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Carter M, Afowork J, Pitt JB, Ayala SA, Goldstein SD. Scoring System to Evaluate Risk of Nonoperative Management Failure in Children With Intussusception. J Surg Res 2024; 300:503-513. [PMID: 38875949 DOI: 10.1016/j.jss.2024.05.030] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/01/2023] [Revised: 05/08/2024] [Accepted: 05/18/2024] [Indexed: 06/16/2024]
Abstract
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.
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Affiliation(s)
- Michela Carter
- Division of Pediatric Surgery, Department of Surgery, Northwestern University Feinberg School of Medicine, Ann and Robert H. Lurie Children's Hospital of Chicago, Chicago, Illinois.
| | - Jonathan Afowork
- Division of Pediatric Surgery, Department of Surgery, Northwestern University Feinberg School of Medicine, Ann and Robert H. Lurie Children's Hospital of Chicago, Chicago, Illinois
| | - J Benjamin Pitt
- Division of Pediatric Surgery, Department of Surgery, Northwestern University Feinberg School of Medicine, Ann and Robert H. Lurie Children's Hospital of Chicago, Chicago, Illinois
| | - Samantha A Ayala
- Division of Pediatric Surgery, Department of Surgery, Northwestern University Feinberg School of Medicine, Ann and Robert H. Lurie Children's Hospital of Chicago, Chicago, Illinois
| | - Seth D Goldstein
- Division of Pediatric Surgery, Department of Surgery, Northwestern University Feinberg School of Medicine, Ann and Robert H. Lurie Children's Hospital of Chicago, Chicago, Illinois
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Liu L, Zhang L, Fang Y, Yang Y, You W, Bai J, Zhang B, Xie S, Fang Y. Air enema reduction versus hydrostatic enema reduction for intussusceptions in children: A systematic review and meta-analysis. PLoS One 2024; 19:e0297985. [PMID: 38498581 PMCID: PMC10947698 DOI: 10.1371/journal.pone.0297985] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/04/2023] [Accepted: 01/15/2024] [Indexed: 03/20/2024] Open
Abstract
OBJECTIVES We conducted a comprehensive meta-analysis to compare the effectiveness and safety of fluoroscopy-guided air enema reduction (FGAR) and ultrasound-guided hydrostatic enema reduction (UGHR) for the treatment of intussusception in pediatric patients. METHODS A systematic review and meta-analysis were conducted on retrospective studies obtained from various databases, including PUBMED, MEDLINE, Cochrane, Google Scholar, China National Knowledge Infrastructure (CNKI), WanFang, and VIP Database. The search included publications from January 1, 2003, to March 31, 2023, with the last search done on Jan 15, 2023. RESULTS We included 49 randomized controlled studies and retrospective cohort studies involving a total of 9,391 patients, with 4,841 in the UGHR and 4,550 in the FGAR. Specifically, UGHR exhibited a significantly shorter time to reduction (WMD = -4.183, 95% CI = (-5.402, -2.964), P < 0.001), a higher rate of successful reduction (RR = 1.128, 95% CI = (1.099, 1.157), P < 0.001), and a reduced length of hospital stay (WMD = -1.215, 95% CI = (-1.58, -0.85), P < 0.001). Furthermore, UGHR repositioning was associated with a diminished overall complication rate (RR = 0.296, 95% CI = (0.225, 0.389), P < 0.001) and a lowered incidence of perforation (RR = 0.405, 95% CI = (0.244, 0.670), P < 0.001). CONCLUSION UGHR offers the benefits of being non-radioactive, achieving a shorter reduction time, demonstrating a higher success rate in repositioning in particular, resulting in a reduced length of postoperative hospital stay, and yielding a lower overall incidence of postoperative complications, including a reduced risk of associated perforations.
