Success with hydrostatic reduction of intussusception in relation to duration of symptoms

High risk and low incidence diseases: Pediatric intussusception

INTRODUCTION

Pediatric intussusception is a serious condition that carries with it a high risk of morbidity and mortality.

OBJECTIVE

This review highlights the pearls and pitfalls of pediatric intussusception, including the presentation, diagnosis, and management in the emergency department (ED) based on current evidence.

DISCUSSION

Intussusception is one of the most common pediatric abdominal emergencies. This is associated with one part of the intestine telescoping into another, resulting in bowel edema. If the intussusception remains untreated, obstruction, ischemia, necrosis, and perforation may result. Most cases are idiopathic, with 10-25 % associated with a pathologic mass or lead point. The most common age group affected includes those between 3 months to 5 years. The triad of intermittent abdominal pain, currant jelly stool, and sausage-shaped mass is uncommon, though most patients will present with intermittent abdominal pain. Nonbilious emesis and bloody stools (gross blood or guaiac positive) are also common. Younger patients can present atypically, including altered mental status or lethargy. Thus, intussusception should be considered in pediatric patients with abdominal pain, emesis, and a sausage-shaped mass, as well as those with atypical presentations such as altered mental status or lethargy if there is no other etiology found on testing. The diagnostic modality of choice is ultrasound. Plain radiography may assist in evaluating for obstruction and perforation. Treatment includes prompt reduction of the intussusception. In patients who are stable and have no evidence of perforation, non-operative reduction with hydrostatic or pneumatic reduction should be attempted. Operative intervention is necessary in those who are unstable, peritonitic, or have a focal lead point. Discharge may be appropriate for patients following successful non-operative reduction if the patient is able to tolerate clear fluids, is asymptomatic, and can return for any recurrence of symptoms.

CONCLUSION

An understanding of pediatric intussusception and its many potential mimics can assist emergency clinicians in diagnosing and managing this high risk disease.

Ultrasound-guided Saline Hydrostatic Reduction in Pediatric Intussusception - Experience from a Tertiary Care Center in India

Context

Intussusception is one of the most common causes of acute abdomen and intestinal obstruction in infants and children which requires emergent management to avoid vascular compromise to the bowel. Ultrasound-guided saline hydrostatic reduction (SHR) is a nonoperative technique used in its management which can avoid surgery in a clinically stable and uncomplicated child.

Aims

The aim of this study was to assess the success rates of SHR in a tertiary care center and also to assess any relationship between success of reduction with age of patient, duration of symptoms, and site of intussusception.

Settings and Design

This was a retrospective study conducted in a single tertiary care center for 3 years.

Materials and Methods

All patients who had undergone an attempt at hydrostatic reduction were included in the study. Children who directly underwent surgery were excluded from the study. All pertinent demographic and clinical data were collected from the medical records department, tabulated, and analyzed.

Statistical Analysis

Statistical testing was conducted with SPSS Statistics 23.0.

Results

Among a total of 103 patients, 93 underwent successful reduction (90.2%). The comparison between success of reduction with age of patients or with site of intussusception was not significant. Success of reduction was also compared with the duration of symptoms at presentation, with increased success seen in early presenters.

Conclusions

Ultrasound-guided SHR of intussusception is an effective method with success rates of 90.2% and can be safely implemented in children who are clinically stable, irrespective of age and site, with increased success seen in early presenters.

Success rate and predictors of failure of enema reduction of intussusception in children with a water-soluble contrast medium at a height of 120 cm or less

BACKGROUND

This study investigates the reduction rate and failure predictors of hydrostatic enema reduction for intussusception. The procedure typically begins with a water-soluble contrast medium at 90 cm above the patient, subsequently elevated to 120 cm. Our focus is on the reduction rate during initial attempts when the contrast medium is positioned at or below 120 cm from the patient.

METHODS

Hydrostatic enema reductions for intussusception, performed between March 2010 and May 2022 at Tokyo Metropolitan Children's Medical Center, were investigated retrospectively. The initial attempts involved one or more trials. The clinical characteristics, treatment modalities, and outcomes were analyzed. Logistic regression was used to identify the predictors of failure when the reduction was performed with the water-soluble contrast medium at a height of 120 cm or less.

