Childhood deaths from intussusception in England and Wales, 1984-9

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

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

Management and outcomes of paediatric ileocolic intussusception at a paediatric tertiary care hospital: A retrospective cohort study

Background

Rapid reduction of ileocolic intussusception is important to minimize the compromise in blood flow to the affected bowel segment. This study aimed to quantify the potentially modifiable time between diagnosis and initiation of pneumatic reduction, identify factors associated with delays, and characterize the outcomes of pneumatic reduction in a recent cohort.

Methods

This retrospective observational study occurred at a tertiary care paediatric hospital with a consecutive sample of all children with ileocolic intussusception September 2015 through September 2018. The primary outcome was the time between ultrasound diagnosis of intussusception and the beginning of pneumatic reduction. Independent variables were age of the patient, time of day of arrival, transfer from another facility, and intravenous access prior to ultrasound. Outcomes of pneumatic reduction were expressed as proportions.

Results

There were 103 cases of ileocolic intussusception (among 257,282 visits) during the study period. The median time between diagnostic confirmation and initiation of reduction was 36 minutes. This was shorter for transferred patients and children with intravenous access prior to ultrasound. One perforation was identified at the beginning of reduction, without hemodynamic instability. Six children (5.8%) underwent either open (n=4) or laparoscopic surgery (n=2) for reduction failure.

Conclusion

The median delay between diagnosis and initiation of reduction at this paediatric hospital was short, especially among patients transferred with a suspicion of intussusception and children with intravenous access prior to diagnosis. Complications from pneumatic reduction were infrequent.

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.

Fatal intussusception in infancy: forensic implications

Intussusception is one of the most common causes of intestinal obstructions in younger children, especially infants. Though rare, fatalities due to intussusception are known to be caused by intestinal obstruction associated with peritonitis, generalized sepsis and shock from intestinal infarction due to disruption in blood supply or electrolyte and fluid imbalance. An eight-month-old female infant, who initially presented with a single episode of vomiting and fever (37.8 °C), was examined as an outpatient at the department of pediatrics of a general hospital. Clinical examination revealed no characteristic features of acute abdomen, so the child was sent home. Nine to ten hours later her condition deteriorated: she became hyperpyretic and stuporous. On her way to the University Children's Hospital, the infant died; the death was confirmed upon admission, i.e. some 15 h after the onset of symptoms. The autopsy revealed an 8 cm long intussusception of the distal part of the ileum to the cecum. There was no gross or microscopic evidence of peritonitis at autopsy. The shock caused by intestinal obstruction with consequent intestinal necrosis was considered to be the cause of death.

Lessons to be learned: a case study approach

Chronic intussusception as a cause of persistent abdominal pain in children is often an overlooked diagnosis. Here we present an eight-year-old boy, who at the age of three years had an acute intussusception reduced hydrostatically with barium and who subsequently had been extensively investigated both in Wales and in Switzerland, for persistent colicky abdominal pain. He was found to have chronic intussusception, with a Meckel’s diverticulum being the cause of his symptoms.

Role of innate immunity and altered intestinal motility in LPS- and MnCl2-induced intestinal intussusception in mice

Intestinal intussusception (ISS) commonly causes intestinal obstruction in children. One mechanism that has been proposed to cause ISS is inflammation-induced alteration of intestinal motility. We investigated whether innate inflammatory factors or altered motility is required for induction of ISS by LPS. We compared rates of ISS among BALB/c and C57BL/6 mice, mice lacking lymphocytes or depleted of phagocytes, or mice with defects in the Toll-like receptor 4 (TLR4) signaling pathway following administration of LPS or the Ca(2+) analog MnCl2. At 6 or 2 h after administration of LPS or MnCl2, respectively, mice underwent image analysis to assess intestinal contraction rate or laparotomy to identify ISS. LPS-induced ISS (LPS-ISS) was observed in BALB/c mice, but not in C57BL/6 mice or any BALB/c mice with disruptions of TLR4 signaling. LPS-induced serum TNF-α, IL-6, and nitric oxide (NO) and intestinal NO levels were similar in BALB/c and C57BL/6 mice. The rate of LPS-ISS was significantly reduced in phagocyte-depleted, but not lymphocyte-deficient, mice. Intestinal contraction rates were reduced in LPS-ISS-susceptible BALB/c mice, but not in LPS-ISS-resistant C57BL/6 or TLR4 mutant mice, suggesting a role for reduced intestinal contraction rate in LPS-ISS susceptibility. This was tested with MnCl2, a Ca(2+) antagonist that reduced intestinal contraction rates and induced ISS, irrespective of mouse strain. Therefore, LPS-ISS is initiated by innate immune signaling that requires TLR4 and phagocytes but may be independent of TNF-α, IL-6, and NO levels. Furthermore, alteration of intestinal motility, specifically, reduced intestinal contraction rate, is a key factor in the development of ISS.

