Pneumatic reduction of intussusception: clinical experience and factors affecting outcome

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.

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 for recurrent intussusception after successful reduction in pediatric patients in a tertiary care hospital of Nepal: A prospective study

Background

Intussusception is defined as the invagination of one segment of intestine into another segment of intestine. It may recur because of persistence or return of some factor responsible for the primary intussusception. Various risk factors have been reported but still not well elucidated.

Materials and methods

This is the prospective observational study. In this study, 78 patients, age <16 years with diagnosis of intussusception between June 2019 and April 2020 who had successful reduction with either hydrostatic reduction and/or operative reduction in Teaching Hospital were enrolled in the study. This is study of early recurrence as patients were followed up to a period of 1 month for recurrence of intussusception. The recurrent cases were thus identified and various variables were compared between recurrent and non-recurrent cases by univariable and multivariable analysis.

Results

Among 78 patients, 13 patients (16.7%) had recurrent intussusception. In the univariable analysis model, the significant risk factors for recurrence of intussusception analyzed were duration of symptoms of 48 h or more, fever, blood in stool and palpable mass. While after multivariable analysis, we found that the significant risk factors for recurrence of intussusception were duration of symptoms ≥48 h (OR = 5.32, p-value = 0.047), Fever (OR = 17.32, p-value = 0.001), palpable mass (OR = 24.12, p-value = 0.017).

Conclusion

Attention and awareness among pediatricians about these sonographic and clinical risk factors especially symptoms for recurrence are needed to minimize pre-hospital delay and identify patients in risk of recurrence. This ultimately helps to improve care for pediatric patients with recurrent intussusception.

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Intussusception is a common abdominal emergency in infancy and childhood.

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Definitive or reliable risk factors for recurrence, other than anatomical features, have not been well elucidated.

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Duration of symptoms >24 h, fever and palpable mass are the risk factors.

The efficacy of delayed, repeated reduction enema in management of intussusception

Background

Management of intussusception varies according to the case, time of presentation, cause, and symptoms. In this study, we focus on describing the demographic and sonographic characteristics of children with intussusception with failed initial enema reduction who were managed by delayed repeated enema attempts and identify predictors associated with successful repeated reduction.

Results

This study was conducted in the period from December 2018 to April 2020 at university hospitals (pediatric surgery unit). This study included 40 patients with intussusceptions; 27 are males, and 13 of them are females. Their ages ranged from 5 months to 3 years old. Patients in this study had failed initial enema reduction attempts under sonographic guidance and had subsequent delayed (≥ 2 h from the initial attempt) repeated enemas made up the study population.

Of the 40 patients, 34 patients (85%) were successfully reduced, and 6 patients (15%) failed reduction and required surgical intervention. There were no deaths, perforation, or resection of gangrenous bowel. Two cases showed recurrences, but required no surgical intervention. It is also noted that early presentation (< 12 h), stable, non-complicated, and with little or no bloody diarrhea are predictors of successful DRE.

Conclusion

Delayed repeated enema in the treatment of intussusception is a viable option in patients with unsuccessful initial enema reduction provided that early presentation, stable vitals, and no signs of perforation or peritonitis are present.

Ileocolic intussusception: Ultrasound-guided hydrostatic reduction with sedation and analgesia

INTRODUCTION

The first-choice treatment for ileocolic intussusception is imaging-guided reduction with water, air, or barium. The objectives of the current study were to evaluate the efficacy and safety of ultrasound-guided reduction of intussusception using water in patients under sedation and analgesia. We compare this approach with our previous experience in reduction using barium under fluoroscopic guidance without sedation and analgesia and investigate what factors predispose to surgical correction.

MATERIAL AND METHODS

We retrospectively reviewed cases of children with ileocolic intussusception treated in a third-level pediatric hospital during a 52-month period: during the first 24 months, reduction was done using barium and fluoroscopy without sedoanalgesia, and during the following 28 months, reduction was done using water and ultrasound with sedoanalgesia. A pediatric radiologist and a pediatrician reviewed the clinical history, surgical records, and imaging studies.

RESULTS

In the 52-month period, 59 children (41 boys and 18 girls; mean age, 16.0 months) were diagnosed with ileocolic intussusception at our hospital. A total of 33 reductions (28 patients and 5 recurrences) were done using barium under fluoroscopic guidance, achieving a 61% success rate. A total of 38 reductions (31 patients and 7 recurrences) were done using water under ultrasound guidance with patients sedated, achieving a success rate of 76%. No significant adverse effects were observed in patients undergoing ultrasound-guided hydrostatic reduction under sedation, and the success rate in this group was higher (p = 0.20). The factors that predisposed to surgical reduction were greater length of the intussusception (p = 0.03), location in areas other than the right colon (p = 0.002), and a greater length of time between symptom onset and imaging tests (p = 0.08).