RESULTS

Reduction was achieved successfully with the water-soluble contrast medium at a height at or below 120 cm in 77.5% of 351 patients. When reductions performed at heights greater than 120 cm were included, 333 (94.9%) were successful during the initial attempts and were unaccompanied by complications. Predictors of failure of reductions performed at or below 120 cm were age less than 12 months and the presence of trapped fluid.

CONCLUSION

The present study found a successful reduction rate of 77.5% during the initial attempts, suggesting that a height greater than 120 cm may yield an even greater success rate. Children aged below 12 months and those with trapped fluid may have a greater failure risk during the initial attempts.

Is enema reduction in pediatric intussusception with a history of over 48 h safe: A retrospective cohort study

BACKGROUND

Intussusception is one of the most common acute abdominal diseases in children. Enema reduction is the first-line treatment for intussusception in good condition. Clinically, a history of disease over 48 h is usually listed as a contraindication for enema reduction. However, with the development of clinical experience and therapy, an increasing number of cases have shown that the prolongation of the clinical course of intussusception in children is not an absolute contraindication for enema treatment. This study aimed to analyze the safety and efficacy of enema reduction in children with a history of disease longer than 48 h.

METHODS

We conducted a retrospective matched-pair cohort study of pediatric patients with acute intussusception between 2017 and 2021. All patients were treated with ultrasound-guided hydrostatic enema reduction. According to the length of history, the cases were classified into two groups: history <48 h (<48 h group) and history greater than or equal to 48 h (≧48 h group). We generated a 1:1 matched-pair cohort matched for sex, age, admission time, main symptoms, and concentric circle size on ultrasound. Clinical outcomes were compared between the two groups, including success, recurrence, and perforation rates.

RESULTS

From January 2016 to November 2021, 2701 patients with intussusception were admitted to the Shengjing Hospital of China Medical University. A total of 494 cases were included in the ≧48 h group, and 494 cases with a history of <48 h were selected for matched comparison in the <48 h group. The success rates of the ≧48 h and <48 h groups were 98.18% vs. 97.37% (p = 0.388), and the recurrence rates were 13.36% vs. 11.94% (p = 0.635), showing no difference according to the length of history. The perforation rate was 0.61% vs. 0%, respectively, with no significant difference (p = 0.247).The comparison of the different history groups showed that in patients with bloody stools, the length of history had no significant effect on the enema reduction outcome(94.90% vs. 86.76%, p = 0.064).

CONCLUSIONS

Ultrasound-guided hydrostatic enema reduction is safe and effective for pediatric idiopathic intussusception with a history of ≧48 h.

Noninvasive hydrostatic reduction of an ileocecocolic intussusception in a puppy

A 5-week-old male intact Golden Retriever puppy was presented for a history of vomiting and diarrhea with hematochezia. Ultrasound findings confirmed the presence of an ileocecocolic intussusception. Surgical correction was declined because of financial concerns. Based on a pediatric procedure used in humans, an ultrasound-guided hydrostatic reduction (USGHR) was performed. This procedure consisted in injecting saline rectally under controlled pressure to mechanically reduce the intussusception. Reduction of the intussusception and evaluation of potential complications were concurrently evaluated by ultrasound during the procedure. No recurrence was observed the next day and the puppy was discharged. Follow-up indicated that the dog was still doing well 6 months later. This case report describes a new technique in veterinary medicine allowing successful nonsurgical reduction of an ileocecocolic intussusception in a dog. This procedure is innovative, simple, and substantially decreases the cost and minimizes morbidity potentially associated with surgical management.

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

OBJECTIVE

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

KEY POINTS

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

Childhood intussusception: Correlation between ultrasound reports and intra-operative findings

Background:

Intussusception, a common cause of intestinal obstruction in children, is usually diagnosed through ultrasound scan. The aim of this study was to evaluate the correlation between the ultrasound report and intra-operating findings in children who had laparotomy for intussusception.

