

RESULTS

Three criteria of "diagnostic criteria,""severity assessment criteria," and "criteria for patient transfer" were proposed aiming at an early diagnosis, selection of appropriate treatment, and patient transfer for referral to a tertiary hospital in severe cases. Barium is no longer recommended for enema reduction (recommendation D) because the patient becomes severely ill once perforation occurs. Use of other contrast media, such as water-soluble iodinated contrast, normal saline, or air, is recommended under either fluoroscopic or sonographic guidance. Delayed repeat enema improves reduction success rate, and is recommended if the initial enema partially reduced the intussusception and if the patient condition is stable.

CONCLUSIONS

The guidelines offer standards of management, but it is not necessarily the purpose of the guidelines to regulate clinical practices. One should judge each individual clinical situation in accordance with experiences, available devices, and the patient's condition.

Role of laparoscopy in non-trauma emergency pediatric surgery: a 5-year, single center experience a retrospective descriptive study with literature review

Background

Although laparoscopy is rapidly becoming the abdominal surgical modality of choice in adults, there are obstacles to its use in children. We analyzed our experience with pediatric laparoscopic surgery over the past 5 years, with particular emphasis on emergency procedures.

Findings

We retrospectively evaluated the records of patients aged <14 years who had undergone laparoscopic procedures for non-trauma emergency conditions at our institution from January 2006 to December 2010. The clinical parameters evaluated included operation time, total length of hospital stay, and postoperative complications.

During the 5-year study period, 482 laparoscopic procedures were performed on patients aged <14 years, comprising 300 emergency and 182 elective operations. The majority of procedures were laparoscopic appendectomies, with most of the others being resections of ovarian cysts or Meckel’s diverticulae, or adhesiolyses. We observed an improvement in outcomes over the 5-year period, as shown by shorter operation times and shorter postoperative hospital stays. The numbers of laparoscopic procedures performed increased over time.

Conclusions

Pediatric laparoscopic surgery for emergency conditions provides excellent results, including better exposure and cosmetic outcomes than laparotomy. At our institution, the numbers and types of laparoscopic procedures performed have increased over time, and the outcomes of laparoscopic procedures have improved.

Diagnosis and management of pediatric appendicitis, intussusception, and Meckel diverticulum

Three of the most common causes of surgical abdominal pain in pediatric patients include appendicitis, Meckel diverticulum, and intussusception. All 3 can present with right lower quadrant pain, and can lead to significant morbidity and even mortality. Although ultrasound is the preferred method of diagnosis with appendicitis and intussusception, considerable variety exists in the modalities needed in the diagnosis of Meckel diverticulum. This article discusses the pathways to diagnosis, the modes of treatment, and the continued areas of controversy.

Intraoperative hydrostatic reduction of intussusception

AIMS

To find out an easier way of reduction of intussusception during open surgery to avoid unnecessary bowel injury.

MATERIALS AND METHODS

Under general anesthesia, before laparotomy, warm normal saline was infused into the rectum with a Foley catheter and an intravenous drip set maintaining the level of the bottle at 80 cm above the operating table. After opening the abdomen, pressure was applied on the colon filled with normal saline distal to the intussusceptum. The pressure was transmitted to the intussusceptum and the walls of the intussuscipient and caused reduction of intussusception without any injury to the intussuscipient and intussusceptum. This procedure was performed on those patients on whom laparotomy was performed as a primary procedure due to nonavailability of fluoroscopy or ultrasonography.

RESULTS

Between August 1998 and July 2005, we had six patients of mean (range) age 11 months (7-17 months). In two cases, at laparotomy, the intussusceptions were found to have already reduced.

CONCLUSIONS

Gentle finger pressure is necessary for reduction of intussusception. This subjective "gentleness" is dependant on experience of the surgeon and varies from person to person. Focal pressure on the intussuscipient and apex of the intussusceptum by the finger during reduction may be more damaging than the diffusely transmitted hydrostatic pressure even by a less-experienced surgeon. This will avoid the needless resection and anastomosis of the intestine on many occasions.

Laparoscopy-assisted hydrostatic in situ reduction of intussusception: A reasonable alternative?

Aim:

To evaluate an alternative way of reducing intussusceptions under laparoscopic guidance.

Materials and Methods:

This is a retrospective observational study of children who underwent laparoscopy-assisted hydrostatic in situ reduction of intussusceptions (LAHIRI). Under general anesthesia with laparoscopic vision, warm saline was infused into the rectum with a 16-18 F Foley catheter and a drip set till the intussusception was reduced.