CONCLUSION

Ultrasound-guided hydrostatic reduction of ileocolic intussusception under sedoanalgesia is efficacious and safe.

Delays in presentation of intussusception and development of gangrene in Zimbabwe

Introduction

prompt diagnosis and treatment are considered key to successful management of intussusception. We examined pre-treatment delay among intussusception cases in Zimbabwe and conducted an exploratory analysis of factors associated with intraoperative finding of gangrene.

Methods

data were prospectively collected as part of the African Intussusception Network using a questionnaire administered on consecutive patients with intussusception managed at Harare Children´s Hospital. Delays were classified using the Three-Delays-Model: care-seeking delay (time from onset of symptoms to first presentation for health care), health-system delay (referral time from presentation to first facility to treatment facility) and treatment delay (time from presentation at treatment facility to treatment).

Results

ninety-two patients were enrolled from August 2014 to December 2016. The mean care-seeking interval was 1.9 days, the mean health-system interval was 1.5 days, and the mean treatment interval was 1.1 days. Mean total time from symptom onset to treatment was 4.4 days. Being transferred from another institution added 1.4 days to the patient journey. Gangrene was found in 2 (25%) of children who received treatment within 1 day, 13 (41%) of children who received treatment 2-3 days, and 26 (50%) of children who received treatment more than 3 days after symptom onset (p = 0.34).

Conclusion

significant care-seeking and health-system delays are encountered by intussusception patients in Zimbabwe. Our findings highlight the need to explore approaches to improve the early diagnosis of intussusception and prompt referral of patients for treatment.

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

OBJECTIVE

To identify predictors of failed enema reduction in children with intussusception.

METHODS

PubMed and EMBASE were searched for all studies published over a 20-year time frame, prior to March 25, 2020. Original articles that reported predictors of failed enema reduction were included. The pooled odds ratio (OR) for successful enema reduction according to various features was calculated. The combined estimates were meta-analytically pooled by random-effects modeling. The risk of bias was assessed using the National Institute of Health Quality Assessment Tool. This review was registered to the PROSPERO (CRD42020190178).

RESULTS

A total of 38 studies, comprising 40,133 cases, were included. The shorter duration of symptoms (< 24 h; combined OR, 3.812; 95% CI, 2.150-6.759) and abdominal pain (combined OR, 2.098; 95% CI, 1.405-3.133) were associated with the success (all p < 0.001). Age < 1 year (combined OR, 0.385; 95% CI, 0.166-0.893; p = 0.026), fever (combined OR, 0.519; 95% CI, 0.371-0.725; p < 0.001), rectal bleeding (combined OR, 0.252; 95% CI, 0.165-0.387; p < 0.001), and vomiting (combined OR, 0.497; 95% CI, 0.372-0.664; p < 0.001) were associated with the failed reduction. The ascites (combined OR, 0.127; 95% CI, 0.044-0.368; p = 0.001), left-sided intussusception (combined OR, 0.121; 95% CI, 0.058-0.252; p < 0.001), and trapped fluid (combined OR, 0.179; 95% CI, 0.061-0.525; p = 0.017) on US were associated with the failed reduction.

CONCLUSIONS

Successful predictors for intussusception reduction have been summarized. This evidence can help identify patients who are more likely to fail non-operative reduction and could be potential surgical candidates.

KEY POINTS

• A shorter duration of symptoms and presence of abdominal pain were associated with increased probability of success. • Age (less than 1 year), presence of fever, rectal bleeding, vomiting, and presence of ascites, left-sided intussusception, or trapped fluid on ultrasonography were associated with decreased probability of success. • This study suggests that various clinical and ultrasonography predictors would help identify patients who are more likely to fail nonoperative reduction and identify potential preoperative candidates.

Management of Intussusception in the Pediatric Emergency Department: Risk Factors for Recurrence

BACKGROUND

The standard treatment for intussusception is air reduction enema (ARE) with inpatient observation for 24 to 48 hours to monitor for recurrence. More recent but limited observations suggest that patients who have undergone successful ARE can safely be discharged after 4 to 6 hours of observation. Our primary objective was to identify risk factors associated with early recurrence. Our secondary objectives included validating risk criteria from prior studies and identifying risk factors for ARE failures.

DESIGN/METHODS

A retrospective cohort study of children discharged from a large urban quaternary hospital with a final diagnosis of intussusception (International Classification of Diseases, Ninth Revision, code 560.0) or who underwent ARE from 2005 to 2015 was identified. Demographic data, radiology images, and clinical course were recorded. Repeat visits, cases with incomplete medical records, and those with incorrect diagnoses were excluded.