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Affiliation(s)
- Lan Liu
- Department of Pediatric Surgery, Fujian Children’s Hospital (Fujian Branch of Shanghai Children’s Medical Center), College of Clinical Medicine for Obstetrics & Gynecology and Pediatrics, Fujian Medical University, Fuzhou, China
| | - Ling Zhang
- Department of Pediatric Surgery, Fujian Children’s Hospital (Fujian Branch of Shanghai Children’s Medical Center), College of Clinical Medicine for Obstetrics & Gynecology and Pediatrics, Fujian Medical University, Fuzhou, China
| | - Yifan Fang
- Department of Pediatric Surgery, Fujian Children’s Hospital (Fujian Branch of Shanghai Children’s Medical Center), College of Clinical Medicine for Obstetrics & Gynecology and Pediatrics, Fujian Medical University, Fuzhou, China
| | - Yingying Yang
- Department of Pediatric Surgery, Fujian Children’s Hospital (Fujian Branch of Shanghai Children’s Medical Center), College of Clinical Medicine for Obstetrics & Gynecology and Pediatrics, Fujian Medical University, Fuzhou, China
| | - Wen You
- Department of Pediatric Surgery, Fujian Children’s Hospital (Fujian Branch of Shanghai Children’s Medical Center), College of Clinical Medicine for Obstetrics & Gynecology and Pediatrics, Fujian Medical University, Fuzhou, China
| | - Jianxi Bai
- Department of Pediatric Surgery, Fujian Children’s Hospital (Fujian Branch of Shanghai Children’s Medical Center), College of Clinical Medicine for Obstetrics & Gynecology and Pediatrics, Fujian Medical University, Fuzhou, China
| | - Bing Zhang
- Department of Pediatric Surgery, Fujian Children’s Hospital (Fujian Branch of Shanghai Children’s Medical Center), College of Clinical Medicine for Obstetrics & Gynecology and Pediatrics, Fujian Medical University, Fuzhou, China
| | - Siqi Xie
- Department of Pediatric Surgery, Fujian Children’s Hospital (Fujian Branch of Shanghai Children’s Medical Center), College of Clinical Medicine for Obstetrics & Gynecology and Pediatrics, Fujian Medical University, Fuzhou, China
| | - Yuanyuan Fang
- Department of Pediatric Surgery, Fujian Children’s Hospital (Fujian Branch of Shanghai Children’s Medical Center), College of Clinical Medicine for Obstetrics & Gynecology and Pediatrics, Fujian Medical University, Fuzhou, China
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Vakaki M, Sfakiotaki R, Liasi S, Hountala A, Koutrouveli E, Vraka I, Zouridaki C, Koumanidou C. Ultrasound-guided pneumatic reduction of intussusception in children: 15-year experience in a tertiary children's hospital. Pediatr Radiol 2023; 53:2436-2445. [PMID: 37665367 DOI: 10.1007/s00247-023-05730-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/25/2023] [Revised: 07/19/2023] [Accepted: 07/20/2023] [Indexed: 09/05/2023]
Abstract
BACKGROUND International practice regarding the method used to nonoperatively reduce pediatric intussusception is variable. OBJECTIVE To provide an overview of ultrasound-guided pneumatic intussusception reduction and assess its safety and effectiveness. MATERIALS AND METHODS A single-center prospective study was conducted in a tertiary referral pediatric hospital during the 15-year period between January 2008 and February 2023. All patients with ileocolic intussusception underwent abdominal sonographic examination for diagnosis. An ultrasound-guided pneumatic reduction of intussusception was then attempted. Children who were hemodynamically unstable, with signs of peritonitis or bowel perforation and those with sonographically detected pathologic lead points were excluded. RESULTS A total of 131 children (age range 2 months to 6 years) were enrolled in this study. Pneumatic intussusception reduction was successful in 128 patients (overall success rate 97.7%). In 117 patients, the intussusception was reduced on the first attempt and in the remaining on the second. In three cases, after three consecutive attempts, the intussusception was only partially reduced. As subsequently surgically proven, two of them were idiopathic and the third was secondary to an ileal polyp. No bowel perforation occurred during the reduction attempts. There was recurrence of intussusception in three patients within 24 h after initial reduction which were again reduced by the same method. CONCLUSION Ultrasound-guided pneumatic intussusception reduction is a well-tolerated, simple, safe and effective technique with a high success rate, no complications and no ionizing radiation exposure. It may be adopted as the first-line nonsurgical treatment of pediatric intussusception.
