Recurrence rates after intussusception enema reduction: a meta-analysis

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

INTRODUCTION

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Factors associated with in-hospital recurrence of intestinal intussusception in children

BACKGROUND

A minority of children experience in-hospital recurrence of intestinal intussusception after treatment. This study investigated the factors associated with in-hospital recurrence of intussusception in pediatric patients in China.

METHODS

This retrospective study included patients aged 0-18 years-old with intestinal intussusception treated at Hainan Women and Children's Medical Center between January 2019 and December 2019. Demographic and clinical characteristics were extracted from the medical records. Factors associated with in-hospital recurrence of intussusception were identified by logistic regression analysis.

RESULTS

The analysis included 624 children (400 boys) with a median age of 1.8 years (range, 2 months and 6 days to 9 years). Seventy-three children (11.7%) had in-hospital recurrence of intussusception after successful reduction with air enema. Multivariate logistic regression analysis identified age > 1 year-old (odds ratio [OR]: 7.65; 95% confidence interval [95%CI]: 2.70-21.71; P < 0.001), secondary intestinal intussusception (OR: 14.40; 95%CI: 4.31-48.14; P < 0.001) and mesenteric lymph node enlargement (OR: 1.90; 95%CI: 1.13-3.18; P = 0.015) as factors independently associated with in-hospital recurrence of intussusception.

CONCLUSIONS

Age > 1 year-old, secondary intussusception and mesenteric lymph node enlargement were independently associated with increased odds of in-hospital recurrence of intussusception after successful reduction with air enema.

Ultrasound guided hydrostatic enema reduction of ileocolic intussusception: a safe and effective technique

BACKGROUND

Currently, the primary management of ileocolic intussusception in children is usually by non-operative image-guided enema reduction. In most centres around the world especially in Australasia the predominant technique is the pneumatic reduction under fluoroscopic guidance. At our institution, we have been performing ultrasound-guided hydrostatic reduction since 2012.This is an audit to determine the efficacy and safety of ultrasound-guided hydrostatic reduction for intussusception.

METHODS

Following ethics approval, a retrospective review of all patients presenting to our institution with intussusception and subsequently undergoing hydrostatic reduction over a period of 9 years (2012 to-2020) was performed. The parameters studied included (i) successful reduction, (ii) recurrence, (iii) need for surgery and (iv) lead point at surgery.

RESULTS

The mean age at presentation was 12 months. One hundred and eight children were diagnosed to have ileocolic intussusception. One hundred and six underwent ultrasound-guided hydrostatic reduction with successful reduction in 96 (90.5%) patients. Reduction was unsuccessful in 10 patients (9.5%). Of these eight were noted to have a pathological lead point (four-Meckel's diverticulum and four-Lymphoma) at the time of the surgery. The intussusception recurred in six patients (6.25%) within 24 h. No reduction related perforation occurred during the study period.

CONCLUSION

Ultrasound-guided hydrostatic reduction is a safe and effective technique for managing intussusception as it allows continuous monitoring of the reduction of the intussusception without exposing the children to ionizing radiation.

Adenovirus infection is a risk factor for recurrent intussusception in pediatric patients

BACKGROUND

Human adenoviruses are the most common pathogens to be isolated from cases of pediatric intussusception. However, the specific clinical characteristics of pediatric intussusception associated with adenovirus infection are poorly known.

METHODS

We reviewed the medical records of pediatric patients (≤18 years of age) with intussusception treated between January 2014 and December 2020. We enrolled patients with febrile episodes, 27 with and 29 without adenovirus infections (the latter serving as control group). The demographic data, clinical characteristics, and the diagnoses and management strategies were evaluated.

RESULTS

The adenovirus group exhibited a significantly longer febrile duration (4.3 ± 1.9 vs. 3.3 ± 1.1 days, p = 0.020) than the control group, with an odds ratio (OR) of 5.098 (95% confidence interval [CI] 1.223-21.254, p = 0.025). The recurrence rates were 48.1% and 13.8% in the two groups (OR 5.804; 95% CI: 1.585-21.245, p = 0.008). Most adenoviruses were non-enteric (85.2%).

CONCLUSION

Adenovirus-related intussusception is associated with a longer febrile period and a higher rate of intussusception recurrence. It is recommended that patients suspected of adenovirus-related intussusception should be observed for longer than others prior to discharge.

Management of intussusception in children: A comparative study of hydrostatic reduction with saline under ultrasound guidance versus laparoscopic assistance

Introduction

Intussusception is a common cause of intestinal obstruction in infants and children. Ultrasound-guided hydrostatic reduction (USGHR) with saline is considered the gold standard with a success rate of more than 90%. Hydrostatic reduction with laparoscopic assistance has its own advantage of direct visualisation, assessment of bowel vascularity and controlled distension. The choice of procedure depends on available resources and surgeon's preference. This study aims to compare the outcomes of the two methods, i.e., laparoscopic-assisted hydrostatic reduction (LAHR) and USGHR under general anaesthesia (GA).

Materials and Methods

This was a prospective study carried out at two different centres over a 3-year period. All patients of intussusception were managed by either hydrostatic reduction with saline under ultrasound guidance or hydrostatic reduction with laparoscopic assistance. Both the procedures were done in operation theatre under GA. The operating time and amount of fluid used for reduction were noted.

Results

There were 27 patients in Group 1 (USGHR) and 20 patients in Group 2 (LAHR). The two groups were similar in terms of demographic parameters. The various outcomes such as number of attempts for reduction, fluid required for reduction, time to start oral feeds, complication and length of stay were similar in both the groups. The mean operating time for Group 1 was 19.4 ± 4.5 min and for Group 2 was 34.9 ± 4.8 min (P < 0.001).

Conclusion

Both the procedures fare equally in terms of outcome except mean operating time, therefore, LAHR is a good alternative to USGHR in resource-poor nations where logistics of intraoperative ultrasound may not be present.

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.

Factors associated with surgical treatment in pediatric intussusception

BACKGROUND

The study aimed to identify factors related to the need for surgical treatment of intussusception in pediatric patients.