Materials and methods:

This was a retrospective study of children aged 12 months and below who had laparotomy for intussusception between January 2017–December 2019 at the pediatric surgery unit of Enugu State University Teaching Hospital Enugu, Nigeria. Findings at ultrasound and findings at surgery were statistically compared.

Results:

A total of 103 cases of intussusceptions were seen during the study period. Out of this number, 69 patients were treated by laparotomy and formed the basis of this report. There was male predominance and the median age of the patients was 8 months. Abdominal pain was the most common presenting symptom. At presentation, about one-quarter of the patients were anemic while one-half of the patients had electrolyte derangement. Comparing the findings at ultrasound and findings at surgery, ultrasound was found to have an accuracy of 89.9%. Approximately, equal number of patients had manual reduction and bowel resection. Surgical site infection was the most common post-operative complication and mortality occurred in 8 (11.6%) patients.

Conclusion:

Ultrasound has high accuracy rate and is quite reliable for the diagnosis of intussusception.

Hydrostatic reduction of intussusception in children: a single centre experience

Introduction

intussusception is a common surgical emergency in children especially in infants. Treatment of intussusception could be non-operative or operative. Non-operative treatment (hydrostatic reduction) of intussusception is increasingly being practiced in developing countries.

Methods

this was a review of our experience in the hydrostatic reduction of intussusception in children at a teaching hospital in Enugu, Nigeria. This study covered an 18-months period, October 2017 to March 2019. Patients on presentation were resuscitated, appropriate investigations done and prepared for surgery before the hydrostatic reduction (using normal saline) was carried out. Patients with features of peritonitis and marked abdominal distension were excluded from hydrostatic reduction.

Results

twenty patients who had 21 episodes of intussusception were analyzed. One patient had a recurrence that necessitated repeat hydrostatic reduction. Eighty percent of the patients were male. The mean and peak age of the patients was 8 months and 6 months respectively. Significant number of the patients presented after 48 hours of onset of their symptoms. Abdominal pain was the predominant presenting symptom. Twenty percent and fifteen percent of the patients had a history of preceding gastrointestinal and respiratory infections preceding the intussusception respectively. Ileocolic intussusception was the most common type and the most distal end of the intussusception was at the transverse colon. Hydrostatic reduction was successful in 13 patients (65%).

Conclusion

hydrostatic reduction is a simple and effective method of treatment of intussusception. However, early presentation and proper patient selection is necessary for optimal outcome.

Practical Imaging Strategies for Intussusception in Children

OBJECTIVE. Intussusception is the most common cause of intestinal obstruction in young children. Radiology has a key role in its diagnosis and treatment. This systematic review summarizes the currently available evidence for best practices in radiologic management of pediatric intussusception. CONCLUSION. High diagnostic accuracy and lack of ionizing radiation make ultrasound (US) the preferred imaging modality for diagnosing intussusception. For intussusception reduction, fluoroscopy-guided pneumatic enema and US-guided hydrostatic enema are equally dependable and safe techniques. The areas that warrant further research in this field include the efficacy and safety of the US-guided pneumatic enema, potential benefits of sedation and general anesthesia for the reduction procedure, and the optimal management of intussusceptions potentially involving pathologic lead points.

Clinical Characteristics of Intussusception with Surgical Reduction: a Single-Center Experience with 568 Cases

BACKGROUND

Intussusception is among the most common acute abdominal emergencies in infancy, but only some cases need surgical reduction. This study assessed the clinical characteristics of patients undergoing surgical reduction of intussusception.

METHODS

This retrospective study reviewed 568 pediatric patients who failed air-enema reduction and underwent surgical reduction for intussusception in our department between 2008 and 2017.