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Affiliation(s)
- Marina Vakaki
- Radiology Department, Children's Hospital P. & A. Kyriakou, Thivon & Livadias, Ampelokipi, 11527, Athens, Greece.
| | - Rodanthi Sfakiotaki
- Radiology Department, Children's Hospital P. & A. Kyriakou, Thivon & Livadias, Ampelokipi, 11527, Athens, Greece
| | - Sergia Liasi
- Radiology Department, Children's Hospital P. & A. Kyriakou, Thivon & Livadias, Ampelokipi, 11527, Athens, Greece
| | - Anna Hountala
- Radiology Department, Children's Hospital P. & A. Kyriakou, Thivon & Livadias, Ampelokipi, 11527, Athens, Greece
| | - Eleni Koutrouveli
- Radiology Department, Children's Hospital P. & A. Kyriakou, Thivon & Livadias, Ampelokipi, 11527, Athens, Greece
| | - Irene Vraka
- Radiology Department, Children's Hospital P. & A. Kyriakou, Thivon & Livadias, Ampelokipi, 11527, Athens, Greece
| | - Christina Zouridaki
- Radiology Department, Children's Hospital P. & A. Kyriakou, Thivon & Livadias, Ampelokipi, 11527, Athens, Greece
| | - Chrysoula Koumanidou
- Radiology Department, Children's Hospital P. & A. Kyriakou, Thivon & Livadias, Ampelokipi, 11527, Athens, Greece
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Binu V, Nicholson C, Granger J, Gent R, Piotto L, Taranath A, Goh DW. Ultrasound guided hydrostatic enema reduction of ileocolic intussusception: a safe and effective technique. ANZ J Surg 2023; 93:1993-1998. [PMID: 37158232 DOI: 10.1111/ans.18502] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/01/2023] [Revised: 04/12/2023] [Accepted: 04/26/2023] [Indexed: 05/10/2023]
Abstract
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.
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Affiliation(s)
- Vineet Binu
- Department of Paediatric Surgery, Women's and Children's Hospital, Adelaide, South Australia, Australia
| | - Cheryl Nicholson
- Department of Paediatric Surgery, Women's and Children's Hospital, Adelaide, South Australia, Australia
| | - Jeremy Granger
- Department of Paediatric Surgery, Women's and Children's Hospital, Adelaide, South Australia, Australia
| | - Roger Gent
- Department of Medical Imaging, Women's and Children's Hospital, Adelaide, South Australia, Australia
| | - Lino Piotto
- Department of Medical Imaging, Women's and Children's Hospital, Adelaide, South Australia, Australia
| | - Ajay Taranath
- Department of Medical Imaging, Women's and Children's Hospital, Adelaide, South Australia, Australia
| | - Day Way Goh
- Department of Paediatric Surgery, Women's and Children's Hospital, Adelaide, South Australia, Australia
- Discipline of Paediatrics, University of Adelaide, Adelaide, South Australia, Australia
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Hwang J, Yoon HM, Kim PH, Jung AY, Lee JS, Cho YA. Current diagnosis and image-guided reduction for intussusception in children. Clin Exp Pediatr 2023; 66:12-21. [PMID: 35798026 PMCID: PMC9815940 DOI: 10.3345/cep.2021.01816] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/08/2021] [Accepted: 06/02/2022] [Indexed: 02/04/2023] Open
Abstract
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.
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Affiliation(s)
- Jisun Hwang
- Department of Radiology, Hallym University Dongtan Sacred Heart Hospital, Hwaseong, Korea
| | - Hee Mang Yoon
- Department of Radiology and Research Institute of Radiology, University of Ulsan College of Medicine, Asan Medical Center, Seoul, Korea
| | - Pyeong Hwa Kim
- Department of Radiology and Research Institute of Radiology, University of Ulsan College of Medicine, Asan Medical Center, Seoul, Korea
| | - Ah Young Jung
- Department of Radiology and Research Institute of Radiology, University of Ulsan College of Medicine, Asan Medical Center, Seoul, Korea
| | - Jin Seong Lee
- Department of Radiology and Research Institute of Radiology, University of Ulsan College of Medicine, Asan Medical Center, Seoul, Korea
| | - Young Ah Cho
- Department of Radiology and Research Institute of Radiology, University of Ulsan College of Medicine, Asan Medical Center, Seoul, Korea
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Osmanlliu E, D'Angelo A, Miron MC, Beaudin M, Gaucher N, Gravel J. Management and outcomes of paediatric ileocolic intussusception at a paediatric tertiary care hospital: A retrospective cohort study. Paediatr Child Health 2021; 26:e252-e257. [PMID: 34676014 DOI: 10.1093/pch/pxaa111] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/02/2020] [Accepted: 08/24/2020] [Indexed: 11/12/2022] Open
Abstract
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.
