Laparoscopic management of intussusception in pediatric patients

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.

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.

Single-incision laparoscopic surgery for idiopathic intussusception in children: Comparison with conventional laparoscopy

BACKGROUND

The aim of this study is to evaluate the feasibility of single-incision laparoscopic surgery (SILS) for idiopathic intussusception in children and compare the outcomes with conventional laparoscopy (CLS).

METHODS

Between January 2011 and December 2012, patients who underwent CLS for idiopathic intussusception were assigned into the group of CLS. Between January 2013 and March 2017, patients who underwent SILS were assigned to the group of SILS. For patients who failed to reduce by SILS, bimanual transabdominal approach was conducted.

RESULTS

A total of 23 patients were enrolled, including 7 and 16 patients in SILS and CLS, respectively. The mean age was similar in both group (22.4 ± 18.7 vs. 24.6 ± 18.6 months, p = 0.80). There is no difference in gender distribution. The main indication was radiological reduction failure in both groups (85.7% vs. 75%, p = 0.58). Ileocolic intussusception was found in 6 (85.7%) and 15 (93.8%) patients of SILS and CLS, respectively (p = 0.25). The level of intussusception was at ascending colon in 3 (42.9%) and 12 (75.0%) patients, respectively (p = 0.11). The operation time was similar in both groups (64.9 ± 53.7 and 70.9 ± 26.1 min, p = 0.79). There were 2 (28.6%) and 1 (6.2%) conversions, respectively (p = 0.15). For the two patients in SILS, the intussusception was successfully reduced by bimanual transabdominal approach. There was no significant difference in time to feeding (1.9 ± 1.1 vs. 1.4 ± 0.7 days, p = 0.21). The mean length of postoperative hospital stay was 3.9 ± 1.6 and 3.1 ± 1.1 days, respectively (p = 0.17).

CONCLUSIONS

SILS for pediatric intussusception is technically feasible and has comparable results to CLS. Transabdominal bimanual reduction is applicable in cases of failed laparoscopic reduction.

LEVEL OF EVIDENCE

III.

The Laparoscopic Versus Open Approach for Reduction of Intussusception in Infants and Children: An Updated Institutional Experience

PURPOSE

We have previously demonstrated successful laparoscopic management after failed enema reduction of children with intussusception. The purpose of this study is to assess the effectiveness of our mature experience with laparoscopic reduction by evaluating operative success, duration of hospital stay, postoperative complications, and hospital readmission rates.

MATERIALS AND METHODS

After IRB approval, a retrospective review was conducted on children (age 0-18 years) who failed enema reduction of intussusception between 2008 and 2017. Cases were classified as either open or laparoscopic. Demographic data, incidence of bowel resection, postoperative length of stay, complications, and hospital readmission rates were abstracted from patient medical records. Comparative analysis was performed in STATA with a P value <.05 determined as significant.

RESULTS

A total of 81 children were included in our study with 63 patients (78%) undergoing a laparoscopic reduction and 18 patients (22%) undergoing an open operation. Laparoscopic reduction carried similar complication rates (11%) when compared with children undergoing an open reduction (11%, P = 1.00). Furthermore, both hospital readmission rates and returns to the operating room were similar between the two groups (P = .345 and P = .672, respectively). The median postoperative length of stay was shorter for patients undergoing a laparoscopic reduction (4 days, interquartile range [IQR], 2-5 days) than for patients undergoing an open reduction (5 days, IQR, 4-6 days, P = .001). Children undergoing a laparoscopic reduction had a decreased rate of bowel resection (43% versus 50%, P = .591) despite similar rate of pathological lead points (21% versus 22%, P = .884).

CONCLUSION

Laparoscopic management of intussusception after failed radiographic reduction yields a reduced hospital length of stay with no increase in hospital readmission rates and reoperations.

Ultrasound vs X-ray for disease diagnosis and guiding enema treatment in infantile intussusception

AIM

To compare ultrasound and X-ray in the diagnosis of infantile intussusception and in the monitoring of enema treatment.