RESULTS

The series comprised 376 boys and 192 girls (2.0:1, male:female ratio) and most of the intussusceptions were primary, which is typical before the age of 1 year. The success rate of air-enema reduction in our hospital was 94.2%. Patients over 3 years old had the highest rate of surgical reduction (ca. 11.8%). The probabilities of primary and secondary intussusception were equal above 2 years old. Intussusception caused by intestinal malignant lymphoma was diagnosed above 2 years of age with atypical symptoms. Gender was irrelevant regarding the presence of bloody stools (P = 0.594), but the younger patients and children with complex/compound intussusception had a higher proportion of bloody stools (n = 148, 40.0%, P = 0.000) and intestinal necrosis (n = 44, 42.3%, P = 0.024). The occurrence time of bloody stools (OTBS) in complex/compound intussusception was shorter than for other types.

CONCLUSIONS

This retrospective study analyzed the clinical features of patients undergoing surgical reduction for intussusception and summarized the characteristics and management of complex/compound intussusception.

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.

Ileocolic intussusception: Predicting the probability of success of ultrasound guided saline enema from clinical and sonographic data

BACKGROUND/PURPOSE

To identify factors that dim the efficacy of ultrasound guided saline enema (USGSE) and to design a mathematical model for predicting the probability of success of USGSE.

METHODS

Retrospective review of patients admitted with the diagnosis of ileocolic intussusception from 2009 to 2014. Demographics, clinical and sonographic data were reviewed.

RESULTS

116 first episodes of ileocolic intussusceptions. 109 USGSE attempts were analyzed. Composite reduction rate was 77%. A significant relationship was found between initial location of the intussusception, free peritoneal fluid (OR=0.329, 95% CI: 0.124-0.875), negative Doppler signal and sonographic signs of intestinal occlusion and unsuccessful USGSE. Initial location beyond the splenic angle was an independent risk factor for USGSE failure (OR=0.053, 95% CI: 0.005-0.534). A predictive model based on onset of symptoms, free peritoneal fluid and intussusception location was a reliable tool for prediction (AUC 0.63, 95% CI: 0.53-0.817). Assuming that a patient with less than 75.3% chance of USGSE success is going to fail, we would identify more than 80.9% of the real failures.

CONCLUSIONS

This predictive model could be a filter selection for the patients at risk of USGSE failure and therefore candidates to further imaging investigations or referral to a surgical unit.

LEVEL OF EVIDENCE

III.

A comparison of hydrostatic reduction in children with intussusception versus surgery: Single-centre experience

BACKGROUND

Intussusception is the most common cause of bowel obstruction in infancy and childhood. Early diagnosis and effective management have reduced its morbidity and mortality in developed countries. Non-surgical reduction remains the first-line treatment of choice for intussusception. The major complication of air enema reduction is bowel perforation and portal venous gas. In recent years, several techniques have been recommended for intussusception treatment. In this study, an evaluation was made of intussusception cases that presented at our clinic and had reduction applied together with saline under ultrasonography and cases, which were surgically treated. Our aim of this study is to evaluate the results of hydrostatic reduction under ultrasound guided and to compare the results with patients treated by surgery for the management of intussusception.

PATIENTS AND METHODS

A retrospective study was done of the records of 100 cases treated for a diagnosis of intussusception between April 2011 and April 2013, in Department of Paediatric Surgery, Zagazig University Hospital. Patients were evaluated demographics, clinical presentation and management strategy, during the hospitalisation and outcome.

RESULTS

This study includes 100 patients diagnosed with intussusception, sixty males and forty females, the age ranged between 1 month and 7 years old. Ultrasound was applied for all patients as a part of diagnosis. Hydrostatic reduction under ultrasound guide was applied to fifty patients, successful hydrostatic reduction was seen in thirty patients and unsuccessful hydrostatic reduction was seen in twenty patients which admitted for surgery, we did not do another chance of hydrostatic reduction for unsuccessful patients, open surgery was done for seventy patients, during surgery, we found ileocolic intussusception in forty patients, ileoileal in twenty patients and colocolic intussusception in ten patients. Leading point of intussusception was seen in 22 patients, Meckel's diverticulum in ten patients, polyp in five patients and lymphoma in seven patients. Manual reduction was done in forty patients and resection anastomosis was done in thirty patients. No mortality in any case.

CONCLUSION

Ultrasound-guided hydrostatic reduction of intussusception is a safe technique which reduces the duration of hospitalisation and treatment costs.