RESULTS

A total of 250 cases were identified. Two hundred cases were included for analysis. Fifty were excluded. Of the 163 who had successful reduction with ARE, 22 patients (13.5%) recurred, and 12 (7.3%) recurred within 48 hours. Fever (odds ratio, 4.25; P = 0.04; 95% confidence interval, 1.04-17.3) and female sex (odds ratio, 7.94; P = 0.01; 95% confidence interval, 1.82-34.6) were independently associated with early recurrence. No radiologic features were associated with early recurrence.

CONCLUSIONS

Early recurrence after successful ARE was low, although more frequent in girls and in those with fever over 100.4°F. We therefore advocate for prospective studies to validate these risk criteria to identify patients who are at low risk for early recurrence and may qualify for early discharge from the emergency department.

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.

Risk Factors for Recurrent Intussusception After Fluoroscopy-Guided Air Enema

OBJECTIVES

The aim of this study was to identify risk factors for recurrent intussusception after a successful reduction by fluoroscopy-guided air enema, the time required for recurrence, and the association between delayed reduction and the recurrence.

METHODS

Medical records of 479 consecutive children with intussusception who underwent fluoroscopy-guided air enema between January 2004 and September 2014 were reviewed. Recurrent intussusception was defined as a recurrence within 48 hours of a reduction. Symptom-to-door time was defined as the time from symptom onset to emergency department arrival. Door-to-reduction time was defined as the time from emergency department arrival to reduction. Time-to-recurrence was defined as the time required for recurrence from the first ultrasound diagnosis.

RESULTS

Of the 360 eligible children, 32 had recurrent intussusceptions (8.9%). Multivariable logistic regression showed that age 2 years or older is an independent predictor of recurrent intussusception (odds ratio, 2.39; 95% confidence interval, 1.13-5.02; P = 0.02). Median time to recurrence was 25 hours (18.0-36.0 hours). Although symptom-to-door and door-to-reduction times tended to be longer in the recurrence group, these differences were not significant (12.5 vs 7.0 hours, P = 0.18; 154.0 vs 143.0 minutes, P = 0.67, respectively).

CONCLUSIONS

Our data suggest that provision for early recurrence and extended observation may be beneficial for children 2 years or older. Delayed reduction was not associated with recurrent intussusception, but further studies with larger sample sizes are needed to explain this issue.

Risk factors for recurrent intussusception in children: a retrospective cohort study

OBJECTIVE

The aim of this study was to assess the frequency of clinical features and pathological lead points in recurrent intussusception, with a special focus on the risk factors that lead to recurrent intussusception.

DESIGN

This is a retrospective cohort study. A 5-year retrospective study was performed between January 2012 and July 2016 in the Children's Hospital of Soochow University, Suzhou, China, to determine the clinical features and pathological lead points of recurrent intussusception.

SETTING

This is a retrospective chart review of recurrent intussusception cases in a large university teaching hospital.

PARTICIPANTS

The medical records were obtained for 1007 cases with intussusception, including demographics, clinical signs and symptoms, imaging and recurrence times if available.

INTERVENTIONS

Univariate and multivariate logistic regression analyses were used to measure significant factors affecting recurrent intussusception and recurrent intussusception with pathological lead points.

RESULTS

There were 481 total episodes of recurrence in 191 patients. Among these, 87 had one recurrence and 104 had multiple recurrences. After comparing recurrent and non-recurrent intussusception cases using univariate analysis, it was determined that the factors associated with recurrent intussusception were age (>1 year), duration of symptoms (≤12 hours), the lack of bloody stool, paroxysmal crying or vomiting, the mass location (right abdomen) and pathological lead point (P<0.05). Age (>1 year), duration of symptoms (≤12 hours), the absence of vomiting, mass location (right abdomen) and pathological lead point were significantly independently predictive of recurrent intussusception. The factors associated with recurrent intussusception with lead points present were vomiting and mass location in the right abdomen (P<0.05). Vomiting and mass location (left abdomen) were significantly predictive of recurrent intussusception with lead points.

CONCLUSIONS

Age (>1 year), symptom duration (≤12 hours), the absence of vomiting, mass location (right abdomen) and pathological lead points were significantly predictive of recurrent intussusception. Vomiting and mass location (left abdomen) were significantly predictive of recurrent intussusception with lead points.

Risk factors associated with intestinal necrosis in children with failed non-surgical reduction for intussusception

BACKGROUND

Intestinal necrosis is the most serious complication of intussusception. The risk factors associated with intestinal necrosis in pediatric patients with intussusception have not been well characterized.

OBJECTIVE

This study aimed to investigate the risk factors associated with intestinal necrosis in pediatric patients with failed non-surgical reduction for intussusception.

METHODS

Hospitalized patients who failed the air-enema reduction for intussusception in the outpatient department and subsequently underwent surgery were retrospectively reviewed. All cases were categorized into two groups: intestinal necrosis group and non-intestinal necrosis group based on the surgical findings. Demographic and clinical features including the findings from the surgery were recorded and analyzed. Factors associated with intestinal necrosis were analyzed using univariate and multivariate unconditional logistic regression analyses.