METHODS

The medical charts of 106 patients diagnosed with intussusception and treated at the Imam Khomeini Medical Center in Ahvaz city between September 2019 and October 2020 were retrospectively reviewed. Patients were compared in terms of risk factor groups treated with surgery (12 pediatric patients) and nonsurgical methods (92 pediatric patients). Size of intussusception, free fluid in the abdomen, and currant jelly stool were compared between the groups.

RESULTS

The mean age in the group treated with surgery was significantly higher (p = 0.01). The duration of symptoms in patients treated with surgery was significantly higher (p = 0.033). The size of intussusception in the surgical treatment group was significantly larger than in the nonsurgical recovery group (p = 0.042). The rates of presence of free fluid in the abdomen and currant jelly stool were significantly higher in patients treated with surgery (p = 0.001 and p = 0.004, respectively).

CONCLUSION

Age > 1 year, duration of symptoms > 24 h, currant jelly stool, intussusception > 3.5 cm, and free peritoneal fluid are factors associated with surgical treatment of intussusception in children.

Ultrasound Findings to Predict Risk of Recurrence in Pediatric Intussusception After Air Enema Reduction

OBJECTIVES

Intussusception is one of the most common abdominal emergencies in early children. Intussusception recurs in 8-20% of children after successful nonoperative reduction. The aim of this study was to explore the ultrasound findings to predict risk of recurrence in pediatric intussusception after air enema reduction.

METHODS

A total of 336 intussusception children were followed up for 1 year after received successful air enema reduction. They were divided into the recurrent group and the non-recurrent group. The differences of clinical characteristics, ultrasonic features, and laboratory tests were analyzed by univariate analyses and the Cox proportional hazard model.

RESULTS

Sixty-five children with recurrent intussusception were identified. There were statistically significances in the diameter of the mass, in the presence or absence of enlarged lymph nodes out of the sleeve, and in the sleeve between recurrent and non-recurrent groups (P < .05). Other ultrasonic features, clinical characteristics, and blood parameters had no differences (P > .05). Multivariate Cox proportional hazard model showed that the diameter of the mass and abdominal lymph nodes may be the risk factors of intussusception recurrence (HR = 1.395, 95% CI: 1.045~1.863 and HR = 2.078, 95% CI: 1.118~3.865, P < .05). The cut-off value of mass diameter was 2.55 cm, above which recurrence is more likely.

CONCLUSIONS

Intussusception recurrence was prone with greater mass diameter (>2.55 cm) and enlarged abdominal lymph nodes. Although these ultrasound findings for recurrence do not necessarily reduce the rate of recurrence, it can predict the recurrent possibility, and help the emergency physicians to be more vigilant in these children and better counsel parents upon discharge.

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.

•

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 Effect of COVID-19 on Pediatric Intussusception: A Retrospective Study of a Single Center in South Korea with 10-Year Experience]

Purpose

To evaluate the effect of the emergence of coronavirus disease-19 (COVID-19) on pediatric intussusception.

Materials and Methods

Patients (< 18 years) who were diagnosed with intussusception and received enema reduction from 2011 to 2020 were included. We reviewed the demographics, yearly/monthly/seasonal incidence of intussusception, method and failure rate of enema reduction, recurrence rate of intussusception, surgical record, and pathologic report. Subsequently, we investigated the differences in mean age, failure rate of enema reduction, and recurrence rate of intussusception between the cases in 2020 and those in the period from 2011 to 2019.

Results

A total of 859 enema reductions were performed during the past decade, more in males and in the age < 1 year (mean age, 22.2 months). The yearly incidence was highest in 2014 and lowest in 2020, and the monthly incidence was highest on December and September. The cases in 2020 (n = 27) had a lower mean age (18.1 months vs. 22.8 months), higher failure rate of enema reduction (7.4% vs. 2.4%), and higher recurrence rate of intussusception (14.8% vs 7.3%) compared with those that occurred between 2011 and 2019 (n = 832). However, these results did not show statistical significance (p = 0.07, p = 0.15, p = 0.14, respectively).

Conclusion

With the emergence of COVID-19, the number of enema reductions was remarkably decreased with a lower mean age, higher failure rate, and higher recurrence rate.

Significance of Follow-Up Ultrasonography 24 Hours Post-Reduction in Detecting Intussusception Recurrence

PURPOSE

The objective of this study was to identify the significance of 24-hour post-reduction ultrasonography (US) in pediatric patients with intussusception.

METHODS

A total of 229 patients with intussusception who were treated with saline reduction at Severance Children's Hospital between January 2014 and September 2020 were retrospectively reviewed. The 229 patients with successful saline reduction were divided into two groups: a recurrence at 24 hours group (R, n=41) and a non-recurrence group (NR, n=188). The full patient sample was divided into two groups: follow-up US (FU) or no follow-up US (NFU); the recurrence group was divided into follow-up (R-FU) and non-follow-up (R-NFU) subgroups, and stratified analyses were performed.

RESULTS

There were no significant differences in age, sex, laboratory findings, symptoms, and sonographic findings between the NR and R groups. In the R group, 24 patients underwent follow-up US, and 17 patients did not. Specific sonographic findings were statistically significant in the R-FU group compared to the R-NFU group (p=0.002). The R-FU group had fewer admissions (p=0.012) and longer mean hospitalization times (p<0.001) than the R-NFU group. The NFU group had a 12.2% recurrence rate, while the R-FU group recurrence rate was 25.8% (p=0.0099), suggesting that the omission of some recurrent events and follow-up US was a significant variable in the recurrence of intussusception. The median time to recurrence was 21 hours which supports the 24-hour follow-up protocol.

CONCLUSION

Twenty-four-hour follow-up US was shown to be valuable for detecting early recurrence of intussusception.

Clinical characteristics of recurrent intussusception: A single-center retrospective study

PURPOSE

we attempted to summarize the clinical characteristics of recurrent intussusception through a large sample size retrospective study.

METHODS

5778 patients who were diagnosed with intussusception and treated in our hospital between January 2014 and December 2018 were reviewed.