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Affiliation(s)
- Esli Osmanlliu
- Department of Emergency Medicine, CHU Sainte-Justine, Montréal, Quebec
| | - Antonio D'Angelo
- Department of Emergency Medicine, CHU Sainte-Justine, Montréal, Quebec
| | | | | | - Nathalie Gaucher
- Department of Emergency Medicine, CHU Sainte-Justine, Montréal, Quebec
| | - Jocelyn Gravel
- Department of Emergency Medicine, CHU Sainte-Justine, Montréal, Quebec
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Kim M, Kim JS, Lee C, Kang BK. Detection of pneumoperitoneum in the abdominal radiograph images using artificial neural networks. Eur J Radiol Open 2020; 8:100316. [PMID: 33385018 PMCID: PMC7770533 DOI: 10.1016/j.ejro.2020.100316] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/06/2020] [Revised: 12/15/2020] [Accepted: 12/16/2020] [Indexed: 12/15/2022] Open
Abstract
The purpose of this study was to assess the diagnostic performance of artificial neural networks (ANNs) to detect pneumoperitoneum in abdominal radiographs for the first time. This approach applied a novel deep-learning algorithm, a simple ANN training process without employing CNN, and also used ResNet-50, for comparison. By applying ResNet-50 to abdominal radiographs, we obtained an area under the ROC curve (AUC) of 0.916 and an accuracy of 85.0 % with a sensitivity of 85.7 % and a predictive value of the negative tests (NPV) of 91.7 %. Compared with CNN, our novel approach used extremely small ANN structures and a simple ANN training process. The diagnostic performance of our approach, with a sensitivity of 88.6 % and NPV of 91.3 %, was compared decently with that of ResNet-50.
Background/purpose The purpose of this study was to assess the diagnostic performance of artificial neural networks (ANNs) to detect pneumoperitoneum in abdominal radiographs for the first time. Materials and methods This approach applied a novel deep-learning algorithm, a simple ANN training process without employing a convolution neural network (CNN), and also used a widely utilized deep-learning method, ResNet-50, for comparison. Results By applying ResNet-50 to abdominal radiographs, we obtained an area under the ROC curve (AUC) of 0.916 and an accuracy of 85.0 % with a sensitivity of 85.7 % and a predictive value of the negative tests (NPV) of 91.7 %. Compared with the most commonly applied deep-learning methods such as a CNN, our novel approach used extremely small ANN structures and a simple ANN training process. The diagnostic performance of our approach, with a sensitivity of 88.6 % and NPV of 91.3 %, was compared decently with that of ResNet-50. Conclusions The results of this study showed that ANN-based computer-assisted diagnostics can be used to accurately detect pneumoperitoneum in abdominal radiographs, reduce the time delay in diagnosing urgent diseases such as pneumoperitoneum, and increase the effectiveness of clinical practice and patient care.
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Affiliation(s)
- Mimi Kim
- Department of Radiology, Hanyang University Seoul Hospital, Seoul, Republic of Korea
| | - Jong Soo Kim
- Institute for Software Convergence, Hanyang University, Seoul, Republic of Korea
| | - Changhwan Lee
- Department of Biomedical Engineering, Hanyang University, Seoul, Republic of Korea
| | - Bo-Kyeong Kang
- Department of Radiology, Hanyang University Seoul Hospital, Seoul, Republic of Korea
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Parikh RS, Weiner T, Dehmer J. Tension Pneumoperitoneum Following Attempted Pneumatic Reduction of Intussusception. Am Surg 2020; 88:534-535. [PMID: 33295225 DOI: 10.1177/0003134820973361] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Tension pneumoperitoneum is a life-threatening complication of pneumatic reduction for intussusception if not immediately recognized and treated. We describe a 3-month-old woman who presented with intussusception, underwent attempted pneumatic reduction, and subsequently developed tension pneumoperitoneum with associated hemodynamic instability requiring emergent laparotomy. This is a known, rare complication of pneumatic reduction which highlights the need to have a high index of suspicion for early surgical management to obtain a positive outcome.