RESULTS

A total of 728 cases were included. Among them, 171 had intestinal necrosis at the time of surgery. The group with intestinal necrosis had a longer duration of symptom or length of illness (P = 0.000), and younger (P = 0.000) than the non-intestinal necrosis group. Complex/compound type of intussusceptions is more likely to have intestinal necrosis. Multivariate analysis showed that the presence of grossly bloody stool (OR = 2.12; 95% CI 1.19-3.76, P = 0.010) and duration of symptom (OR = 1.07; 95% CI 1.06-1.08, P = 0.000) were independent risk factors for intestinal necrosis in patients hospitalized for surgical reduction for intussusceptions.

CONCLUSION

At time of admission, the presence of bloody stools and duration of symptom are the important risk factors for developing intestinal necrosis for those patients who failed non-surgical reduction. The length of illness has the highest sensitivity and specificity to correlate with intestinal necrosis. This finding may suggest that we should take the intussusception cases that have the longer duration of symptom directly to operation room for reduction.

Expression of p38 mitogen-activated protein kinase (p38MAPK) and pathological change in intussusception

BACKGROUND

The aim of this study was to develop a mouse model and further assess the pathological changes associated with the expression of p38mitogen-activated protein kinase (p38MAPK) in intussusception.

METHODS

Sixty-two adult Balb/C mice were used. A longitudinal incision was made in the middle rectus muscle in the body cavity. The ileum was intussuscepted into the colon. Measurements were taken at the onset of intussusception and at 5, 15, 30, 60, and 120 min. Mucosal impairment was assessed on microscopy. Ten of the intussuscepted mice were used as an ischemia-reperfusion (I/R) model. Immunohistochemistry was used to assess expression of p38MAPK in the I/R model and pediatric patients specimens of intussusception.

RESULTS

The intussusception model was successfully established in 46 mice. After 15 min, vascular compromise became visible in these 46 mice. Over time, vascular function worsened. There were significant differences in microscopy injury score in the intestinal mucosa between the 15 min and 30 min groups (P = 0.0006), 30 min and 60 min groups (P = 0.0046), and the 60 min and 120 min groups (P = 0.0050). There was no significant difference between the 5 min and 15 min groups (P = 0.0597). p38MAPK was expressed strongly in pediatric specimens of intussusception. Immunostained sections of intestinal epithelium had significantly higher mean quick score for p38MAPK in the intussusception I/R model group than in the intussusception group and controls (P = 0.0130). On each two-group comparison there was a significant difference between groups (all P < 0.01; Fig. ).

CONCLUSIONS

The present mouse model can be used to assess the dynamic pathological changes associated with intussusception. I/R is associated with upregulation of p38MAPK in intussusception.

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.

Recurrence rates after intussusception enema reduction: a meta-analysis

BACKGROUND AND OBJECTIVE

Reported rates of recurrence after enema reduction for intussusception are variable. Concerns for recurrence influence postreduction management. The objective of this study was to conduct a systematic review and meta-analysis to estimate overall, 24-hour, and 48-hour recurrence rates after enema reduction in children.

METHODS

PubMed, Cochrane Database, and OVID Medline were searched from 1946 through December 2011 using the search terms: intussusception, recurrence, and enema. Sixty-nine studies of patients age 0 to 18 years with radiographically proven intussusception reduced by enema that report the number of enema reductions and the number of recurrences were included. Extraction was done by the primary author (M.P.G.) with 10% of included studies independently audited to ensure concordance.

RESULTS

Overall recurrence rates were 12.7% (95% confidence interval [CI]: 11.1%-14.4%, I2 = 28.8%) for contrast enema (CE), 7.5% (95% CI: 5.7%-9.8%, I2 = 52.4%) for ultrasound-guided noncontrast enema (UGNCE), and 8.5% (95% CI: 6.9%-10.4%, I2 = 50.1%) for fluoroscopy-guided air enema (FGAE). Recurrence rates within 24 hours were 3.9% (95% CI: 2.2%-6.7%, I2 = 47.0%) for CE, 3.9% (95% CI: 1.5%-10.1%, I2 = 0.0%) for UGNCE, and 2.2% (95% CI: 0.7%-6.5%, I2 = 59.8%) for FGAE. Recurrence rates within 48 hours were 5.4% (95% CI 3.7%-7.8%, I2 = 32.3%) for CE, 6.6% (95% CI: 4.0%-10.7%, I2 = 0.0%) for UGNCE, and 2.7% (95% CI: 1.2%-6.5%, I2 = 73.8%) for FGAE. Most included studies are retrospective and vary in quality of reporting. Few studies reported detailed patient characteristics including timing of recurrences.