RESULTS

the overall recurrence rate was 20.0%, with the recurrence frequency ranged from 1 to 17 episodes and the recurrence interval ranged from 0 to 5 years. 80.0% (926/1158) patients had only 1 to 2 episodes of recurrence. Most of the patients (88.3%) relapsed within 1 year after successful reduction, among which 616 patients (53.2%) relapsed within 3 days. The recurrence rate of intussusception was the lowest when the age was less than 1 year, increased and kept high level in patients aged from 1 to 5 years old, then decreased after 5 years. The pathologic lead point (PLP) proportion of recurrence group was higher than that of non-recurrence group (2.2% VS 1.2%, P = 0.005).

CONCLUSIONS

the overall recurrence rate was 20.0%. Most of the patients had only 1 to 2 episodes of recurrence and relapsed within 1 year after successful reduction. Age and PLP were risk factors for intussusception recurrence.

Effect of general anesthesia on delayed repeat enema in pediatric intussusception

BACKGROUND

The study aimed to assess the efficacy and safety of delayed repeated enema (DRE) and to evaluate the effect of general anesthesia (GA) on DRE.

METHODS

A retrospective analysis was conducted of all children below 3 years with primary intussusception who were offered DRE in our tertiary center, from 2014 until 2019. Following a standardized pneumatic enema protocol, those who showed a partially successful result were offered DRE 2 h later, either awake (Group A) or under GA (Group B). DRE under GA was our preferred procedure unless there were no pediatric anesthetists available at that time. Data collected for each group included age, sex, duration of symptoms, success rate of the DRE, and any complications noted.

RESULTS

The study included 57 children (32 males and 25 females). The median age in Group A (31 patients) was 10 months while in Group B (26 patients) it was 11 months. The number of patients with duration of symptoms < 24 h vs > 24 h was 12:19 and 9:17 in Group A and B patients respectively. DRE was successful in 14/31 (45.2%) of Group A patients with one complication and in 9/26 (34.6%) of Group B patients with no complications. There was no statistically significant difference between both groups' success rate and complication rate. Both groups were similar in age, sex, and duration of symptoms.

CONCLUSIONS

DRE can effectively increase the overall success rate of pneumatic enema in selected patients with pediatric intussusception. However, the current evidence does not justify the routine use of GA during attempts DRE attempts.

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.

Routine Ultrasound Control after Successful Intussusception Reduction in Children: Is It Really Necessary?

INTRODUCTION

 Recurrence of ileocolic intussusception (ICI) has been related to residual bowel wall edema after enema reduction. Early oral tolerance has been associated with a higher risk of re-intussusception, so an imaging test (ultrasound) has traditionally been performed before restarting oral tolerance. Our aim is to analyze the cost-effectiveness of performing a routine ultrasound in patients who remain asymptomatic after successful enema reduction.

MATERIALS AND METHODS

 A retrospective observational study was performed in patients with ICI who underwent a successful enema reduction between 2005 and 2019 and distributed in two groups according to whether or not a routine ultrasound was performed before restarting oral tolerance: group A (ultrasound) or B (no ultrasound). We analyzed demographic, clinical and laboratory variables, length of hospital stay, and recurrence rate.

RESULTS

 We included 366 patients who presented 373 ICI episodes (165 in group A and 208 in group B), without significant differences in gender and age. Group A patients presented a higher percentage of vomiting and bloody stools than those in group B without differences in the other clinical features studied, time of evolution, or laboratory variables. Group A presented a higher length of hospital stay than group B (36 vs. 24 hours), although it was not statistically significant (p = 0.30). No statistically significant differences were observed in the recurrence rate between both groups (10.3% A vs. 10.8% B; p = 0.83).

CONCLUSION

 Performing routine ultrasound before restarting oral tolerance in asymptomatic patients after successful ICI reduction does not decrease the risk of re-intussusception and should not be routinely encouraged.

Periprocedural analgesia and sedation in air enema reduction for intussusception: A retrospective Australian cohort study

AIM

Periprocedural analgesia or sedation for air enema reduction (AER) of intussusception is a matter of debate. We set out to review Australian periprocedural pain management in AER.

METHODS

Retrospective electronic medical record review of emergency department presentations of intussusception at an Australian children's hospital over 2 years for periprocedural analgesia and sedation and short-term outcomes.

RESULTS

A total of 73 patients (mean age 23 months) had ultrasound-confirmed intussusception. Prior to AER, analgesia was administered to 61 of 73 (83.5%) patients. Opioids were administered in 48 of 73 (65.8%) and 8 of 73 (11.0%) received sedation. Thirteen of 73 (17.8%, 95% confidence interval 9.0-26.6) had spontaneously reduced; 60/73 that underwent primary AER had successful reduction in 54 (90.0%, 95% confidence interval 82.4-97.6). A total of seven patients required surgery. No AER attempts were complicated by bowel perforation.

CONCLUSION

The use of periprocedural analgesia for AER in this Australian series was common, whilst sedation use was infrequent. No perforations occurred.

Sedated ultrasound guided saline reduction (SUR) of ileocolic intussusception: 20 year experience

BACKGROUND

Ileocolic intussusception is a common abdominal emergency in children, diagnosed routinely with ultrasound and treated most frequently with fluoroscopic pneumatic reduction without sedation. Alternatively, ultrasound can also be used to obviate ionizing radiation and sedation can be used to avoid discomfort from the procedure. The purpose of this study was to present our experience with sedation using saline enema under ultrasound guided control to reduce ileocolic intussusception.

MATERIALS AND METHODS

This is a retrospective study of patients with ileocolic intussusception presenting to a tertiary care hospital between 1998 and 2018. We excluded the data of patients that underwent either fluoroscopic guided reduction with barium enema or primary surgery. All patients received sedation with propofol and subsequently underwent our sedated ultrasound guided saline reduction (SUR) protocol until reduction was confirmed.

RESULTS

414 total reductions were performed in the 338 children who underwent our SUR protocol, of which 86.0% were successful. Zero perforations occurred during attempted reduction. 58 patients required surgery after a failed reduction (14.0%). There were 76 recurrent episodes that underwent our SUR protocol, of which 93.4% had a successful reduction.