Reduction of intussusception: defining a better index of successful non-operative treatment

The reported non-operative reduction rate for intussusception is usually the proportion of attempted non-operative (radiological) reductions that succeed, which we term the "selective reduction rate." This value shows wide variation that may result from selection bias that is difficult to quantify because data regarding primary operative treatment are frequently lacking. The proportion of patients with late clinical presentation or pathological lead points can also distort the apparent efficacy of non-operative treatment. We found no definitions of outcome measures in the literature or practice guidelines to inform analysis. Based on analysis of our own audit data we derived a "composite reduction rate" from first principles that can account for variations in radiological and surgical treatment thresholds that might bias other measures of successful non-operative treatment. This index is the proportion of intussusceptions not requiring resection that are successfully reduced non-operatively. We propose that the composite reduction rate be used as a key component of standardised multidisciplinary outcome reporting for intussusception rather than the selective reduction rate. The reduced bias and confounding would allow fairer comparisons and lead to better outcome standards.

Adult intussusception: diagnostic pitfalls, morbidity and mortality in a developing country

OBJECTIVE

To study diagnostic pitfalls, morbidity and mortality of adult intussusception.

PATIENTS AND METHODS

Retrospective study of adult patients records operated between 1979 and 2007 with the diagnosis of adult intussusception.

RESULTS

We found 41 cases of adult intussusception. The mean age was 35.2 years (standard deviation (SD)=7.1). The delay between onset and medical consultation was 15 days. The diagnosis was made pre-operatively in 11 cases. Abdominal ultrasound showed an abdominal mass in 11 cases. Ileo-ileal intussusception was most frequent (16 cases). Intussusception was secondary in 24 cases. There were seven instances of intestinal necrosis. Intestinal resection was performed in 34 cases. Surgical site infection occurred in four patients, three patients died.

CONCLUSION

The pre-operative diagnosis of acute intestinal intussusception is difficult. Morbidity and mortality rates are high. Improved diagnostic investigations in developing countries could improve the prognosis of this condition.

Role of surgery in the era of highly successful air enema reduction of intussusception

BACKGROUND

Despite routine use of air enema reduction in childhood intussusceptions, some still require operative management. This study evaluated the role of surgery and identified factors associated with failed air enema reduction and bowel resection.

METHODS

We reviewed 24 patients who underwent laparotomies for intussusception between 1 July 1999 and 31 July 2002. Demographic data, clinical presentations, investigations, surgical interventions and their outcomes were reviewed.

RESULTS

Twenty-four (14.5%) of 166 patients treated for intussusceptions between 1 July 1999 and 31 July 2002 underwent laparotomies. A significant proportion (45.8%) was younger than 3 months and older than 36 months of age. Intussusception was diagnosed on ultrasonography in 21 patients. Eighteen underwent attempted air enema reduction. Ileocolic intussusceptions occurred in 54.2% of patients. Five patients had small bowel intussusceptions, all of whom required bowel resection. Seven patients (29.2%) had pathological lead points. Presence of pathological lead points and intussusceptions occurring outside the ileocolic region strongly predicted the need for bowel resection.

CONCLUSION

Air enema reductions are less likely to succeed in patients less than 3 months old and those more than 3 years old. Bowel resection is most likely required when pathological lead points are present and when intussusceptions occur outside the ileocolic region. Early surgical intervention may obviate the need for bowel resection in selected patients, thereby reducing surgical morbidity.