CONCLUSIONS

The risk of early (within 48 hours) recurrence after enema reduction is low, suggesting outpatient management of well-appearing patients should be considered.

Predictors of successful air enema reduction of intussusception in infants younger than 4 months

OBJECTIVES

Intussusception is rare in infants younger than 4 months, and the use of air enema for reduction of intussusception has been limited. In this retrospective study, we analyzed the predictors of successful reduction of intussusception using air enema in infants younger than 4 months.

METHODS

This is a retrospective chart review of 97 intussusception patients of younger than 4 months between January 2008 and December 2012. Demographic data, clinical presentation, and outcomes of air enemas were collected and analyzed. We used univariate and multivariate logistic regression analyses for significant predictors of successful reduction of intussusception using air enemas.

RESULTS

Of the 97 infants younger than 4 months (median age 97.6 days, age range 41-119 days), 63 (65%) were boys and 34 (35%) were girls. The duration of symptoms ranged from 5 to 53 hours, with a median of 16.3 hours. The clinical features included paroxysmal crying (75%), vomiting (68%), bloody stools (61%), and palpable abdominal masses (32%). The duration of symptoms, bloody stools, and the shape of the intussusceptum were found to be significantly predictive of the outcome of air enema reduction of intussusception.

CONCLUSIONS

The rate of successful reduction of intussusception using air enemas in infants younger than 4 months is low. Factors such as the duration of symptoms, bloody stools, and the shape of the intussusceptum are predictive of the outcome of air enema reduction of intussusception.

Intussusception: incidence and treatment-insights from the nationwide German surveillance

OBJECTIVE

Intussusception (IS) is one of the most common paediatric emergencies, and the best mode of conservative reduction and its exact incidence remains unclear. For different reasons, availability of reliable incidence data are useful and additionally may be fundamental to monitor potential effects of recently introduced rotavirus (RV) vaccines.

METHODS

We performed a prospective German nationwide surveillance between January 1, 2006 and December 31, 2007, followed by separate collection of all IS cases in a random sample of 31 clinics for an unbiased estimation of underreporting. For case definition, the Brighton Collaboration (BC) criteria were applied.

RESULTS

A total of 1200 children with at least 1 episode of IS were included. For children younger than 1 year the incidence was calculated to be 60.4/100,000 child-years. The risk for surgery increased 2-fold if the interval between onset of symptoms and first attempt of conservative reduction exceeded 5 hours (95% confidence interval [CI] 1.2-3.1). We also observed a 2.8-fold increased risk for surgery for hydrostatic (CI 1.2-6.4) and a 3.7-fold for barium enema reduction (CI 1.6-8.8) compared to pneumatic reduction. The level of specialisation of the hospital did not influence the success of conservative management.

CONCLUSIONS

For children with IS a fast attempt of pneumatic reduction seems to be the optimal management. Considering the current practice we estimated that approximately 104 (CI 46-161) surgical interventions would be preventable in Germany every year. Also, conduction of reliable postmarketing monitoring of the new RV vaccines is now possible based on the provided incidence data.

Pneumatic reduction of intussusception: factors affecting outcome in Thailand

Background: Pneumatic reduction has become a therapeutic method for intussusception instead of surgery. It is more successful than barium reduction, but it depends on how much the operator is familiar with the method and equipment.

Objective: Determine success rate and recurrent rate of intussusception and factors affecting outcome of pneumatic reduction in Thailand.

Materials and methods: Fifty-eight children with 73 numbers of intussusception who underwent pneumatic reduction at Songklanagarind Hospital, Thailand between January 2002 and March 2007 were retrospectively reviewed. Age, sex, clinical parameters, physical examination, imaging findings, and reduction technique were evaluated.

Results: Overall success rate was 54 out of the 73 episodes and recurrent rate was 10 out of 58 patients with intussusception. Long duration of symptom, rectal bleeding, dehydration, and leukocytosis significantly affected poor outcome. Radiographic findings of gut obstruction and ascites as well as sonographic findings of thickened colonic wall, trapped fluid between intussusceptum and intussuscipien, and small bowel obstruction could also predict the poor outcome.

Conclusion: Many factors from clinical presentation, plain radiographic, and sonographic findings affect poor outcome of pneumatic reduction. However, it can be performed unless peritonitis and sepsis/shock are present.

Delayed repeat enema in the management of intussusception

OBJECTIVE

To describe the demographic and clinical characteristics of children with intussusception and failed initial air enema reduction who were managed by delayed repeat enema attempts and identify predictors associated with successful reduction.