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Comparative safety and efficacy of balloon use in air enema reduction for pediatric intussusception. Pediatr Radiol 2018; 48:1423-1431. [PMID: 29797036 DOI: 10.1007/s00247-018-4156-2] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/20/2017] [Revised: 04/11/2018] [Accepted: 04/30/2018] [Indexed: 10/16/2022]
Abstract
BACKGROUND Intussusception, a common cause of bowel obstruction in young children, is primarily treated with air enema reduction. There is little literature comparing the safety and efficacy of air reduction without or with a rectal balloon. OBJECTIVE To determine the safety and efficacy of a rectal balloon seal in air enema reduction. MATERIALS AND METHODS We retrospectively reviewed the records of children who underwent air reduction for ileocolic or ileo-ileocolic intussusception over an 8-year period. We sorted data from 566 children according to whether a rectal balloon was used in the reduction, and further sorted them by type and experience level of the practitioner. Using logistic regression analyses, we identified risk factors for iatrogenic bowel perforation or failed reduction. RESULTS Significant associations with bowel perforation included balloon use (P=0.038), age <1 year (P<0.0001), and attending physician's level of experience <5 years (P=0.043). Younger age was associated with both perforation (P<0.0001) and procedural failure (P=0.001). The risk-adjusted predicted probability of perforation decreased with age, approaching zero by 10 months regardless of balloon use. For cases without bowel resection, the risk-adjusted predicted probability of failure decreased toward zero by 30 months with balloon use, while remaining constant at 3-12% regardless of age when not using a balloon. CONCLUSION The likelihood of a successful air reduction might be safely increased by using an inflated rectal balloon in children older than 9 months. Use of a balloon in younger infants is associated with a higher risk of iatrogenic bowel injury.
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Hemodynamic Shock Caused by Tension Pneumoperitoneum in a 5-Year-Old Girl. Pediatr Emerg Care 2018; 34:e102-e103. [PMID: 29762333 DOI: 10.1097/pec.0000000000001471] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
Tension pneumoperitoneum is a relatively rare occurrence in the pediatric population. However, tension pneumoperitoneum is associated with significant morbidity and mortality if it is not promptly diagnosed and treated. A 5-year-old girl was admitted to emergency department with abdominal pain. She was in shock, and the radiograph film of the abdomen revealed a voluminous tension pneumoperitoneum. Aggressive fluid challenges were performed in intensive care followed by urgent laparotomy. Primary abdominal compartment due to trapped gas caused a decreased venous return and visceral perfusion. In the absence of hemodynamic improvement after vascular filling, needle decompression was performed before surgery.
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Carroll AG, Kavanagh RG, Ni Leidhin C, Cullinan NM, Lavelle LP, Malone DE. Comparative Effectiveness of Imaging Modalities for the Diagnosis and Treatment of Intussusception: A Critically Appraised Topic. Acad Radiol 2017; 24:521-529. [PMID: 28268146 DOI: 10.1016/j.acra.2017.01.002] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/20/2016] [Revised: 01/11/2017] [Accepted: 01/12/2017] [Indexed: 11/15/2022]
Abstract
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.
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Affiliation(s)
- Anne G Carroll
- Department of Radiology, St. Vincent's University Hospital, Elm Park, Dublin 4, Ireland.
| | - Richard G Kavanagh
- Department of Radiology, St. Vincent's University Hospital, Elm Park, Dublin 4, Ireland
| | | | - Noelle M Cullinan
- Department of Pediatrics, Our Lady's Children's Hospital, Dublin, Ireland
| | - Lisa P Lavelle
- Department of Radiology, St. Vincent's University Hospital, Elm Park, Dublin 4, Ireland
| | - Dermot E Malone
- Department of Radiology, St. Vincent's University Hospital, Elm Park, Dublin 4, Ireland
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Schooler GR, Davis JT, Lee EY. Gastrointestinal Tract Perforation in the Newborn and Child: Imaging Assessment. Semin Ultrasound CT MR 2016; 37:54-65. [PMID: 26827739 DOI: 10.1053/j.sult.2015.10.001] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/18/2023]
Abstract
Gastrointestinal tract perforation can arise from various underlying etiologies ranging from congenital causes to ingested foreign bodies in the pediatric patient population. Imaging assessment in patients with suspected gastrointestinal tract perforation plays a central role in making the diagnosis and follow-up evaluation. This article reviews the more common etiologies of gastrointestinal tract perforation in pediatric patients, their imaging manifestations, and strategies for imaging assessment to assist the radiologist in arriving at a timely and accurate diagnosis.
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Affiliation(s)
- Gary R Schooler
- Department of Radiology, Duke University Medical Center, 1905 Children׳s Health Center, Durham, NC
| | - Joseph T Davis
- Department of Radiology, Duke University Medical Center, 1905 Children׳s Health Center, Durham, NC
| | - Edward Y Lee
- Department of Radiology, Boston Children׳s Hospital and Harvard Medical School, Boston, MA.