CONCLUSION

The success rate of reduction was high and compared similarly to techniques that either use pneumatic reduction under radiation or refrain from administering a sedative prior to enema.

LEVEL OF EVIDENCE

Treatment study level III.

Clinical management and recommendations for children with more than four episodes of recurrent intussusception following successful reduction of each: an institutional review

AIM

To describe patterns and risk factors of multiple recurrences to optimise management for pediatric patients with more than four episodes of intussusception.

MATERIALS AND METHODS

Following IRB approval, all sonographic evaluations for intussusception in patients <18 years over a 6-year period were reviewed. Data extracted included age at onset of first intussusception, gender, presenting symptoms, symptoms upon recurrence, presence of pathological lead points, and surgical findings.

RESULTS

During a 6-year period, five cases had four or more instances of recurrence after enema reduction attempts. All patients were male with an average age of 16 months. Two of the five cases resolved after the fourth enema reduction and no lead points were identified. Two other cases involved surgical reduction with intraoperative findings of Meckel's diverticulum and juvenile polyp. The final case had five recurrence episodes and six separate enema reductions. Ultimately, lymphoid hyperplasia was discovered on colonoscopy and the patient never recurred after being treated with steroids.

CONCLUSION

Given the favorable reduction rate in re-recurrent cases and complete lack of perforation observed, up to four attempts at enema reduction is recommended before considering an alternative strategy. If recurrence continues past the fourth reduction attempt, computed tomography (CT) is recommended to identify a lead point. If CT remains inconclusive, then consider exploratory laparotomy.

Intussusception: A 14-year experience at a UK tertiary referral centre

AIMS

Intussusception is the most common cause of acute intestinal obstruction in infants. First line management in uncomplicated cases at our centre is fluoroscopy guided air enema reduction. This study reports a 14 year UK single centre experience highlighting management and outcomes of intussusception in children.

METHODS

All cases of intussusception (ICD 10-code K56.1) at a single tertiary referral centre from 2004 to 2017 were analyzed. Data evaluated included patient demographics, clinical presentation, treatment modality(s), complications and outcome(s).

RESULTS

Two hundred ninety confirmed cases (69% male) of intussusception were identified during the study period. The median age at presentation was 9.5 months (range 4 days-15 years). One hundred eighty-six (64%) cases occurred in children who were transferred to Alder Hey from peripheral district hospitals. One hundred ninety-six cases (68%) proceeded directly to air enema reduction and successful reduction was achieved in 129 cases (66%). A single case (0.5%) of attempted air enema reduction was complicated by perforation. Early recurrence rate following air enema reduction was 9%. Operative management was indicated in 140 (48%) cases of which 66 required bowel resection (47%). There were no deaths.

CONCLUSIONS

We highlight one of the largest single centre UK studies defining practice outcomes for intussusception across the British Isles. Our centre has achieved a 66% success rate of non-operative reduction over 14 years in line with the British Society Pediatric Radiology (BSPR) recommendations and within 5% of the national median metric (71%). Moreover these outcomes were achieved with a very low complication rate (0.5%) from air enema reduction and no mortality in the series.

TYPE OF STUDY

Retrospective study.

LEVEL OF EVIDENCE

III.

Impact of a Standardized Clinical Pathway for Suspected and Confirmed Ileocolic Intussusception

Supplemental Digital Content is available in the text.

Introduction:

Clinical pathways for specific diagnoses may improve patient outcomes, decrease resource utilization, and diminish costs. This study examines the impact of a clinical pathway for emergency department (ED) care of suspected and confirmed pediatric ileocolic intussusception.

Methods:

Our multidisciplinary team designed an intussusception clinical pathway and implemented it in a tertiary children’s hospital ED in October 2016. Process measures included the proportion of patients who underwent abdominal radiography, had laboratory studies, received antibiotics, or required admission following reduction of intussusception. The primary outcome measure was the cost per encounter. Balancing measures included unplanned ED visits within 72 hours of discharge. Data analyzed compared 24 months before and 21 months following pathway implementation.

Results:

After pathway implementation, the use of abdominal radiography in patients with suspected intussusception decreased from 50% to 12%. In patients with confirmed intussusception, laboratory studies decreased from 58% to 25%, antibiotic use decreased from 100% to 2%, and hospital admissions decreased from 100% to 12%. The average cost per encounter for confirmed intussusception decreased from $6,724 to $2,975. There was a small increase in unplanned returns to the ED within 72 hours but no increase in readmissions after pathway implementation.

Conclusion:

Implementation of a standardized ED pathway for the management of suspected and confirmed pediatric ileocolic intussusception is associated with a reduction in abdominal radiographs, improved antibiotic stewardship, reduction in laboratory studies, fewer inpatient admissions, and decreased cost, with no compromise in patient safety.

Nationwide Population-Based Epidemiologic Study on Childhood Intussusception in South Korea: Emphasis on Treatment and Outcomes

PURPOSE

This was a nationwide population-based study conducted to investigate the epidemiology, treatment, disease outcomes, and associated factors of childhood intussusception in South Korea.

METHODS

Data from the Korean National Health Insurance Service database on all patients <18 years old diagnosed with intussusception from 2007 to 2017 were analyzed.

RESULTS

A total of 34,688 cases were identified among 30,444 patients. The overall incidence was 28.3/100,000 person-years with a male predominance. Most cases (83.1%) occurred in children <3 years old, with an annual incidence of 195.2, 200.1, and 118.6 cases per 100,000 children in their first, second, and third year of life, respectively. The median age at the first occurrence was 18.7 months, and it was higher in boys than in girls. The post-discharge recurrence rate was 10.6% (3,226/30,444) and the in-hospital recurrence rate was 6.1% (1,842/30,444). The total recurrence rate (post-discharge recurrence and/or in-hospital recurrence) was 15.0% (4,580/30,444). Enema reduction was successful in 90.0% of cases. Enema reduction was more successful in girls than in boys. A total of 3,296 (10.8%) patients underwent 3,481 surgeries, including 735 (21.1%) laparoscopic surgeries. Post-discharge recurrence and surgery were significantly affected by age, sex, and hospital type. Mortality was noted in nine cases (0.03%).