METHODS

This is a retrospective cross-sectional study of children diagnosed with intussusception who received care at an urban 110-bed children's hospital. Patients who had failed initial enema reduction attempts under fluoroscopic guidance and had subsequent delayed (≥2 hours from the initial attempt) repeat enemas made up the study population. The primary outcome variable was success of delayed repeat enema reduction. Predictor variables included duration of presenting symptoms (≤1 day vs ≥2 days), gross bloody stools, dehydration, altered mental status, ileus per radiograph, time from initial to delayed repeat enema, and lack of partial reduction to the ileocecal valve with the first attempt.

RESULTS

During a 74-month period, 20 patients with 21 intussusception events managed by delayed repeat air enemas were identified. Of the 20 patients, there were 12 boys (60%). Distribution of race was as follows: 9 white (45%), 7 African Americans (35%), and 4 Hispanics (20%). Of the 21 events, the mean (SD) age at the time of intussusception was 14.4 (12.8) months, with a median of 8 months and ranging from 2.5 to 43 months. Of the first 21 attempted delayed repeat enemas, 9 (43%) were successful. Of the 12 unsuccessful attempts, 4 had a second delayed repeat enema attempt and 3 were successful. Overall delayed repeat enemas were successful in 12 patient events (57%). For the total 25 delayed repeat enemas, 12 (48%) were successful.Surgical reduction was performed in 9 patient events (43%). Of these, manual reduction was performed in 7 and surgical incision was performed in 2, with resection of a portion of the distal ileum. There were 19 ileocolic (90%) and 2 ileoileocolic (10%) intussusceptions. There were no pathologic lead points and no patient deaths.In comparing the successful from the failed delayed repeat enema reduction groups, there was no significant difference in demographic characteristics, clinical characteristics, or time from initial enema to first repeat enema. However, there was a trend toward a significant difference regarding the failed group having a greater rate of bloody stools, dehydration, or altered mental status. There was a significant difference for the degree of partial reduction achieved on the initial enema. For the successful delayed repeat enema reduction group, the location of the lead point of the intussusceptum after the initial enema was at the ileocecal valve for 9 patients (90%) versus 3 patients (33%) in the failed group. Although not significantly different, the successful versus failed delayed repeat enema reduction group trended toward significance regarding more patients with clinical improvement after initial enema (82% vs 43%).

CONCLUSIONS

With the coordinated care of emergency medicine, surgery, and radiology services, delayed repeat enema seems to be an option to consider in the management of clinically stable children who, on initial air enema, have partial reduction. Our study showed that the success rate of delayed repeat enemas was greatest when the intussusceptum was initially reduced to the ileocecal valve.

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 in children--clinical presentation, diagnosis and management

PURPOSE

The aim of this study was to evaluate the clinical presentation, diagnosis and management of patients with intussusception, with special regard to the duration of symptoms, referral from other hospitals, outcome and complications related to delayed diagnosis.

METHODS

This retrospective study was performed using hospital charts, ultrasound and radiological reports and surgical notes from patients treated in our institution from 1996-2005.

RESULTS

Altogether 98 patients were included in the study. The study revealed idiopathic intussusception in 95% of the cases. The remaining patients presented with Meckel's diverticulum and schwannoma of the small bowel. We used ultrasound as the primary modality for diagnosis in all the patients, with a diagnostic accuracy of 100% in our study. Conservative treatment using an air enema was successful in 79.5% of cases. A higher rate of surgical intervention was found in patients who had symptoms for more than 24 h and in referred patients.

CONCLUSIONS

Particular attention needs to be paid to the rapid diagnosis and appropriate treatment of intussusception. Uncertain cases should be urgently referred to specialised paediatric centres. Ultrasound should be the diagnostic method of choice, since it is very effective in making this diagnosis. The first treatment option for intussusception remains the enema. Delayed diagnosis leads to an increased number of open surgeries.

Reduction of intussusception in infants by a pediatric surgical team: improvement in safety and outcome

Commonly, reduction of intussusception is performed by experienced radiologists. We review the performance of a pediatric surgical team for treating intussusception according to a standard protocol and present our findings. Three hundred and seventy eight patients with signs and symptoms of intussusception we treated from 1980 to 2005 were reviewed. Hydrostatic reduction (HR) was performed using a water-soluble contrast agent under fluoroscopy unless there was a serious condition clinically. Before 1998, HR was performed exclusively by pediatric surgical trainees (period A). In 1998, a standard protocol (double-balloon tube, maximum pressure of 120 cm H2O, repeated a maximum of five times, and HR performed by a pediatric surgical trainee under the supervision of a consultant pediatric surgeon) was adopted (period B). As part of the protocol, the operating room was notified of the HR procedure and placed on call for emergency surgery. Of the 378 patients, 21 required immediate laparotomy due to serious general condition, leaving 138 during period A and 219 during period B who had HR. Patient age, sex, and duration of symptoms (period A, 14.5 +/- 7.8 h; period B, 13.1 +/- 9.9 h) were not statistically significant. Success of HR during period A was 64.5%, and significantly improved for period B at 94.5% (P < 0.01). During period B, 128 of our patients had been referred from elsewhere for failed reduction attempted by radiologists or pediatricians. We were able to perform HR successfully in 118 of these (92.2%). During period A, it was significantly less at 54.0% (P < 0.01). Bowel perforation during HR occurred in two patients during period A (1.4%) and two patients during period B (0.9%), but the latter cases were transferred immediately for emergency surgery with good outcome. Reduction of intussusception by a pediatric surgical team would appear to be significantly safer with better outcome, and is thus more efficient.