Intussusception among young children in Europe

Intussusception, a potentially lethal condition with poorly understood etiology, is the most common cause of acute intestinal obstruction in children younger than 5 years old. In some cases, the condition has been associated with administration of the first licensed rotavirus vaccine, the reassortant rhesus-human tetravalent rotavirus vaccine (RRV-TV; RotaShield). No such association has to date been reported from large phase III safety trials with new rotavirus vaccines. As 2 new, live-attenuated oral rotavirus vaccines are currently under review for approval by the European Union regulatory authorities, a review of the clinical, etiologic and epidemiologic aspects of intussusception in Europe is urgently needed. We conducted a review of Medline literature, published from 1995 onwards on intussusception in the World Health Organization's European Region. The results are compared with data from previous reviews and other regions. The classic triad of intussusception symptoms (abdominal pain, abdominal mass, bloody stools) was present in 29-33% of patients according to the medical literature reviewed. Conservative treatment (barium, air or saline enema) was the rule (81% of cases), and few complications were observed during treatment. Treatment outcome was generally favorable, with recurrence occurring in approximately 1 in 10 patients, and only 1 death reported. Structural lead points were seen in 3% of patients; no other reliable data on the etiology of intussusception were found. The incidence of acute intussusception in young children in Europe, according to 6 heterogeneous hospital-based studies, ranged from 0.66 to 2.24 per 1000 children in inpatient departments and from 0.75 to 1.00 per 1000 children in emergency departments. Peak incidences were found in children 3-9 months of age. There are still gaps in our knowledge of intussusception with respect to its etiology and especially by which mechanisms RRV-TV might have caused it to occur. Data from regions outside Europe showed that rotavirus infection and disease are not associated with intussusception. As new rotavirus vaccines become available for use in Europe, postlicensure surveillance for intussusception is indicated and may be instrumental in further understanding the epidemiology of this condition and in further assessing the safety of future vaccines.

Complex presentation of intussusception in childhood

The simultaneous occurrence of intussusception and volvulus in the paediatric age group is rare. We report the case of a volvulus of an ileoileal intussusception in an 8-year-old boy. This is the first time that computerised tomography (CT) images of a volvulus of an ileoileal intussusception have been published, and they clearly demonstrate both pathologies. This case highlights the use of CT in determining the nature of an abdominal mass and demonstrates how helpful it can be in diagnosing the cause of small bowel obstruction in children.

Fatal intussusception in infancy: an experience in forensic autopsy

Intussusception, although a common cause of pediatric surgical emergencies, is a rarely fatal condition. A 7-month-old infant who was discovered in her cot was unresponsive and pronounced dead after 2 h of uneventful cardiopulmonary resuscitation in an emergency hospital. Forensic autopsy which was performed in order to clarify the circumstances surrounding the death revealed intussusceptions at two sites of the ileum. Although morbidity and mortality rates from the condition have progressively declined in recent decades but avoidable deaths still occur as was experienced in the present case. The forensic pathology significance in this case was the occurrence of 'painless intussusception' whereby the affected child clinically exhibited no discomfort or characteristic features of acute abdomen until death. In summary, the present case has exhibited an uncommon fatal occurrence and demonstrated the importance of forensic autopsy in such unexpected sudden infant deaths.

Intussusception, rotavirus diarrhea, and rotavirus vaccine use among children in New York state

OBJECTIVE

To describe epidemiologic features of intussusception and rotavirus diarrhea in New York, to examine the baseline incidence and trends over time, and to ascertain whether an excess of cases occurred in the 9 months of vaccination with the newly licensed rotavirus vaccine.

METHODS

Hospital discharge data from 1989 through 1998 were reviewed for children (<1 year old) whose primary or secondary diagnosis was coded as intussusception or rotavirus diarrhea. Characteristics of patients admitted for intussusception and rotavirus diarrhea were compared, and trends over time were examined. For a subset of patients, medical records and vaccine histories for intussusception hospitalizations from October 1998 through June 1999 were analyzed. The number of intussusception cases attributable to rotavirus vaccine was calculated based on the penetration of the vaccine (21%) and a range of excess risks of intussusception among vaccinated children as estimated by the National Immunization Program (NIP).

RESULTS

From 1989 through 1998, 1450 intussusception-associated hospitalizations were reported in children <1 year old (average annual incidence 5.4/10 000). Among these children, 47% were treated medically and 53% had surgery, with 9% needing surgical resection. The incidence of intussusception declined over time from 6.1 per 10 000 in 1989 to 3.9 per 10 000 in 1998. Intussusception hospitalizations occurred throughout the year, whereas rotavirus-associated hospitalizations peaked from February to April. Of 20 patients with intussusception whose hospitalization charts were reviewed, 5 had received rotavirus vaccine. All 5 were hospitalized after their first dose of vaccine, were admitted before 7 months of age, were white, and had private insurance. A total of 81 cases of intussusception occurred during the 9-month period of rotavirus vaccination, compared with 78 during the same period in the prevaccination year. The number of excess intussusception cases observed (n = 3) was lower than expected using the NIP estimate of excess risk (1.8) among rotavirus vaccinated children (n = 12) but not significantly different from the risks identified in the NIP cohort studies (1 in 12 000).