CONCLUSION

Our study provides accurate epidemiologic data on the treatment and outcomes of intussusception through complete enumeration during an 11-year-period.

Incidence of recurrent intussusception in young children: A nationwide readmissions analysis

BACKGROUND/PURPOSE

Recurrent intussusception following successful nonoperative reduction has previously been reported with a frequency of 8%-12% based on data from individual institutions. Meanwhile, the timing of discharge after successful reduction continues to be debated. Here, we evaluate readmissions for recurrent intussusception in young children using a large-scale national database.

METHODS

The National Readmissions Database (2010-2014) was queried to identify young children (age < 5 years) diagnosed with intussusception. We compared procedures performed during the index admission and frequency of readmissions for recurrent intussusception. Results were weighted for national estimates.

RESULTS

We identified 8289 children diagnosed with intussusception during an index admission. These patients received definitive treatment with nonoperative reduction alone (43%), surgical reduction (42%), or bowel resection (15%). Readmission for recurrent intussusception was required for 3.7% of patients managed with nonoperative reduction alone, 2.3% of patients that underwent surgical reduction, and 0% of those that underwent bowel resection. Median time to readmission was 4 days after nonoperative reduction, and only 1.5% of these patients experienced recurrence within 48 h of discharge.

CONCLUSIONS

Recurrent intussusception may be substantially less common than previously reported. Our findings support the practice of discharge shortly after successful nonoperative reduction.

TYPE OF STUDY

Retrospective, prognosis study.

LEVEL OF EVIDENCE

III.

Air contrast enema reduction of single and recurrent ileocolic intussusceptions in children: patterns, management and outcomes

BACKGROUND

There is no consensus as to when surgical intervention should be considered for recurrent ileocolic intussusceptions in a stable patient after previous successful air contrast enema.

OBJECTIVE

To review the patterns of ileocolic intussusceptions, air contrast enema success rates, and pathologic lead point rates in patients with and without recurrence to evaluate whether treatment outcomes depend on the number and timing between episodes.

MATERIALS AND METHODS

We retrospectively reviewed 683 children with air contrast enema performed for ileocolic intussusception between January 2000 and May 2018. Recurrent intussusceptions were separated into mutually exclusive categories: short-term only (≤7 days between episodes) and long-term (>7 days between episodes) intussusceptions. Long-term recurrences included both long-term only and long- and short-term intussusceptions.

RESULTS

Of the 683 patients, 606 (89%) had at least 1 successful air contrast enema. Of the 606, 115 (19%) had recurrent intussusceptions after successful reduction. The air contrast enema success rate for a single intussusception was 86% (491/568) and for recurrent intussusceptions was 96% (110/115) (P=0.004). Single and recurrent intussusceptions had similar pathologic lead point rates (3.5% vs. 4.3%; P=0.593). Short-term and long-term recurrences did not differ in air contrast enema success rates (96% vs. 95%). Long-term recurrences had higher pathologic lead point rate compared to short-term only (13% vs. 0%; P=0.003). Of short-term recurrences, 99% (76/77) were ≤5 intussusceptions; 92% had successful air contrast enema without surgery.

CONCLUSION

The majority of recurrent intussusceptions were successfully treated by air contrast enema. Short-term recurrences have lower pathologic lead point rates, suggesting that a higher surgical threshold may be plausible relative to long-term recurrences. In the appropriate clinical context, repeat air contrast enemas are a safe option for short-term recurrences, which can be attempted at least five times, potentially precluding the need for surgical intervention.

Laparoscopic Ileopexy Versus Laparoscopic Simple Reduction in Children with Multiple Recurrences of Ileocolic Intussusception: A Single-Institution Retrospective Cohort Study

Background: Laparoscopy has been widely used in treatment of pediatric intussusception. However, controversy still exists on the best surgical approach for children with multiple recurrences. This cohort study is aimed to compare the efficacy and safety of laparoscopic ileopexy versus laparoscopic simple reduction for treatment of ileocolic intussusception with three or more episodes of recurrence in pediatric patients. Patients and Methods: This study enrolled 74 children with three or more recurrences of ileocolic intussusception treated at our department between January 2016 and June 2018. Of these children, 37 cases undergoing laparoscopic ileopexy were matched with 37 cases undergoing laparoscopic simple reduction according to age. Data on patient characteristics, duration of follow-up, operative parameters, and recurrence rate after laparoscopic operation were reviewed and analyzed. Results: Patient characteristics, including age, gender, weight, number of recurrences at surgery, clinical manifestations, and duration of follow-up, were well comparable between the two groups (each P > .05). During follow-up, recurrence occurred in 16 (43.24%) children undergoing laparoscopic simple reduction, whereas recurrence occurred in 1 (2.70%) case undergoing laparoscopic ileopexy. In comparison, laparoscopic ileopexy significantly decreased the risk of recurrence (P < .001). No statistical difference was observed between the two groups in terms of operative time, length of postoperative stay, and intra- and postoperative complications (each P > .05). No morbidity was documented in both groups. Conclusions: Laparoscopic ileopexy is effective and safe as a surgical approach for multiple recurrences of ileocolic intussusception in pediatric patients. The underlying mechanisms are yet to be fully clarified.

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.

Point-of-Care Ultrasound Could Streamline the Emergency Department Workflow of Clinically Nonspecific Intussusception

OBJECTIVES

The aim of this study was to evaluate whether point-of-care ultrasound (POCUS) for intussusception screening streamlines the workflow of clinically nonspecific intussusception (CNI), an intussusception presenting with only 1 manifestation of the classic triad, and/or vomiting.

METHODS

We reviewed 274 consecutive children with intussusception, aged 6 years or younger, who visited a tertiary care hospital emergency department between May 2012 and April 2016. This period was dichotomized by May 2014 (the "PRE" and "POST" groups), starting point of implementation of the POCUS protocol for intussusception screening. All children with CNI who had positive results on or forwent POCUS underwent radiologist-performed ultrasound (US). We measured and compared emergency department length of stay (EDLOS), the sum of door-to-reduction and observation times, and the frequency of POCUS and positive US results between the 2 groups.