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Meta-analysis of Air Versus Liquid Enema for Intussusception Reduction in Children. AJR Am J Roentgenol 2016; 205:W542-9. [PMID: 26496576 DOI: 10.2214/ajr.14.14060] [Citation(s) in RCA: 58] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
OBJECTIVE The purpose of this study was to assess the effectiveness and safety of air versus liquid enema reduction in the treatment of intussusception in children. MATERIALS AND METHODS Literature searches of the PubMed, Embase, and Cochrane Library databases were conducted from January 1, 1966, through May 31, 2013. Articles on the use of air or liquid enema in children with a confirmed diagnosis of intussusception and reporting either a success rate for enema reduction of intussusception or a perforation rate were selected. Enema reduction success rate, perforation rate, and recurrence rate were the main outcomes and were calculated by random effects modeling. RESULTS One hundred two articles (101 reporting success rate, 71 reporting perforation rate) were included that presented results for 32,451 children (age range, 1 day-22 years; boys, 66%; girls, 34%). In 44 studies (16,187 children), the combined estimate for success rate of air enema was 82.7% (95% CI, 79.9-85.6%; inconsistency index [I(2)] = 97%), and in 52 studies (13,081 children) of liquid enema, it was 69.6% (95% CI, 65.0-74.1%; I(2) = 98%). In 38 studies (15,752 children), the combined estimate of perforation rate for air enema was 0.39% (95% CI, 0.23- 0.55%; I(2) = 40%), and in 30 studies (9429 children) of liquid enema, it was 0.43% (95% CI, 0.24- 0.62%; I(2) = 9%). Among 10,494 children (26 studies) undergoing air enema reduction, the rate of first intussusception recurrence was 6% (95% CI, 4.5-7.5%; I(2) = 89%), similar to the 7.3% (95% CI, 5.8-8.8%; I(2) = 71%) found for 4004 children (24 studies) undergoing liquid enema reduction. CONCLUSION Air enema was superior to liquid enema for intussusception reduction. The success rate was higher without a difference in perforation rate. Limitations included heterogeneity and publication bias.
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Thornton SL, Hunter J, Scott M. Fatal Tension Pneumoperitoneum Due to Non-Accidental Trauma. West J Emerg Med 2015; 16:788-9. [PMID: 26587113 PMCID: PMC4644057 DOI: 10.5811/westjem.2015.7.28022] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/09/2015] [Accepted: 07/17/2015] [Indexed: 11/18/2022] Open
Affiliation(s)
- Stephen L Thornton
- Department of Emergency Medicine, University of Kansas Hospital, Kansas City, Kansas
| | - Jeremy Hunter
- Department of Emergency Medicine, University of Kansas Hospital, Kansas City, Kansas
| | - Mark Scott
- Department of Emergency Medicine, University of Kansas Hospital, Kansas City, Kansas
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Fisher JG, Sparks EA, Turner CGB, Klein JD, Pennington E, Khan FA, Zurakowski D, Durkin ET, Fauza DO, Modi BP. Operative indications in recurrent ileocolic intussusception. J Pediatr Surg 2015; 50:126-30. [PMID: 25598108 DOI: 10.1016/j.jpedsurg.2014.10.012] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/03/2014] [Accepted: 10/06/2014] [Indexed: 11/19/2022]
Abstract
BACKGROUND Air-contrast enema (ACE) is standard treatment for primary ileocolic intussusception. Management of recurrences is less clear. This study aimed to delineate appropriate therapy by quantifying the relationship between recurrence and need for bowel resection, pathologic lead points (PLP), and complication rates. METHODS After IRB approval, a single institution review of patients with ileocolic intussusception from 1997 to 2013 was performed, noting recurrences, outcomes, and complications. Fisher's exact and t-tests were used. RESULTS Of 716 intussusceptions, 666 were ileocecal. Forty-four underwent bowel resection, with 29 PLPs and 9 ischemia/perforation. Recurrence after ACE occurred in 96 (14%). Recurrence did not predict PLP (P=0.25). Recurrence (≥3) was associated with higher resection rate (P=0.03), but not ischemia/perforation (P=0.75). ACE-related complications occurred in 4 (0.5%) patients. Successful initial ACE had 98% negative predictive value for resection and PLP (e.g., after successful ACE, 2% had resections, 2% PLP). After failed initial ACE, 36% received resection, and 23% had PLP (P<0.001). CONCLUSIONS Recurrence is associated with a greater risk of resection but not PLP or ACE-complication. Failed ACE is associated with increased risk for harboring PLP and receiving resection. ACE should be the standard treatment in recurrent intussusception, regardless of number of recurrences.