Results:

Eleven patients [age 7.8 (±2.8) months] were operated over a period of 1 year. Ten (90.9%) patients had ileocolic intussusception, which got completely reduced, but one (9%) had ileo-ileocolic intusussception, in whom manual reduction by extending the subumbilical incision was required to reduce the ileoileal part. The mean duration of surgery was 38.5 (±6.6) min. No patient had bowel ischemia and there were no intra- or postoperative complications.

Conclusions:

LAHIRI appears to be an effective and safe technique in children. Specific advantages are that it is performed in a controlled environment in the operating room, avoids patient apprehension and discomfort, avoids bowel handling, provides a safe opportunity to create higher intraluminal pressure, ensures visual assessment of bowel vascularity and completeness of reduction.

Diagnosis and laparoscopic treatment of ileoileal intussusception secondary to heterotopic pancreas in an infant: case report and review of the literature

Small bowel intussusception in infancy owing to a pathologic lead point is a rare event requiring immediate surgical attention. We report a case of a 7-month-old patient presenting with ileoileal intussusception with isolated heterotopic pancreas as the lead point. We review the literature of small bowel intussusception focusing on diagnosis and treatment. In contrast to comparable previous reports of infants with heterotopic pancreas and intussusception, the diagnosis was based solely on ultrasound findings followed by operative management using a laparoscopically assisted surgical approach.

Laparoscopic reduction of intussusception in children by a single surgeon in comparison with open surgery

The surgical approach for managing intussusception is controversial. In this study, a retrospective analysis of patients undergoing surgical reduction for intussusception over a period of five years was conducted. All patients received either open surgery or laparoscopic approach after failing enema reduction of intussusception. The clinical and operative data were collected and analyzed. Eight patients received open surgery (OPEN group), and 37 patients received laparoscopic surgery, while two (5.4%) of them converted to open surgery. The remaining 35 patients were included in the LAP group. There was no difference in age, gender, clinical symptoms and signs, duration of symptoms, level of intussusception, and complications between the OPEN and LAP groups. In contrast, the operation time and length of hospital stay in the LAP group were significantly shorter than those in the OPEN group (P = 0.013 and P = 0.001 respectively). No recurrence was disclosed in the OPEN group but three patients in the LAP group had recurrent intussusception (8.6%); however, the difference of the recurrence rate between these two groups was not statistically significant (P = 0.40). In conclusion, reducing intussusception with the laparoscopic approach is highly successful and can be performed first for stable patients requiring surgical intervention.

Triple intussusception involving heterotopic pancreatic tissue: a case report

INTRODUCTION

Intussusception involving heterotopic pancreatic tissue is a rare condition where a portion of the bowel telescopes into an adjacent segment with intraluminal pancreatic tissue as the lead point. Cases of heterotopic pancreas are most often described in the upper intestinal tract, particularly the stomach.

CASE PRESENTATION

We present the case of a five-month-old boy of Caucasian ethnicity suffering acute abdominal pain and vomiting with an abdominal mass in the upper right quadrant. Work-up including ultrasound scan confirmed the intussusception. Repeated attempts at radiological reduction and two laparoscopic procedures were performed within 24 hours, which eventually led to the diagnosis of a triple intussusception.

CONCLUSION

To our knowledge, such a case of triple intussusception involving isolated heterotopic pancreatic tissue is previously unreported.

Laparoscopic management of intussusception in pediatric patients

INTRODUCTION

Minimally invasive approaches are beginning to be employed in the management of pediatric patients with intussusception who fail radiographic reduction. Successful laparoscopic reduction has been demonstrated, but the utility of laparoscopy, for more complex cases, is less well documented. Therefore, we reviewed our experience with laparoscopy in patients with radiographically irreducible intussusception to document the safety and effectiveness of this approach.

METHODS

We conducted a retrospective review of all of the patients who had a radiographically irreducible intussusception treated via the laparoscopic approach at a single institution from 1998 to 2008. Means are expressed +/- standard deviation.

RESULTS

A total of 22 patients were identified, with an average age of 2.9 +/- 3.0 years. Average length of stay was 2.67 +/- 1.5 days (median, 2). Sixteen (73%) of the 22 patients were male. There were 19 ileocecal and 3 small bowel intussusceptions. Twenty patients (91%) were able to be managed entirely laparoscopically or via extension of the umbilical incision, while 2 necessitated conversion, using a right-lower quadrant incision. Nine patients had an extension of the umbilical incision; 7 of these underwent a bowel resection. Ten patients (46%) had a bowel resection, of which 5 were an ileocecectomy and 5 were segmental small bowel resection. There were a total of 9 patients with a pathologic lead point, 5 patients with lymphoid hyperplasia, and 4 with Meckel's diverticula.