RESULTS

Of 160 children with CNI, 93 visited the emergency department since May 2014. The POST group showed a shorter median EDLOS (856 vs 630 minutes, P < 0.001), door-to-reduction time (137 vs 111 minutes, P = 0.002), and observation time (700 vs 532 minutes, P < 0.001). The POST group had a higher frequency of POCUS (12% vs 60%, P < 0.001) with positive US results (33% vs 59%, P < 0.001). The PRE group had a higher frequency of severe bowel edema (16% vs 1%, P < 0.001). No significant differences were found in the severity, recurrence, admission, and surgery. One child had a false-negative result on POCUS.

CONCLUSIONS

Point-of-care ultrasound could streamline the workflow of CNI via decrease in EDLOS and unnecessary referrals for US.

Emergency department discharge following successful radiologic reduction of ileocolic intussusception in children: A protocol based prospective observational study

PURPOSE

Pediatric intussusception's first line treatment consists of fluoroscopic guided air enema reduction. Postprocedure, these patients are usually admitted overnight for observation. The purpose of our study was to document the results of emergency department (ED) observation and discharge protocol after successful reduction of ileocolic intussusception.

METHODS

A prospective observational study was conducted after implementation of an ED protocol for ileocolic intussusception from 10/2014 to 7/2017 and compared these patients to a historical cohort immediately prior to protocol initiation (10/2011-9/2014). Data collected included demographics, total time in the ED and hospital, enema reduction, recurrence, and requirement for operative intervention. Results reported as means with standard deviation and medians reported with interquartile ranges (IQR).

RESULTS

115 patients were treated with the prospective protocol and were compared to a 90 patient historical cohort. Reduction was successful in 84%-89% of cases. Median hospital time after enema was shorter in the protocol group [4.8 h (4.25, 14.97) versus 19.7 h (13.9, 33.45), p < 0.01]. Only 33% of patients were admitted following the protocol; the most common admission reason was persistent abdominal discomfort.

CONCLUSION

ED observation and discharge after successful air enema reduction in children with ileocolic intussusception are safe, facilitate early discharge, and reduce hospital resource utilization.

LEVEL OF EVIDENCE

III.

Intussusception Protocol Implementation: Single-Site Outcomes With Clinician and Family Satisfaction

BACKGROUND

The objective of this study was to evaluate clinical outcomes, costs, and clinician and parent satisfaction after implementation of a protocol to discharge patients from the emergency department (ED) after successful reduction of uncomplicated ileocolic intussusception.

MATERIALS AND METHODS

In March 2017, an intussusception management protocol was implemented for children presenting with ultrasound findings of ileocolic intussusception. Those meeting inclusion criteria were observed after successful radiological reduction in the ED and discharged after 6 h with resolution of symptoms. Retrospective chart review was completed for cases before and after protocol implementation for clinical outcomes and costs. Clinicians and parents were surveyed to assess overall satisfaction.

RESULTS

Charts were reviewed before (42 encounters, 37 patients) and after (30 encounters, 23 patients) protocol implementation. After implementation, admission rates decreased from 95% (40/42) to 23% (7/30; P < 0.001) and antibiotic use was eliminated (91% to 0%, P < 0.001). There was no difference in recurrence rates (17% versus 23%, P = 0.44). Median total length of stay decreased from 18.87 to 9.52 h (P < 0.001), whereas median ED length of stay increased from 4.37 to 9.87 h (P < 0.001). In addition, there was an overall hospital cost saving of over $2000 ($9595 ± 3424 to $7465 ± 3723; P = 0.009) per encounter. Clinicians and parents were overall satisfied with the protocol and parents showed no changes in patient satisfaction with protocol implementation.

CONCLUSIONS

An intussusception protocol can facilitate early discharge from the ED and improve patient care without increased risk of recurrence. Additional benefits include decreased hospital- and patient-related costs, elimination of antibiotic use, and parent as well as clinician satisfaction.

Outpatient management of intussusception: a systematic review and meta-analysis

BACKGROUND

Variability in management of intussusception after enema reduction exists. Historically, inpatient observation was recommended; however, there is a lack of evidence-based guidelines for this practice.

METHODS

A systematic review and meta-analysis evaluating outcomes between inpatient (IP) and outpatient (OP) management after enema reduction was performed. The following databases were searched: PubMed, EBSCOhost CINAHL, EMBASE, Web of Science, and Cochrane Database. Data from an institutional review were included in the meta-analysis.

RESULTS

Ten studies of patients aged 0-18 years with intussusception who underwent successful enema reduction that reported outcomes of outpatient management were included. Overall recurrence rates were 6% for IP and 8% for OP (p = 0.20). Recurrences within 24 (IP: 1% vs OP: 0%, p = 0.90) and 48 h (IP: 1% vs OP: 2%, p = 0.11) were similar. There was no significant difference in the rate of return to the emergency department (IP: 6% vs OP: 14%, p = 0.11). Both groups had a similar rate of requiring an operation (IP: 2% vs OP: 1%, p = 0.84).

CONCLUSIONS

Outpatient management of intussusception after enema reduction results in a shorter hospital stay with no difference in the rate of return to the emergency department, recurrence, need for operation, or mortality. The findings of the meta-analysis suggest that outpatient management may be safe and could reduce hospital resource utilization.

TYPE OF STUDY

Treatment study.

LEVEL OF EVIDENCE

III.