The Effect of Midazolam on Decreasing the Duration of Intussusception Hydrostatic Reduction in Children

BACKGROUND AND OBJECTIVE

The use of sedative medications may be effective in the success and facilitation of the intussusception non-surgical treatment. Therefore, the purpose of this study was to examine the effect of midazolam on decreasing the duration of intussusception hydrostatic reduction in children.

MATERIALS AND METHODS

In a double-blind clinical trial, 32 children were diagnosed with ileocolic intussusception based on sonographic findings, were studied and randomly divided into two groups. After obtaining written informed consent from the parents, 5 minutes before reduction, an intravenous Midazolam at the concentration of 1.0 mg/kg (up to 3 mg) was infused, and then barium reduction was performed under fluoroscopy guideline. In the control group, sterile water was injected as placebo and the remaining reduction steps were performed compared with the experiment group.

RESULTS

Of 16 patients that received Midazolam, 15 patients demonstrated successful reduction; and of 16 patients that received distilled water, only 11 patients showed successful reduction (P=0.07). The mean duration of a successful reduction in the Midazolam group and placebo was 34.8±11.35 and 32.73±19.2 min, respectively (P=0.733).

CONCLUSIONS

The use of Midazolam as a benzodiazepine with known sedative and muscle relaxant effects can increase the success rate of enema reduction in intussusception.

Recurrence rates after intussusception enema reduction: a meta-analysis

BACKGROUND AND OBJECTIVE

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Contemporary management of abdominal surgical emergencies in infants and children

BACKGROUND

Acute abdominal complaints in children are common presentations in the emergency department. The aetiology, presentation, diagnosis and management often differ from those in adults.

METHODS

This review was based on expert paediatric surgical experience confirmed by evidence from the literature obtained by searching PubMed and the Cochrane Library. Keywords used were the combinations of 'abdominal emergencies', 'acute abdomen' and the disorders 'acute appendicitis', 'intussusception', 'volvulus', 'Meckel's diverticulum', 'incarcerated inguinal hernia', 'testicular torsion' and 'ovarian torsion' with 'children'. Information was included from reviews, randomized clinical trials, meta-analyses, and prospective and retrospective cohort studies.

RESULTS

Presentation and symptoms of abdominal emergencies, especially in young children, vary widely, which renders recognition of the underlying disorder and treatment challenging. Critically targeted imaging techniques are becoming increasingly important in obtaining the correct diagnosis without unnecessary delay. Minimally invasive techniques have become the method of choice for the diagnosis and treatment of many abdominal emergencies in children.

CONCLUSION

Knowledge of abdominal disorders in childhood, their specific presentation, diagnosis and treatment facilitates management of children with acute abdomen in emergency departments. Imaging and minimally invasive techniques are becoming increasingly important in the diagnosis of acute abdomen in children. Urgent operation remains the cornerstone of therapy for most acute abdominal disorders.

Experience with Sonogram-guided hydrostatic reduction of Intussusception in Children in South-West Nigeria

BACKGROUND

Intussusception is a common cause of intestinal obstruction in young children. The diagnosis and treatment of intussusception has evolved over the years with ultrasound being the first choice imaging technique and a major player in the non-operative reduction of intussusception owing to its advantage of reduced morbidity and non-exposure to ionizing radiation when compared to other modalities of treatment. Aim & Objectives: The aim of this study was to evaluate the efficiency of ultrasound guided hydrostatic reduction in the management of intussusception in children and assess the predictors of reducibility.

METHODS

A prospective study of all infants and children who presented with uncomplicated intussusception was conducted between January, 2005 and September, 2013. The diagnosis of intussusception was made clinically and this was confirmed by an abdominal ultrasonography. Ultrasound guided hydrostatic reduction of intussusception was performed on the selected patients after they were adequately resuscitated. Failed reduction was abandoned in favour of operative reduction in some patients. Data collected included the age of the patients, duration of symptoms and the outcomes of the procedure and these were analyzed.