CONCLUSION

We conclude that laparoscopy is a reasonable approach to pediatric intussusception, even in the event when bowel resection is necessary.

Recent advances and controversies in pediatric laparoscopic surgery

Children represent a unique group of patients who are likely to greatly benefit from minimally invasive surgery (MIS). The promise of less postoperative pain, smaller scars, shorter hospital stays, and a faster return to school continues to drive growth in this area. The development of pediatric-specific techniques and documentation of improved outcomes form a critical gateway to widespread application of pediatric MIS. A brief perspective on current approaches to MIS for pediatric congenital and acquired disease is provided in this report. Technical departures from standardized adult MIS and the rationale for their modification are highlighted.

Indications for laparoscopy in the management of intussusception: A multicenter retrospective study conducted by the French Study Group for Pediatric Laparoscopy (GECI)

INTRODUCTION

Surgical management of intussusception is required for cases where enema reduction fails. Some articles report an advantage of the laparoscopic over the open approach, but complications such as serosal tearing and frank perforation have been described. We aim to determine the best indication of laparoscopy in the decisional management tree of intussusception.

PATIENT AND METHOD

This is a retrospective chart review of all children with intussusception who failed hydrostatic enema reduction and who underwent immediate laparoscopic management. Cases were compiled from 7 pediatric surgical centers (French Study Group of Pediatric Laparoscopy) between 1992 and 2005. Data collected included age, duration of symptoms, findings on initial assessment, level of intussusceptum after attempted hydrostatic enema reduction, type of laparoscopic approach, operative time, conversion to open surgery, etiology, and postoperative complications. Two groups were analyzed-conversion to open surgery or not.

RESULTS

Sixty-nine patients (48 males and 21 females) were reviewed. In total, 22 patients required a conversion to open surgery (31.9%). Eleven of these were converted because of failure of laparoscopic reduction. The risk for conversion to open surgery is directly linked to the length of time between onset of symptoms and diagnosis (1.6 vs 3.1 days for conversion group, P = .048), the presence of signs of peritonitis on the initial clinical assessment (10.6% vs 41% in conversion group, P = .003), and the presence or absence of a pathologic lead point (17% vs 50% in conversion group, P = .004).

CONCLUSION

The child seen early after the onset of symptoms (<1.5 days) with no signs of peritonitis is the best candidate for a laparoscopic approach in management of intussusception requiring surgery. Particular attention must be paid to not miss a pathologic lead point, especially as most tactile cues are lost.

Early laparoscopy for ileocolic intussusception with multiple recurrences in children

BACKGROUND

The risks of subsequent episodes and a lead point are common problems in ileocolic intussusception with more than two recurrences. To decrease subsequent recurrence and to detect a lead point, an early laparoscopy was performed for children with ileocolic intussusception.

METHODS

This study enrolled six children with multiple recurrences of ileocolic intussusception from January 2004 to August 2007. Using a 5-mm laparoscope and two additional transabdominal wall stab incisions, an appendectomy and an ileocolonic pixie with nonabsorbable sutures were performed simultaneously for all the children after the last successful hydrostatic reduction.

RESULTS

The mean operating time was 68.8 +/- 12.6 min (range, 55-86 min). There was no operative morbidity, and no lead point was found in any child. The mean follow-up period was 10.8 +/- 6.7 months (range, 2-20 months). No recurrence was observed during this period.

CONCLUSION

The authors suggest that early intervention should be undertaken for ileocolic intussusception with multiple recurrences in children after the last nonsurgical reduction has been attempted successfully. Under this strategy, laparoscopy is an acceptable approach. It allows differentiation of a specific etiologic lesion, the possibility of incomplete reduction, and additional proximal invaginations. Later complications, such as repeat recurrence and associated surgical morbidity, also can be avoided.

Minimal access surgery for adult intussusception with subacute intestinal obstruction: a single center's decade-long experience

INTRODUCTION

In adults, 1% to 5% of bowel obstruction is caused by intussusception. In adult intussusception, there will be a demonstrable cause in 90% of cases, acting as the lead point. Laparoscopy is becoming more and more popular in its management. We present our series of intussusception in adults managed laparoscopically.

MATERIALS AND METHODS

Between 1996 and 2006, we have treated 12 adults with intussusception who presented with acute or subacute intestinal obstruction. Computed tomographic scan confirmed the diagnosis in all cases. Laparoscopic-assisted resection with primary anastomosis was successfully performed for all cases.

RESULTS

Males were more common, average being 38 years. Two patients had colonic carcinoma, as the leading point and the rest were benign tumors. There were no conversions or anastomotic leaks in any patient.