Risk Factors for Recurrent Intussusception in Children: A Systematic Review and Meta-Analysis

Background: Intussusception is a common abdominal emergency in infancy and childhood, and the recurrence rate is reported to be up to 20%. Numerous potential risk factors for recurrence have been reported, although some of them are still controversial. Objective: The present study was conducted to identify the risk factors or predictive symptoms for recurrent intussusception in children who successfully recovered via enema reduction. Methods: The databases of PUBMED, EMBASE, and Cochrane were searched up to August 2018. The primary outcome was the odds ratio involving the following potential risk factors: sex, the presence of blood in stool, fever, abdominal pain, right abdominal mass, pathological lead point, and vomiting. Results: A total of 12,008 participants from 10 studies included in the abovementioned databases were enrolled in this meta-analysis. The correlation strength with each risk factor was as follows: Sex (OR = 0.87 [0.69, 1.09], P = 0.22); fever (OR = 1.85 [1.29, 2.65], P = 0.0008); blood in stool (OR = 0.93 [0.52, 1.67], P = 0.25); abdominal pain (OR = 0.82 [0.49, 1.37], P = 0.46); vomiting (OR = 0.55 [0.37, 0.80], P = 0.002); pathological lead point (PLP) (OR = 7.71 [1.96,30.29], P = 0.003); location of the mass (OR = 0.51 [0.03, 8.28], P = 0.64). Besides, children who were relatively older (over 1-2 years of age) were seen to have a higher risk of recurrence. Conclusion: The main conclusion of this meta-analysis was that children with the presence of fever and PLP may have a higher risk of recurrence following enema reduction for intussusception. The prevalence of vomiting was found to be lower in RI (Recurrent Intussusception) patients than in the non-RI patients (control group).

Sonographic guided hydrostatic saline enema reduction of childhood intussusception: a prospective study

Background

The management of childhood intussusception in our sub-region is still via surgical intervention. Currently, the gold standard of treatment is non-operative reduction. We sought to assess the suitability of hydrostatic (saline) reduction of intussusception in children in our institution.

Materials and methods

A prospective study was conducted between January 2016 and June 2017 in all children with ultrasound confirmed intussusception at a tertiary teaching hospital in Nigeria. All children excluding those with signs of peritonitis, bowel gangrene and intestinal prolapse were selected for ultrasound-guided hydrostatic reduction (USGHR). We allowed a maximum of three attempts at reduction.

Results

The age range was 3 months to 48 months with a mean of 10.8 ± 9.1 months. Forty percent (N = 18) presented after 24 h of onset of symptoms. The success rate of hydrostatic reduction with saline enema was 84.4% (N = 38). Two (4.4%) perforations occurred during the procedure. Three (7.5%) patients had recurrent intussusception within six months. The duration of symptoms greater than 24 h, age and sex of patients did not influence successful reduction p > 0.05. The duration of admission between those who had successful non-operative reduction and those who subsequently had operative reduction and or resection attained statistical significant difference, p = 0.001. There was no mortality. We achieved a 68% decrease in the operative reduction of intussusception using USGHR as the primary modality of treatment.

Conclusion

Our study found out that USGHR is a suitable alternative for the treatment of childhood intussusception.

Factors associated with ultrasound-guided water enema reduction for pediatric intussusception in resource-limited setting: potential predictive role of thrombocytosis and anemia

BACKGROUND/PURPOSE

Although ultrasound-guided hydrostatic reduction (USGHR) is increasingly used in managing pediatric intussusception, there is limited literature concerning its use in Malaysia. We aim to examine the experience and factors associated with the effectiveness of USGHR using water.

METHODS

This is a single-center retrospective observational study in a Malaysian tertiary referral center. Children with intussusception admitted between year 2012 and 2016 were included and medical records reviewed. Factors associated with success or failure of USGHR were identified using multivariable logistic regression.

RESULTS

Of the 172 cases included, 151 cases (87.8%) underwent USGHR, of whom 129 cases were successfully reduced (success rate of 85.4%). One perforation (0.7%) was reported. Age more than 3years old (aOR=7.16; 95% CI=1.07-47.94; p=0.042), anemia (aOR=10.12; 95% CI=1.12-91.35; p=0.039), thrombocytosis (aOR=11.21; 95% CI=2.06-64.33; p=0.005) and ultrasound findings of free fluid (aOR=9.39; 95% CI=1.62-54.38; p=0.012) and left-sided intussusception (aOR=8.18;95% CI=1.22-54.90, p=0.031) were independently associated with USGHR irreducibility. Symptom duration, blood in stool, vomiting and other clinical presentations, however, showed no association.

CONCLUSIONS

USGHR with water is effective in the non-operative management of pediatric intussusception. Prolonged symptom duration need not necessarily preclude USGHR. The findings of anemia and thrombocytosis as independent predictors of USGHR irreducibility deserve further study.

TYPE OF STUDY

Treatment study LEVEL OF EVIDENCE: III.

Risk factors for recurrence of intussusception in pediatric patients: A retrospective study

OBJECTIVES

The aim of this study was to explore the risk factors associated with recurrence of intussusception after operative or nonoperative reduction in children.

METHODS

Between January 2004 and December 2012, patients with intussusception treated with nonoperative and operative reduction were retrospectively analyzed. We included the patients who were diagnosed with intussusception from the age of 0 year to 18 years who received nonoperative and operative reduction as an initial treatment. The data collected included demographic data (sex, age, and bodyweight), symptoms (vomiting, abdominal pain, rectal bleeding, diarrhea, distention, constipation, and duration of symptoms), signs (temperature, palpable mass, and location of the mass), investigations (ultrasound findings) and the method of reduction.

RESULTS

The risk factors for recurrence of idiopathic intussusception were analyzed by the univariable analysis and multivariable analysis. In the univariable model, the significant risk factors for recurrence of intussusception analyzed were age, bodyweight, duration of symptoms, rectal bleeding, poor prognosis signs on ultrasound scans, location of mass, and pathological lead point. After multivariable analysis was done, we found that the significant risk factors for recurrence of intussusception were age ≥ 2 years (OR = 5.597, P = 0.044), duration of symptoms ≥48 h (OR = 91.664, P < 0.001), rectal bleeding (OR = 4.758, P = 0.009), location of mass (left over right side) (OR = 0.038, P < 0.001), pathological lead point (OR = 0.002, P < 0.001).

CONCLUSION

Our study found that age ≥ 2 years, duration of symptoms≥48 h, rectal bleeding, location of mass (left over right side) and pathological lead point were risk factors for recurrence of intussusception.

LEVEL OF EVIDENCE

Prognosis study.

TYPE OF STUDY

Retrospective study.

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.