CONCLUSION

Our data suggest that in New York the rate of intussusception has declined, and approximately 1 child in 2600 develops intussusception before 1 year of age. The different seasonality between intussusception and rotavirus-related hospitalizations suggests that if any causal association exists, it must be small. Unlike other studies, analysis of New York hospitalized discharge data failed to show an appreciable increase in the incidence of intussusception after introduction of the rotavirus vaccine.

Endotoxin, cytokines and lipid peroxides in children with intussusception

BACKGROUND

Intussusception is a relatively common paediatric surgical emergency. The aim of this study was to investigate selected inflammatory mediators in children with acute intussusception and to identify potentially useful plasma markers of clinical outcome.

METHODS

Clinical, radiographic, operative and pathological details were recorded prospectively of all children presenting to a single institution with a confirmed diagnosis of acute intussusception during 1 year. Paired acute and convalescent venous blood samples were collected in a standard manner for blinded analysis of the following: malondialdehyde, C-reactive protein (CRP), interleukin (IL) 6, neopterin, tumour necrosis factor alpha, endotoxin, and immunoglobulin (Ig) G and IgM antiendotoxin core antibody (EndoCAb).

RESULTS

Thirty-two consecutive children (23 boys, nine girls) with a median age of 4 months were studied. Acute ileocolic intussusception was managed by air enema reduction (n = 19), operative reduction (n = 8) or surgical resection (n = 5). Peripheral blood cultures were sterile. Acute levels of plasma IL-6, neopterin and CRP were significantly raised in comparison to both normal laboratory ranges and convalescent samples (P < 0.001). Using stepwise discriminant analysis, CRP was identified as the best variable at distinguishing between the three treatment groups (P < 0.001). IgM EndoCAb concentrations were significantly greater in the convalescent sera of all the patients (P < 0.001).

CONCLUSION

Acute ileocolic intussusception in childhood is associated with endotoxinaemia and significantly raised levels of circulating inflammatory cytokines. Plasma CRP at diagnosis showed a statistically significant positive correlation with disease severity.

Patterns of management of intussusception outside tertiary centres

BACKGROUND/PURPOSE

Intussusception is a common problem in young children and should have an excellent outcome in expert hands. Many children are treated in district general hospitals (DGH), which do not have specialist paediatric surgeons. The aim of this study was to clarify current patterns of management for such patients.

METHODS

The authors conducted a postal survey of DGH consultant paediatricians, radiologists, and general surgeons in a populous region of England.

RESULTS

One hundred forty-one (44%) consultants who responded comprised similar proportions of consultants from each specialty. Most respondents (79%) thought that in their location paediatricians should take responsibility for resuscitation of children with suspected intussusception. Two-thirds indicated that abdominal ultrasound scan, either alone or in combination with another modality, was their investigation of choice for confirming the diagnosis. Preferences for contrast medium for radiologic reduction varied; paediatricians favoured air (46%) or saline (28%), surgeons preferred water-soluble contrast (58%), and radiologists preferred to use barium (49%). Fifty-three percent of consultants indicated they would transfer a child with confirmed intussusception to a tertiary centre before attempting reduction, 42% would attempt reduction locally, and 5% would operate locally without attempting radiologic reduction. After failed reduction, a further 23% of consultants would consider transfer, but the remainder would operate locally. Only 13% of paediatricians thought that their surgeons had appropriate facilities and support to operate on intussusception, but 36% of surgeons claimed to be doing so. Most consultants (84%) admitted seeing fewer than 5 cases per year; 98% of surgeons were in this group. Only 16% of consultants (mostly paediatricians) were aware of any written clinical policy for managing paediatric intussusception in their hospital.

CONCLUSION

This study shows that the management of paediatric intussusception outside tertiary centres is not uniform or standardised, and that improvements are necessary. J Pediatr Surg 36:312-315.