DISCUSSION

The basic principles of surgery involve straightening or removing the involved section of bowel. The outcome of surgery depends on the stage of the intussusception at diagnosis and the underlying cause. If no underlying cause is found in these cases, no specific treatment is required. With early treatment, the outcome is generally excellent.

CONCLUSIONS

Laparoscopy is a valuable diagnostic and therapeutic tool in the management of adult intussusception. It provides all the benefits of minimal access surgery.

Minimally invasive approach in the management of childhood intussusception

BACKGROUND

Intussusception is one of the most common causes of intestinal obstruction in infancy. Non-operative reduction using air enema or other hydrostatic reduction methods has been the standard treatment in most cases. However, if the non-operative method is not indicated or fails, open surgery is still necessary. With the tremendous development of the minimally invasive approach in handling surgical conditions in children in the last decade, this has been applied recently for the reduction of intussusception in children. We herein reviewed our experience of using the combined approach, namely, pneumatic reduction and, if failed, laparoscopic reduction in the management of childhood intussusception.

METHODS

We carried out a retrospective analysis of all children with intussusception managed at Prince of Wales Hospital between December 1998 and December 2004. The minimally invasive approach was used as far as possible. The method of reduction, success rate and the incidence of complication were analysed.

RESULTS

Over a 6-year period, there were 146 patients with 167 episodes of intussusception. Pneumatic reduction was carried out in 160 occasions and was successful in 134 (83.8%). In 33 patients, operative reduction was required. Of these, laparoscopic reduction was attempted in 15 and was successful in 13 (86.7%). In those with either pneumatic or laparoscopic reduction, no procedure-related complication was encountered and they had a significant shorter hospital stay (median 3.0 day) than those requiring laparotomy (median 8.0 day) (t-test, P < 0.0001).

CONCLUSION

The minimally invasive approach, that is, pneumatic and/or laparoscopic reduction, was successful in reducing intussusception in 88% of patients with minimal morbidity and shorter hospital stay.

Minimally invasive surgery in the diagnosis and treatment of abdominal pain in children

PURPOSE OF REVIEW

Children with abdominal pain sometimes require surgical intervention, and laparoscopy is increasingly the preferred approach for the diagnosis and treatment of both acute and chronic abdominal pain in children. This review describes the current state of the art and recent developments in the application of minimally invasive surgical techniques for the treatment of children with various abdominal pain syndromes.

RECENT FINDINGS

Laparoscopy provides distinct advantages over traditional open surgery, including less pain, shorter recovery and improved cosmesis. Cumulative experience and ongoing outcomes research continue to substantiate the safety and efficacy of the approach when applied thoughtfully and by experienced practitioners. In fact, as minimally invasive surgery is being applied to treat more wide-ranging disorders, it is becoming apparent that for many conditions laparoscopy should be adopted as the standard of care.

SUMMARY

Recent advances in minimally invasive surgery have clearly benefited children with abdominal pain who need surgery, and as techniques improve and instruments get smaller we can expect this trend to continue into the future.

Laparoscopic versus open reduction of intussusception in children: a single-institution comparative experience

BACKGROUND

The role of laparoscopic surgery in treating intussusception has been controversial. This study reviews our institution's experience with the laparoscopic approach (LAP) compared to the open surgical approach (OPEN).

METHODS

Retrospective analysis of all patients undergoing surgery for intussusception at our center from January 2002 to February 2006. Statistical assessment included Student's t test and chi2 analysis.

RESULTS

A total of 41 patients required operation for intussusception (18 LAP, 23 OPEN). Mean age was 22 months for LAP and 11 months for OPEN (P = .17). In the LAP group, 28% (5/18) were converted to an open procedure. Operative times and complications were not significantly different. Pathologic lead points were found in 33% (6/18) LAP and 35% (8/23) OPEN patients (P = 1.0). Time to full feeds was significantly shorter (LAP vs OPEN: 3.4 +/- 2.7 vs 5.6 +/- 3.4 days, P = .02). Length of stay was shorter (LAP vs OPEN: 4.8 +/- 3.5 vs 9.1 +/- 7.5 days, P = .03).

CONCLUSIONS

Intussusception can be treated safely and effectively using a LAP with a significant decrease in time to full feeds and length of stay. The LAP should be considered as the initial approach for stable patients with intussusception requiring operative intervention.

Pediatric minimal-access surgery: update 2006

Pediatric patients continue to benefit from the advances made in minimal-access surgery. Improvements in techniques and tools have made minimal-access procedures increasingly available to children. Growing popularity of laparoscopy and thoracoscopy has resulted in greater numbers of patients available for outcomes analysis. Randomized, controlled studies have been difficult to perform because of parent, patient, and physician selection bias.