Postreduction management of intussusception in a children's hospital emergency department

OBJECTIVE

To evaluate the current management of patients with intussusception who have undergone successful reduction by contrast enema in a tertiary care children's hospital. To compare differences in the incidence of recurrence and adverse events between those patients who were hospitalized after enema reduction and those who were observed in the emergency department (ED).

METHODS

This was a retrospective cohort study of children 0 to 18 years of age who underwent uncomplicated enema reduction for intussusception. Hospitalization versus ED observation management were compared for length of stay, incidence of recurrence, and adverse events.

RESULTS

One hundred twenty-three children were identified with an International Classification of Diseases, Ninth Revision code for intussusception. Of those, 106 patients (86%) had an enema reduction attempted. Three had a normal enema and were given the diagnosis of "resolved intussusception." Eighty-three (80%) of the patients had a successful reduction. Seventy-eight (94%) of those patients had no preexisting condition and had complete medical records. Of those 78 patients, 27 (35%) were hospitalized and 51 (65%) were observed in the ED. The mean length of hospitalization was 22.7 hours (range: 10-50 hours), and the mean length of ED observation was 7.2 hours (range: 0-21 hours). Eleven recurrences were observed in 8 of these 78 patients (10% recurrence rate). Four patients in the hospitalized group and 4 patients in the ED observation group had recurrences (5 hours-10.9 months). Four of the 8 patients had a recurrence within the first 48 hours. All first recurrences occurred after the patient had been discharged from the hospital or ED observation unit. No adverse events occurred in any of the patients who had a successful initial reduction (95% confidence interval [0%-4.6%]).

CONCLUSIONS

The postreduction management of intussusception is variable at our institution. Previously healthy patients who have undergone successful enema reductions are unlikely to have adverse outcomes. Postreduction observation in the ED or the hospital does not seem to affect outcomes in this clinical setting.

Sonographically guided hydrostatic reduction of intussusception in children

PURPOSE

The aim of this study was to assess the efficacy of sonographically guided hydrostatic enema in therapeutic reduction of intussusception in children and to determine whether certain factors may predict the outcome of this technique.

METHODS

We retrospectively reviewed the medical records and sonographic examinations of 83 consecutive children sonographically diagnosed with 101 cases of intussusception over a 40-month period. In 99 cases, sonographically guided hydrostatic reduction was attempted. The presence of free peritoneal fluid, the presence of fluid inside the intussusception, and the initial location of the intussusception, as confirmed by sonography, along with the level of experience of the radiologist who performed the reduction were statistically analyzed to determine their effect on outcome. A p value less than 0.05 was considered significant.

RESULTS

In 88 (89%) of the 99 cases, hydrostatic reduction was successful. No complications during or after hydrostatic enema were noted. The success rate was significantly lower among patients whose intussusception was located in the left side of the abdomen (p < 0.01) or contained entrapped fluid (p < 0.02) or those in whom hydrostatic reduction was not performed by an experienced sonologist (p < 0.01). The presence of free peritoneal fluid was not a predictor of outcome (p > 0.1). No complications during or after hydrostatic enema were noted.

CONCLUSIONS

Sonographically guided hydrostatic reduction of intussusception is safe and effective. We recommend that this method be attempted before surgery is considered, even in cases in which the intussusception contains entrapped fluid or is located in the left side of the abdomen. The level of experience of the radiologist who performs the reduction significantly affects the results of this procedure and should be carefully considered, particularly in cases in which initial sonography reveals the presence of risk factors.

Idiopathic intussusception: the role of laparoscopy

BACKGROUND

The use of a barium enema affords both diagnostic confirmation and a chance for nonsurgical complete reduction of the intussusception, which must be proven by adequate reflux of barium into the distal ileum. If this does not occur, it is assumed that the intussusception has not been reduced, and the infant is taken straight to the operating room for laparotomy and surgical treatment. The aim of this study is to limit unnecessary surgical explorations by the diagnostic and the therapeutic policy of laparoscopy with assisted hydrostatic saline reduction under general anesthesia.