Sudden death and intussusception in infancy and childhood--autopsy considerations

Search of the autopsy files of the Department of Histopathology at the Women's and Children's Hospital (WCH), Adelaide, Australia for cases of intussusception from January 1961 to December 1995 revealed two deaths due to intussusception out of a total of 4,384 autopsies (0.05%). Both cases occurred in infants (aged five months and six months respectively) who had only non-specific and apparently minor manifestations of illness, until precipitate deterioration occurred. The intussusceptions were ileo-ileal and ileocaecal in location, respectively. A total of 204 cases of intussusception were found in a search of 28,123 surgical pathology cases (0.73%) at the WCH over the 20-year period from 1976 to 1995. Mesenteric lymphadenopathy was found in 16 cases (including one with possible Yersinia infection), Meckels diverticulum in 14, isolated gastric/pancreatic heterotopia in two, cystic fibrosis in two and Henoch-Schonlein purpura in one. Although it has been shown that unexpected death is more likely to occur in older children with purely small intestinal intussusception, the current cases demonstrate that unexpected death may occur at any age, with intussusception at any level. The autopsy assessment of deaths due to intussusception requires careful evaluation of cases for evidence of local or systemic disease, particularly given the hereditary nature of certain predisposing conditions. Careful review of the presenting history is also required to assess the quality of care received by the child in the time preceding death.

Trends in intussusception-associated hospitalizations and deaths among US infants

CONTEXT

The newly licensed tetravalent rhesus-human reassortant rotavirus vaccine has been withdrawn following reports of intussusception among vaccinated infants.

OBJECTIVE

To describe the epidemiology of intussusception-associated hospitalizations and deaths among US infants.

DESIGN

This retrospective cohort study examined hospital discharge data from the National Hospital Discharge Survey for 1988-1997, Indian Health Service (IHS) for 1980-1997, California for 1990-1997, Indiana for 1994-1998, Georgia for 1997-1998, and MarketScan for 1993-1996, and mortality data from the national multiple cause-of-death data for 1979-1997 and linked birth/infant death data for 1995-1997.

PATIENTS

Infants (<1 year old) with an International Classification of Diseases, Ninth Revision, Clinical Modification code for intussusception (560.0) listed on their hospital discharge or mortality record, respectively.

RESULTS

During 1994-1996, annual rates for intussusception-associated infant hospitalization varied among the data sets, being lowest for the IHS (18 per 100 000; 95% confidence interval [CI] = 9-35 per 100 000) and greatest for the National Hospital Discharge Survey (56 per 100 000; 95% CI = 33-79 per 100 000) data sets. Rates among IHS infants declined from 87 per 100 000 during 1980-1982 to 12 per 100 000 during 1995-1997 (relative risk =7.6, 95% CI = 3.2-18.2). Intussusception-associated hospitalizations were uncommon in the first 2 months of life, peaked from 5 to 7 months old, and showed no consistent seasonality. Intussusception-associated infant mortality rates declined from 6.4 per 1 000 000 live births during 1979-1981 to 2.3 per 1 000 000 live births during 1995-1997 (relative risk = 2.8, 95% CI = 1.8-4.3). Infants whose mothers were <20 years old, nonwhite, unmarried, and had an education level below grade 12 years were at an increased risk for intussusception-associated death.

CONCLUSIONS

Intussusception-associated hospitalization rates varied among the data sets and decreased substantially over time in the IHS data. Although intussusception-associated infant deaths in the United States have declined substantially over the past 2 decades, some deaths seem to be related to reduced access to, or delays in seeking, health care and are potentially preventable.intussusception, hospitalizations, deaths, risk factors, infants.

Sudden infant death, large intestinal volvulus, and a duplication cyst of the terminal ileum

A previously well 7-week-old boy was found unresponsive and cyanotic in his cot in the morning. Resuscitative attempts achieved only partial response with subsequent terminal cardiac arrest occurring later in the day. At autopsy a large intestinal volvulus was found associated with disseminated Clostridium perfringens sepsis. In addition, a duplication cyst of the terminal ileum was present. Although rare, right-sided colonic volvulus may be a cause of unexpected death in infancy. While predisposing factors to volvulus may include intestinal duplication cysts, the anatomic relation of the duplication to the volvulus must be carefully determined before a causal relation can be accepted; the cyst in this case was most likely incidental to the terminal event.

John Hunter, Frederick Treves and intussusception

Early this century, intussusception in childhood was usually fatal. John Hunter, one of the founding fathers of scientific surgery was amongst the first to accurately describe the clinico-pathological features of the condition and one of the great nineteenth century surgeons, Sir Frederick Treves, suggested a plan of management for intussusception which remains little changed up to the present day.

The frequency and outcome of biliary atresia in the UK and Ireland

BACKGROUND

Biliary atresia is an obliterative cholangiopathy of infancy that is fatal if untreated. Surgical treatment, the Kasai portoenterostomy, may restore bile flow and clear jaundice, and, if successful, achieve a 10-year survival of 90% with a native liver. The outcome of a 2-year cohort of children with biliary atresia in the UK and Ireland was assessed to find the current frequency, the factors influencing outcome, and the medium-term need for liver transplantation.