RESULTS

Eighty-four patients with intussusception were treated over this period, 36(42.9%) patients were found suitable for hydrostatic reduction of intussusception. Twenty-four(66.7%) patients presented within 48 hours of onset of symptoms. Twenty-one(58.3%) patients had successful hydrostatic reduction of intussusception while 15(41.7%) patients had failed reduction. The procedure was successful in majority (58%) of the patients under the age of 1 year and one of the three (33%) patients older than one year. Hydrostatic reduction of intussusception was successful in 14 out of 24 patients (58.3%) who presented within 48 hours of onset of symptoms.

CONCLUSION

Hydrostatic reduction of intussusception under ultrasound guidance is an effective and useful conservative method of management in carefully selected children with intussusception. Overall, this modality of treatment is cost effective and could readily be used for patients in resource poor environment. It also monitors the reduction process and visualizes the components of the intussusception including the lead points.

Japanese guidelines for the management of intussusception in children, 2011

BACKGROUND

The Japanese Society of Emergency Pediatrics has formulated evidence-based guidelines for the management of intussusception in children in order to diagnose intussusceptions promptly, to initiate appropriate treatment as early as possible, and to protect intussuscepted children from death.

METHODS

Literature was collected systematically via the Internet using the key words "intussusception" and "children." The evidence level of each paper was rated in accordance with the levels of evidence of the Oxford Center for Evidence-based Medicine. The guidelines consisted of 50 clinical questions and the answers. Grades of recommendation were added to the procedures recommended on the basis of the strength of evidence levels.

RESULTS

Three criteria of "diagnostic criteria,""severity assessment criteria," and "criteria for patient transfer" were proposed aiming at an early diagnosis, selection of appropriate treatment, and patient transfer for referral to a tertiary hospital in severe cases. Barium is no longer recommended for enema reduction (recommendation D) because the patient becomes severely ill once perforation occurs. Use of other contrast media, such as water-soluble iodinated contrast, normal saline, or air, is recommended under either fluoroscopic or sonographic guidance. Delayed repeat enema improves reduction success rate, and is recommended if the initial enema partially reduced the intussusception and if the patient condition is stable.

CONCLUSIONS

The guidelines offer standards of management, but it is not necessarily the purpose of the guidelines to regulate clinical practices. One should judge each individual clinical situation in accordance with experiences, available devices, and the patient's condition.

Rescue by pneumoenema under general anaesthesia of apparently non-reducible intestinal intussusception

When an enema in the radiology unit is unsuccessful in treating intussusception, patients must undergo surgery. A further attempt at reduction under general anaesthesia in the operating room prior to laparotomy could avoid surgical intervention. A prospective study was carried out from 2002 to 2010 on paediatric patients with intestinal intussusception who underwent a deinvagination procedure in radiology with no anaesthesia. Unresolved cases were included in either group 3a (direct surgery) or group 3b (pneumoenema under general anaesthesia in the operating room), depending if the paediatric surgeon on duty wanted or not to participate in the study. Ninety-eight patients were included in the study. Six patients (group 1) were immediately operated after diagnosis because peritonitis was clinically suspected. Sixty-seven patients were successfully treated with an anaesthesia-free procedure in the radiology department (group 2). Of the 25 cases with initial treatment failure (group 3), 11 were assigned to group 3a (immediate laparotomy) and 14 to group 3b (pneumoenema with general anaesthesia). All patients in the 3b group were successfully treated by this procedure. There were no differences between the groups in terms of age, sex or evolution time. The average length of hospital stay and the number of repeated hospitalizations were significantly higher for group 3a.

CONCLUSION

We consider that general anaesthesia increases effective reduction pressures and could avoid many surgeries in apparently non-reducible intestinal intussusceptions.

Comparison of different modalities for reducing childhood intussusception

BACKGROUND/OBJECTIVE

Idiopathic intussusception is an important abdominal emergency in infancy and childhood. Non operative management for treatment is firstly considered due to less invasiveness, less complications and cost effectiveness compared to surgical treatment. This study summarizes our experience in the management of intussusception in children who were referred to a children hospital.