Recurrent intussusception among infants less than 2 years of age in Vietnam

In some settings, rotavirus vaccines have been associated with a low-level risk of intussusception, the most common cause of bowel obstruction in infants. As Vietnam prepares to introduce rotavirus vaccine into the national immunization program, we sought to better characterize the epidemiology of recurrent intussusception. We enrolled children <2 years of age who were hospitalized for intussusception retrospectively from January 2013 through December 2014 and prospectively from January 2015 through December 2016 at 2 hospitals in Vietnam. We enrolled 2477 children. Nearly all children were successfully treated by enema with low surgery rate (1%). We found 10% of children (n = 254) experienced at least once recurrence (range: 1-6) and 57% of first recurrences happened within the first 12 weeks after treatment of the first episode. The median age at first intussusception was 13 months for children without a recurrent episode and 10 months for children with a recurrence. The symptoms of the recurrent cases were milder with less vomiting (67%), bloody stool (7%) and fever (10%) compared to the initial cases (p < 0.01). We found the rate of recurrences following enema reduction of intussusception to be similar to that reported from other countries. Due to the high rate of intussusception and recurrent episodes in Vietnam, a better understanding of the cause of recurrent intussusception will be critical in assessing intussusception cases after rotavirus introduction.

Hospital admission unnecessary for successful uncomplicated radiographic reduction of pediatric intussusception

PURPOSE

After radiologic reduction, patients with ileocolic intussusception are often admitted. We hypothesize that discharge of stable patients after 4 h of emergency department (ED) observation does not result in an increase of adverse outcomes.

METHODS

We retrospectively reviewed pediatric patients with ileocolic intussusception between 2011 and 2016, managed with either 24-h inpatient or 4-h ED observation. Outcomes included length of stay, adverse outcomes, and total hospital charges.

RESULTS

Fifty-one patients were managed with ED observation and 79 with inpatient observation. Recurrence rates, time to recurrence, and adverse outcomes were similar in both protocols. Total recurrence rates for ED observation was 15% versus 14% for inpatient observation. ED observation reduced time in the hospital by 26.8 h (4.9 versus 31.7 h).

CONCLUSION

Discharging patients following uncomplicated hydrostatic reduction of ileocolic intussusception after a 4-h observation period does not result in an increase in adverse outcomes.

The role of dexamethasone in decreasing early recurrence of acute intussusception in children: A retrospective study

BACKGROUND

Early recurrent intussusception (RI) is a concern after a successful pneumatic reduction. Steroids have been suggested as a treatment that decreases early RI. The purpose of this study was to examine the role of dexamethasone in decreasing early RI.

METHODS

A retrospective review of 174 pediatric patients that underwent successful pneumatic reduction was conducted. Two groups were identified: group 1 that received intravenous dexamethasone (0.5mg/kg/dose) on diagnosis or immediately after the reduction maneuver, and group 2 that were not given dexamethasone.

RESULTS

There were 113 boys and 61 girls ranging in age from 2 to 36months. There were no statistical differences between the groups except for younger age in the dexamethasone group (P=0.03). There was no significant difference (p=0.08) in the rate of early RI between the non-steroid group (5.4%, 4/74) and the steroid group 14% (14/100). Mean admission length was 30h. The majority of RIs occurred in the first 8h of admission.

CONCLUSIONS

We found that premedication of children with idiopathic intussusception with dexamethasone did not decrease early RI.

LEVEL OF EVIDENCE

Level III retrospective comparative study.

Management for intussusception in children

BACKGROUND

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

OBJECTIVES

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

SEARCH METHODS

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

SELECTION CRITERIA

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

DATA COLLECTION AND ANALYSIS

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

MAIN RESULTS

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

AUTHORS' CONCLUSIONS

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

Comparative Effectiveness of Imaging Modalities for the Diagnosis and Treatment of Intussusception: A Critically Appraised Topic

RATIONALE AND OBJECTIVES

The purpose of this study was to critically appraise and compare the diagnostic performance of imaging modalities that are used for the diagnosis of intussusception and methods used in the treatment of ileocolic intussusception.

METHODS

A focused clinical question was constructed and the literature was searched using the patient, intervention, comparison, outcome (PICO) method comparing radiography, ultrasound, and computed tomography in the detection of intussusception. The same methods were used to compare pneumatic (gas) reduction and hydrostatic (liquid) reduction using saline, water-soluble contrast, and barium. Retrieved articles were appraised and assigned a level of evidence based on the Oxford University Centre for Evidence-Based Medicine hierarchy of validity for diagnostic studies.

RESULTS

The retrieved sensitivity for the diagnosis of intussusception using plain radiography is 48% (95% confidence interval [CI], 44%-52%), with a specificity of 21% (95% CI, 18%-24%). The retrieved sensitivity for the diagnosis of intussusception using ultrasound is 97.9% (95% CI, 95%-100%), with a specificity of 97.8% (95% CI, 97%-99%). Based on a good quality meta-analysis, the combined success rate of gas enema reduction was shown to be 82.7% (95% CI, 79.9%-85.6%) compared to a combined success rate of 69.6% (95% CI, 65.0%-74.1%) for liquid enema reduction.

CONCLUSIONS

The best available evidence recommends ultrasound as the diagnostic modality of choice for the diagnosis of ileocolic intussusception in children. In stable children without signs of peritonism, nonoperative reduction is the treatment of choice. Pneumatic (gas) reduction enema has been shown to be superior to hydrostatic (liquid) enema reduction.

Rectal Bleeding and Abdominal Pain Following Vaccination in a 4-Month-Old Infant

Intussusception is one of the most frequent causes of intestinal obstruction in infants. Rotavirus vaccination has been associated with intussusception in the medical literature. We report a case of a 4-month-old female with intussusception requiring hemicolectomy one week following rotavirus vaccination. We review the pathophysiology, presentation, and management of intussusception with a distinct focus on the history of rotavirus vaccination and risks of intussusception associated with timing of rotavirus vaccine administration. The discussion makes a strong case for rotavirus vaccine counseling regarding signs of intestinal obstruction and the importance of early recognition.