METHODS

Cases diagnosed between March, 1993, and February, 1995, were notified by paediatricians to the British Paediatric Surveillance Unit via a monthly reporting system. Confirmed cases were followed up by postal questionnaires to notifying paediatricians.

FINDINGS

93 cases were confirmed, a frequency of 1/16700 livebirths. Primary surgery was done in 91 children in 15 surgical centres with an early success rate for clearing jaundice of 55% overall. Centres were grouped according to caseload; group A had more than 5 cases/year and group B fewer than 5 cases/year. Early success was higher in group-A centres, odds ratio 2.02 (95% CI 0.86-4.73), but this did not reach statistical significance. Of 41 children in whom surgery was unsuccessful in clearing jaundice 9 (22%) died and 30 (73%) underwent liver transplantation. Survival without liver transplantation and overall survival were both significantly greater in group-A centres, rate ratios 0.48 (95% CI 0.27-0.86) and 0.32 (0.11-0.94). Actuarial 5-year survival without transplantation was 61.3% in group-A centres and 13.7% in groupB centres. Actuarial 5-year overall survival was 91.2% in group A and 75% in group B. Once centre size was taken into account, no other factor, including age at surgery, was predictive of survival without transplantation or overall survival.

INTERPRETATION

The outcome of children with biliary atresia is related to the caseload of the surgical centre where they have their primary surgery. Children with biliary atresia should be managed in surgical centres with a caseload of more than five cases annually.

Survey of intussusception reduction in England, Scotland and Wales: how and why we could do better

AIM

The aim of our study was to assess the variation in technique among hospitals in England, Wales and Scotland. In addition, local in hospital variation among paediatric radiologists at our own institution was assessed.

METHOD

Postal questionnaires were distributed to the radiology departments of 301 hospitals.

RESULTS

183 (60.8%) replies were received. 122 institutions reduced intussusceptions and 61 did not. A lack of paediatric surgical and/or anaesthetic cover, and a lack of radiological experience were the major reasons cited by the departments which did not attempt intussusception reduction. Sixty-five hospitals use barium for hydrostatic reduction, 43 employ pneumatic reduction, 10 use water-soluble enemas and four use ultrasound. Of the 65 centres using barium 16 (25%) reported a success rate of less than 50%, 24 (37%) had a 50-70% success rate, seven (11%) reduce greater than 70% of intussusceptions and 18 (27%) did not know. In the 43 institutions employing air reduction, one (2%) had a success rate less than 50%, 20 (47%) had a 50-70% success rate, 17 (40%) a success rate greater than 70% and five (11%) did not know. Overall, of the total number of hospitals which replied to our survey, 28 (23%) reported that they were not aware of their success rates. Within the pneumatic reduction group in particular there was marked variation in the methods and duration of attempted reduction - between different hospitals and within the same institution. In six departments the machine used for pneumatic reduction did not measure intraluminal pressure.

CONCLUSIONS

Ultrasound is underutilized despite being a sensitive method in diagnosis. There is almost certainly an over-reliance on plain radiographs and on the use of sedation, antibiotics and anti-spasmodics in general. We believe a 70% or greater success rate should be achievable in most institutions whether by pneumatic or hydrostatic reduction, and all departments should strive to achieve success rates in this range. Less than a quarter of centres who replied currently achieve this standard. Successful reduction rates below 50% are unacceptable in our opinion. Not surprisingly, success rates are generally highest in those centres treating more than 20 cases per annum. Twenty-eight (23%) of hospitals performing intussusception reductions did not know their success rates. Regular audits of intussesception figures should take place in all institutions. Unacceptably wide variations in intussusception reduction techniques currently exist. An accurate pressure release valve at least, and preferably intraluminal pressure monitoring should be an integral component of all pneumatic reduction devices. The British Paediatric Radiology and Imaging Group or the Royal College of Radiology should address these issues and introduce some standardization of practice.

[Hypertensive manifestation of an acute intestinal intussusception]

BACKGROUND

Hypertension may be associated with intussusception.

CASE REPORT

An 8-month-old infant showed the following symptoms: lethargy, vomiting and hypertension. Abdominal ultrasound suggested the diagnosis of intussusception, which was confirmed by barium enema. The hypertension resolved after the intussusception was reduced.