PATIENTS AND METHODS

A total of 102 children who were diagnosed as having intussusception were referred to one children hospital in Tehran during a period of 10 years, from 1997 to 2007. Reductions were performed upon 57 cases by a radiologist or radiology residents, if there was no medical contraindication. We used chi-square test for analysis.

RESULTS

The success rate of reduction was eight out of 13 (61.5%) with barium, nine out of 17 (53.5%) with air and 22 out of 27 (81.5%) with saline (p value=0.116). One patient had recurrence with air reduction. Another case was complicated by peritonitis using barium enema.

CONCLUSION

There was no significant relationship between the success rate of reduction and the type of reduction.

Ultrasound guided hydrostatic reduction of intussusception in children at Korle Bu Teaching Hospital: an initial experience

Intussusceptions is the telescoping or invagination of a portion of intestine (intussusceptum) into an adjacent segment (intussuscipiens). It is one of the common causes of bowel obstruction in infants and toddlers.Sonography has now been accepted as a method for guiding hydrostatic reduction of intussusception with tap water, normal saline or Ringer's lactate solution. This method is currently being used at Korle Bu Teaching Hospital. It is a very simple, efficient, economical and quick method of managing intussusception. The duration of the procedure ranges between two minutes and thirty minutes, with the majority being under ten minutes. A total of twenty intussusceptions were managed in eighteen patients over a nine month period. In fifteen patients (75%) the intussusception was reduced successfully. In five patients (25%), the procedure failed to reduce the intussusceptions.

Computed tomography findings of unanticipated prolonged ileocolic intussusception in children

BACKGROUND

Attempted nonsurgical reduction of ileocolic intussusceptions after 48 hours is controversial because of the low probability of reduction and an increased risk of perforation. We sought to retrospectively identify computed tomography (CT) criteria that may help to predict bowel viability and successful enema reduction in children with ileocolic intussusception.

METHODS

Unanticipated intussusception was diagnosed using CT in six children with mild, atypical symptoms of four to seven days' duration at a single institution during a one-year period. All patients underwent laparotomy without prior contrast enema. Surgical findings were compared with preoperative CT scan findings to identify any criteria that may predict successful nonsurgical management.

RESULTS

Contrast CT scan findings were diagnostic of ileocolic intussusception. At the time of laparotomy, three children had easily reducible ileocolic intussusception with nonischemic bowel. Two children had irreducible intussusception with ischemic bowel requiring resection, and one child had a difficult reduction of nonischemic but edematous bowel. Preoperative CT scan findings correlated well with intraoperative findings for all patients. Findings of bowel-wall edema of the intussuscipiens and partial small-bowel obstruction shown on CT were associated with intussusception that was nonreducible or difficult to reduce.

CONCLUSION

Patients with prolonged intussusception diagnosed using CT scan may safely undergo contrast enema reduction if no bowel-wall edema of the intussuscipiens or obstruction is demonstrated.

Intussusception

Intussusception is the most common cause of intestinal obstruction in children between 3 months and 6 years. Intussusception occurs when a more proximal portion of bowel invaginates into more distal bowel. These patients often present with a wide range of non-specific symptoms, with less than one quarter presenting with the classic triad of vomiting, abdominal pain, and bloody stools. Thus, the diagnosis continues to rely on clinical suspicion. This review article discusses the clinical presentation of intussusception and the state-of-the art diagnostic and treatment options, as well as a review of the pertinent literature.

Ultrasound guided hydrostatic reduction of intussusception in children by saline enema: our experience

BACKGROUND

Intussusception is a common cause of acute intestinal obstruction with potentially serious complications. The treatment of choice is an attempt at initial non-operative treatment.

AIM

The purpose of the study was to evaluate the efficacy of the technique of hydrostatic reduction of intussusception using saline enema and ultrasound being practiced in our institute; the secondary goal was to identify patient subset in which it is more successful.

MATERIAL AND METHODS

The case records of all patients treated for intussusception in our institute from 1st January 2000 to 30th June 2007 were retrospectively analyzed to collect information. All patients with ultrasound diagnosed intussusception that were not having signs of shock or peritonitis were treated with normal saline enema under ultrasound guidance. Failure of three such attempts was an indication for operation.