METHODS

Over a period of 3 years, 90 patients with intussusception were treated. Twenty patients in whom hydrostatic reduction was contraindicated were treated initially by surgery. In the remaining 70 patients, hydrostatic reduction was successful in 50 (71%), and laparoscopy was performed in 20 patients before laparotomy. Hydrostatic saline reduction was used when there was failure of reduction seen by laparoscopy.

RESULTS

In 20 patients, laparoscopy showed reduction of intussusception in eight patients (40%), and saline hydrostatic reduction was successful in six patients (30%), with failure of reduction in six patients (30%) necessitating laparotomy.

CONCLUSION

The use of laparoscopy for diagnosis of failure of reduction of intussusception and the hydrostatic reduction by saline enema during laparoscopy saved 14 patients from unnecessary laparotomy.

Ileoileocolic intussusception in children: diagnosis and significance

The ileoileocolic type of childhood intussusception is difficult to diagnose pre-operatively and is associated with increased morbidity. This study describes the clinical and imaging features of 10 consecutive ileoileocolic intussusceptions diagnosed ultrasonically in 10 patients over a 36 month period. Ultrasound-guided hydrostatic reduction using Hartmann's solution was attempted in all 10 patients. Clinical and imaging features were compared with those of 28 ileocolic intussusceptions in 25 patients diagnosed and treated using the same methods during the same period. Most of the clinical and plain radiographic features of the patients with the ileoileocolic and ileocolic types of intussusception were similar. The two types of intussusception had the classical doughnut or pseudokidney, or both, signs on pre-reduction ultrasound scans. During the reduction process, when surrounded by fluid within the caecal lumen, the ileoileocolic type of intussusception had a typical complex appearance due to frond-like loops of intussuscepted small bowel. This finding was present in all cases. The hydrostatic reduction rate was only 10% (1/10) for ileoileocolic intussusception, compared with 92.9% (26/28) for the ileocolic type. All unsuccessfully-reduced cases underwent surgery, with surgical confirmation of the intussusception type in all cases. Only one patient was found to have a lead point, caused by a Meckel's diverticulum. In conclusion, the diagnosis of ileoileocolic intussusception can be made pre-operatively and these patients require surgical management.

Laparoscopic-assisted pneumatic reduction of intussusception

The nonoperative treatment of intussusception is done by fluoroscopy, however, false-positive and negative images may lead to unnecessary operations. The aim of this study was to evaluate the feasibility of laparoscopy in pneumatic reduction. Surgical ileoileocolic intussusception was performed in 27 dogs. Sixteen dogs were observed for 3 days (group A), and 11 were observed for 5 days (group B). Laparoscopy was performed in the intussuscepted dogs during pneumatic reduction. Under general anesthesia, a 10-mm trocar was inserted supraumblically in the midline, and the laparoscope was introduced. The intussuscepted bowel was observed on the video monitor. A 5-mm trocar was inserted in the right upper quadrant. The mesentery of the terminal ileum was manipulated using grasping forceps to assist reduction. CO2 was insufflated into the rectum using a Foley catheter, and the reduction was observed on the video monitor. The success rate was 94% (mean reduction time, 2.5 minutes +/- 1.0) for group A and 100% (mean reduction time, 3.7 minutes +/- 0.8) for group B. Bowel perforation was observed in one dog, and recurrence of intussusception in another. The authors claim that observing the bowel on the video monitor may help in the differential diagnosis and reduction of difficult cases such as ileoileocolic and delayed intussusceptions. Therefore, unnecessary open surgery may be prevented.

Incidence of recurrent intussusception following barium versus air enema

The aim of this study was to determine whether using air enema for acute intussusception is related to a higher rate of recurrence than other methods of treatment. A 10-y (1986-95) retrospective study was performed in a university-affiliated paediatric division. The overall recurrence rate for 97 patients with acute intussusception was 7.8% (10% of whom were treated non-surgically). There were no recurrences following the surgical treatment. In matched groups of patients, no risk factors were found for recurrence following air vs barium enema.

Intussusception presenting to a paediatric accident and emergency department

In a retrospective study, 110 patients episodes with intussusception presenting to a paediatric accident and emergency (A&E) department were reviewed, with particular attention being paid to presenting symptoms, time to diagnosis, radiological investigation, management and outcome. Between 1983 and 1993 100 patients presented to this department with 110 episodes of intussusception. Delay in diagnosis of greater than 12 h from initial medical contact was associated with increased morbidity. Associated factors in delayed diagnosis were departure from the classical symptoms (pain, vomiting and blood per rectum) and the presence of diarrhoea. General practitioner (GP) referral was to the medical team (rather than the surgical team) in around 50% of cases. Irrespective of the specialty of the first hospital doctor to see the patient only 42% were diagnosed correctly within 3 h of admission. In this population diarrhoea is a common symptom of intussusception and should alert the clinician rather than reassure. Because of its many presentations and relative rarity, intussusception remains a difficult condition to diagnose.