CONCLUSION

Intussusception should be considered a diagnostic possibility in infants who show a history of vomiting and in whom lethargy and systematic hypertension are noted. This case re-affirms the diagnostic usefulness of abdominal ultrasonography.

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.

Where should paediatric surgery be performed?

We have tried to review the evidence for the organisation of paediatric surgical care. Difficulties arise because of the lack of published data from district general hospitals concerning paediatric surgical conditions. Hence much of the debate about the surgical management of children is based on anecdotal evidence. However, at a time when the provision of health care is being radically reorganised to an internal market based on a system of purchasers and providers it is more important than ever to understand the issues at stake. Two separate issues have been discussed: the role of the specialist paediatric centre and the provision of non-specialist paediatric surgery in district general hospitals. There are arguments for and against large regional specialist paediatric centres. The benefits of centralisation include concentration of expertise, more appropriate consultant on call commitment, development of support services, and junior doctor training. The disadvantages include children and their families having to travel long distances for care, and the loss of expertise at a local level. If specialist paediatric emergency transport is available the benefits of centralisation far outweigh the adverse effects of having to take children to a regional paediatric intensive care centre. Specialist paediatric centres are aware of the importance of treating children and their parents as a family unit as highlighted by the Platt committee; this is an important challenge and enormous improvements have occurred to provide proper accommodation for families while their children are treated in hospital. To keep these arguments of large distances and separation from the home in context, one paediatric intensive care unit in Victoria, Australia, providing a centralised service to a region larger in are than England and with a similar admission rate, has a lower mortality rate than the decentralised paediatric intensive care provided in the Trent region of the UK. There is clear evidence that all neonatal surgery and anaesthesia should be conducted only by specialists. The debate now centres around the number of complex surgical cases a unit should treat to maintain its specialist status. The NHS executive, in its guidelines on contracting for specialist services, emphasises that "Sensible contracting needs to take into account the optimum population size not only for the stability of contracted referrals but also to give sufficient 'critical mass' for clinical effectiveness." Achieving this balance has consequences, not just for the maintenance of surgical expertise, but for the essential ancilliary services. There is clear evidence in anaesthesia that anaesthetists doing small numbers of neonatal procedures had significantly worse results. The same seems to be true in the fields of oncology, radiology, pathology, and intensive care. The reasons why the results of management of certain paediatric conditions are better at specialist centres are open to speculation. Presumably greater exposure to rare complex cases, concentration of expertise, more peer review, and a trickle down effect of the multidisciplinary approach all help to keep health care workers up to date with current world practice. In addition, it allows for appropriate specialist on call rotas and dedicated junior staff. If insufficient numbers of specialist surgical cases are being treated at a centre then the whole multidisciplinary team suffers. The 1989 NCEPOD report states "that paediatricians and general surgeons must recognise that small babies differ from other patients not only in size, and that they pose quite separate problems of pathology and management." The need for large centres of paediatric surgical expertise is now accepted by the Royal College of Surgeons of England, the British Association of Paediatric Surgeons, the Senate of Surgery of Great Britain and Ireland, the Royal College of Paediatrics and Child Health, the Royal College of Anaesthetists, the Audit

Intussusception: agonal phenomenon or cause of death?

This paper describes two cases of small intestinal intussusception, one in a child and one in an adult, where the findings at autopsy were atypical. The significance of intussusception in this situation is discussed and the literature related to deaths accompanied by acute small intestinal intussusception in the adult and paediatric population is reviewed. It is concluded that the findings represent a true pathological entity and not an 'agonal' event.

Controversies in abdominal imaging

Technologic improvement in ultrasound equipment, together with new clinical information, has altered the imaging of the abdomen in infants. Improvements in ultrasound equipment have allowed this to become the diagnostic test of choice for hypertrophic pyloric stenosis. Barium upper gastrointestinal radiography still remains the diagnostic test of choice for malrotation. New technologies for reduction of intussusception include air reduction and saline enemas with ultrasound monitoring. Controversies surrounding the different technologies and imaging strategies are discussed.