METHODS

From February 2015 to July 2016, 120 children with intussusception treated at the First Affiliated Hospital of Guangxi Medical University were selected and divided into an ultrasound group and an X-ray group, with 60 cases in each group. Ultrasound-guided water enema reduction treatment was used in the ultrasound group, while X-ray-guided air enema treatment was applied in the X-ray group. The diagnostic and therapeutic effects and complications were compared between the two groups.

RESULTS

The diagnostic accuracy was significantly higher in the ultrasound group than in the X-ray group (96.67% vs 85%, P < 0.05). The treatment success rate was also significantly higher in the ultrasound group than in the X-ray group (98.33% vs 78.34%, P < 0.05). The rate of complications was significantly lower in the ultrasound group than in the X-ray group (11.67% vs 26.67%, P < 0.05).

CONCLUSION

Ultrasound is better than X-ray in the diagnosis and treatment of infantile intussusception and has no radiation and better safety. Therefore, ultrasound can be the first choice in the diagnosis and treatment of infantile intussusception.

Intraluminal Meckel's Duplication Cyst Causing Bowel Obstruction in an Infant: A Role for Laparotomy

This report describes a two-month-old girl who presented with signs and symptoms of a distal small bowel obstruction. She underwent an abdominal ultrasound that revealed a right lower quadrant cystic mass. A Technetium-99 scan revealed increased activity in the right lower quadrant consistent with a Meckel's diverticulum. Following a nondiagnostic laparoscopic evaluation, a laparotomy was performed to allow direct palpation of the small bowel and colon. Direct palpation of the ileum revealed a soft intraluminal mass at the ileocecal valve. The child underwent an ileocecectomy and anastomosis incorporating the intraluminal mass. Pathologic analysis revealed an intraluminal enteric duplication cyst containing ectopic gastric mucosa. This case represents the first report of such an entity in an infant. A discussion of the diagnostic and therapeutic aspects of the case and enteric duplication cysts is provided.

Laparoscopic treatment of intussusception

•

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.

The ACGME case log: general surgery resident experience in pediatric surgery

BACKGROUND

General surgery (GS) residents in ACGME programs log cases performed during their residency. We reviewed designated pediatric surgery (PS) cases to assess for changes in performed cases over time.

METHODS

The ACGME case logs for graduating GS residents were reviewed from academic year (AY) 1989-1990 to 2010-2011 for designated pediatric cases. Overall and designated PS cases were analyzed. Data were combined into five blocks: Period I (AY1989-90 to AY1993-94), Period II (AY1994-95 to AY1998-99), Period III (AY1999-00 to AY2002-03), Period IV (AY2003-04 to AY2006-07), and Period V (AY2007-08 to AY2010-11). Periods IV and V were delineated by implementation of duty hour restrictions. Student t-tests compared averages among the time periods with significance at P < .05.

RESULTS

Overall GS case load remained relatively stable. Of total cases, PS cases accounted for 5.4% in Period I and 3.7% in Period V. Designated pediatric cases declined for each period from an average of 47.7 in Period I to 33.8 in Period V. These changes are due to a decline in hernia repairs, which account for half of cases. All other cases contributed only minimally to the pediatric cases. The only laparoscopic cases in the database were anti-reflux procedures, which increased over time.

CONCLUSIONS

GS residents perform a diminishing number of designated PS cases. This decline occurred before the onset of work-hour restrictions. These changes have implications on the capabilities of the current graduating workforce. However, the case log does not reflect all cases trainees may be exposed to, so revision of this list is recommended.

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

INTRODUCTION

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

METHODS

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

RESULTS

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

CONCLUSION

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

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.

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.

Intussusception incidentally detected by FDG-PET/CT in a pediatric lymphoma patient

An FDG-PET/CT scan was performed in a 14-year-old boy for the purpose of staging known lymphoma. The PET images identified the primary bowel lymphoma while the corresponding CT portion of the study found the intussusception caused by the lymphoma. The incidental finding of intussusception changed the management regime of the patient. Careful evaluation of both PET and CT images of the PET/CT is essential in providing the best patient care.