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Affiliation(s)
- Jeremy G Fisher
- Department of Surgery, Boston Children's Hospital and Harvard Medical School, Boston, MA
| | - Eric A Sparks
- Department of Surgery, Boston Children's Hospital and Harvard Medical School, Boston, MA
| | - Christopher G B Turner
- Department of Surgery, Boston Children's Hospital and Harvard Medical School, Boston, MA
| | - Justin D Klein
- Department of Surgery, Boston Children's Hospital and Harvard Medical School, Boston, MA
| | - Elliot Pennington
- Department of Surgery, Boston Children's Hospital and Harvard Medical School, Boston, MA
| | - Faraz A Khan
- Department of Surgery, Boston Children's Hospital and Harvard Medical School, Boston, MA
| | - David Zurakowski
- Department of Surgery, Boston Children's Hospital and Harvard Medical School, Boston, MA
| | - Emily T Durkin
- Department of Surgery, Boston Children's Hospital and Harvard Medical School, Boston, MA
| | - Dario O Fauza
- Department of Surgery, Boston Children's Hospital and Harvard Medical School, Boston, MA
| | - Biren P Modi
- Department of Surgery, Boston Children's Hospital and Harvard Medical School, Boston, MA.
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Sanchez TR, Doskocil B, Stein-Wexler R. Nonsurgical management of childhood intussusception: retrospective comparison between sonographic and fluoroscopic guidance. JOURNAL OF ULTRASOUND IN MEDICINE : OFFICIAL JOURNAL OF THE AMERICAN INSTITUTE OF ULTRASOUND IN MEDICINE 2015; 34:59-63. [PMID: 25542940 DOI: 10.7863/ultra.34.1.59] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/04/2023]
Abstract
OBJECTIVES The purpose of this study was to compare the effectiveness of sonography and fluoroscopy in guiding intussusception reduction and evaluate possible complications for each procedure. METHODS A retrospective analysis was performed by reviewing 31 cases of intussusception diagnosed and managed between January 2009 and January 2014 at the University of California, Davis Children's Hospital, after obtaining approval from the Institutional Review Board. To eliminate other confounding factors related to technique and experience, only cases performed by 2 pediatric radiologists who exclusively used either fluoroscopy or sonography were compared. RESULTS Fourteen patients (age range, 6-35 months) were treated by sonographic guidance using saline, and another 17 patients (age range, 2-57 months) were treated by fluoroscopy using either air or a water-soluble contrast agent. All 14 patients (100%) who underwent sonographically guided reduction were successfully treated without complications. Fourteen of the 17 patients (82%) who underwent fluoroscopic guidance had successful reductions. One complication of perforation was documented. CONCLUSIONS Sonography and fluoroscopy are equally effective in the nonsurgical management of childhood intussusception. The absence of ionizing radiation and better visualization of possible pathologic lead points makes sonography the ideal method.
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Affiliation(s)
- Thomas Ray Sanchez
- Department of Radiology, University of California, Davis Children's Hospital, Sacramento, California USA (T.R.S., R.S.-W.); and Department of Radiology, University of California, Davis, Sacramento, California USA (B.D.).
| | - Brandon Doskocil
- Department of Radiology, University of California, Davis Children's Hospital, Sacramento, California USA (T.R.S., R.S.-W.); and Department of Radiology, University of California, Davis, Sacramento, California USA (B.D.)
| | - Rebecca Stein-Wexler
- Department of Radiology, University of California, Davis Children's Hospital, Sacramento, California USA (T.R.S., R.S.-W.); and Department of Radiology, University of California, Davis, Sacramento, California USA (B.D.)
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Re: UK intussusception audit: A national survey of practice and audit of reduction rates. Clin Radiol 2014; 69:e432. [DOI: 10.1016/j.crad.2014.05.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/22/2014] [Accepted: 05/13/2014] [Indexed: 11/23/2022]
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Intussusception Revisited: Is Immediate On-Site Surgeon Availability at the Time of Reduction Necessary? AJR Am J Roentgenol 2014; 202:432-6. [DOI: 10.2214/ajr.13.10731] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
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Affiliation(s)
- William E Shiels
- Nationwide Children's Hospital, 700 Children's Drive, Columbus, OH 43205, USA.
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