RESULT AND CONCLUSIONS

We found that this technique is easy, safe and extremely effective in treating intussusception in children. The success rate was 81.37% (83 out of 102 cases) and mortality rate was 1.2%. Ileoileocolic type of intussusception failed enema reduction more often (statistically significant; P value = 0.0032) while older patients (statistically significant, P value = 0.001) had higher success rates with the technique. Patients who had colocolic type of intussusception (P value = 0.29) and patients who present early (P value = 0.262) appear to have higher success rates but this was not statistically significant.

Minimally invasive approach in the management of childhood intussusception

BACKGROUND

Intussusception is one of the most common causes of intestinal obstruction in infancy. Non-operative reduction using air enema or other hydrostatic reduction methods has been the standard treatment in most cases. However, if the non-operative method is not indicated or fails, open surgery is still necessary. With the tremendous development of the minimally invasive approach in handling surgical conditions in children in the last decade, this has been applied recently for the reduction of intussusception in children. We herein reviewed our experience of using the combined approach, namely, pneumatic reduction and, if failed, laparoscopic reduction in the management of childhood intussusception.

METHODS

We carried out a retrospective analysis of all children with intussusception managed at Prince of Wales Hospital between December 1998 and December 2004. The minimally invasive approach was used as far as possible. The method of reduction, success rate and the incidence of complication were analysed.

RESULTS

Over a 6-year period, there were 146 patients with 167 episodes of intussusception. Pneumatic reduction was carried out in 160 occasions and was successful in 134 (83.8%). In 33 patients, operative reduction was required. Of these, laparoscopic reduction was attempted in 15 and was successful in 13 (86.7%). In those with either pneumatic or laparoscopic reduction, no procedure-related complication was encountered and they had a significant shorter hospital stay (median 3.0 day) than those requiring laparotomy (median 8.0 day) (t-test, P < 0.0001).

CONCLUSION

The minimally invasive approach, that is, pneumatic and/or laparoscopic reduction, was successful in reducing intussusception in 88% of patients with minimal morbidity and shorter hospital stay.

Pneumatic reduction of childhood intussusception. Is prediction of failure important?

BACKGROUND/PURPOSE

Exclusion criteria for enema reduction of intussusception are still a matter of debate. The current study aimed to search for risk factors and to design and evaluate a predictive model of air enema failure.

METHODS

The design was a cross-sectional study. The study was conducted at a tertiary university hospital. The participants were 164 children (mean [SD] age of 11.6 [10.7] months) with intestinal intussusception. The intervention done was pneumatic reduction only contraindicated in case of peritonitis and/or sepsis. For main outcome measures, logistic regression analysis was used to estimate the contribution of clinical parameters (age, sex, weight, clinical evolution, temperature, rectal bleeding, white blood cell count, and neutrophils) to predict the risk of enema failure. To evaluate the discriminating power of the model, a receiver operating characteristic curve was constructed, and the effectiveness at different cutoffs was calculated.

RESULTS

Overall efficacy was 85%; manual reduction was performed in 12 (7.3%) cases, and there were 9 (6.5%) recurrences. Multivariable analysis adjusted for age and sex revealed that delayed diagnosis (evolution >24 hours) and raised neutrophils (%) were associated with failure: odds ratio of 11.52 (95% CI, 3.73-35.54) and 1.06 (95% CI, 1.02-1.11), respectively. The area under the receiver operating characteristic curve was 0.826 (95% CI, 0.740-0.912). At the best cutoff (0.15), the positive predictive value was 35% and the negative 93%. At the cutoff of 0.50, the positive predictive value was 70% and the negative 87%; the sensitivity was 29%.

CONCLUSIONS

The efficacy and safety of pneumatic reduction in childhood intussusception was confirmed. Delayed diagnosis and neutrophils significantly predict outcome. Despite consistent high negative predictive values, the model has low effectiveness in predicting enema failure and may not be clinically relevant; there is no rationale for stricter exclusion criteria.