A comparison of colo-colic and ileo-colic intussusception

There are many differences in the clinical features of intussusception between African and temperate countries. The records of 192 patients with intussusception who presented to the Pediatric Surgical Service at King Edward VIII Hospital, Durban, South Africa during a 10-year period were reviewed. Compared with temperate countries, the patients were older (median, 1 year 7 months), presented later (median, 4.2 days), had a higher proportion of colo-colic lesions (17%), had absence of primary bowel pathology, and had a high surgical rate (82%). To define clinically important differences, the clinical and pathological features of 158 cases of ileo-colic intussusceptions were compared with 34 colo-colic cases. Compared with the ileo-colic group, colo-colic lesions occurred in older children (median, 3.8 years) (v 1.5 years; P < .001). In the colo-colic group, there were fewer shocked and pyrexial patients, and the rate of successful nonoperative reduction was higher. The groups had a similar incidence of surgical intervention (82%). In the ileo-colic group, there was a higher mortality rate and more complications, but only the higher resection rate (P < .001) was statistically significant.

Studies of avoidable factors influencing death: a call for explicit criteria

OBJECTIVE

To analyse studies evaluating cases of potentially "avoidable" death.

DESIGN

The definitions, sources of information, and methods were reviewed with a structured protocol. The different types of avoidable factors,--that is, deficiencies in medical care that may have contributed to death--were categorised. The presence of explicit classifications and standards was examined. basic criteria for quality of the studies were defined and the numbers of studies fulfilling these criteria were assessed.

SETTING AND PARTICIPANTS

65 studies, published during 1988-93 in peer reviewed medical journal for which the title, or abstract, or both indicated that they had analysed potentially avoidable factors influencing death. Studies analysing aggregated data only, were not included.

RESULTS

Only one third of the studies fulfilled basic quality criteria,--namely, that the avoidable factors examined should be defined and the sources of information and people responsible for the judgements presented. The definitions used comprised two levels, one stating that there had been errors in management (process) and the other that the errors may have contributed to the deaths (outcome). Only 15% of the studies explicitly defined what type of factors they had looked for and 8% referred to specified standards of care.

CONCLUSIONS

Studies of avoidable factors influencing death may have considerable potential as part of a system of improving medical care and reducing avoidable mortality. At present, however, the results from different studies are not comparable, due to differences in materials and methods. There is a need to improve the quality of the studies and to define standardised explicit definitions and classifications.

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.

Ultrasonography is accurate enough for the diagnosis of intussusception

For more than 10 years the authors have been using ultrasonography to confirm clinically suspected intussusception without performing a contrast enema. The aim of this study is to review this diagnostic policy. Between 1980 and 1989, 163 children who, on clinical examination and plain abdominal radiographs were suspected of having intussusception, underwent ultrasonography to confirm the diagnosis. In 33 children, ultrasonography did not show intussusception; of the remaining 130 children, intussusception was diagnosed in 128. In two children in whom intussusception was noted subsequently, the diagnosis was not established on ultrasound. Thus, ultrasonography had a sensitivity of 98.5% and a specificity of 100% in the diagnosis of intussusception. It is a quick, simple, noninvasive method to diagnose intussusception, with high accuracy. The role of contrast enema is limited to therapeutic application.

Adenovirus and intranuclear inclusions in appendices in intussusception

AIMS

To examine the light and electron microscopic features of appendices removed at the time of surgical reduction of intussusception in children; and to confirm that the viral inclusions seen in some of them are due to adenovirus.

METHODS

A series of 39 appendices from cases of intussusception and 15 control appendices were reviewed. Light microscopic examination of haematoxylin and eosin stained sections was performed on all of them and one appendix with large numbers of inclusions was examined by electron microscopy. Non-isotopic in situ hybridisation using a biotinylated DNA probe was carried out on sections of appendix from 30 of the cases of intussusception and from the 15 controls.

RESULTS

Light microscopic examination showed viral inclusions in 19 of the appendices from the cases of intussusception and in none of the controls. Electron microscopic examination showed viral particles with the typical features of adenovirus. Most of the appendices with viral inclusions in the haematoxylin and eosin stained sections also contained adenovirus DNA as shown by in situ hybridisation.

CONCLUSIONS

Viral inclusions seen in appendices from cases of intussusception are caused by adenovirus. Adenovirus DNA was not demonstrable in appendices from cases of intussusception without viral inclusions and the aetiological factors involved in intussusception in these children remain unknown.

Paediatric intussusception

Intussusception is one of the commonest causes of intestinal obstruction in infants and accounts for about 700 hospital admissions each year in England and Wales. Improved results of treatment have followed recent technological developments, which include ultrasonographic imaging and pneumatic reduction techniques. Most intussusceptions can be reduced successfully without the need for operation but close cooperation between surgeon and radiologist is essential. Mortality and morbidity rates from the condition have progressively declined in recent decades but avoidable deaths still occur.