Laparoscopy-assisted hydrostatic in situ reduction of intussusception: A reasonable alternative?

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.

Laparoscopic and open surgery methods in managing surgical intussusceptions: A randomized clinical trial of postoperative complications

PURPOSE

To compare postoperative complications of laparoscopic surgery (LS) with open surgery (OS) in surgical intussusception patients.

METHODS

From March 2015 to February 2018, infants between 6 to 24 months old had the clinical and sono-graphical signs of intussusception enrolled in this double-blind, randomized clinical trial. We divided surgical intussusception patients into two groups. In the LS group, we evaluated patients by direct laparoscopic observation, on-table hydrostatic enema, and mechanical reduction of intussusception. In the OS group, we performed the conventional technique. These patients were followed for 2 years after procedures for comparison of postoperative complications between the two groups.

RESULTS

We had 52 patients who needed surgical exploration (26 in each group). There were four (15%) and seven (27%) patients with self-reduced intussusception in LS and OS groups, respectively. The conversion rate was 31% (eight cases). Five cases (19%) in the LS group and four cases (15%) in the OS group needed bowel resections. Operating time was longer in the LS group (P ≤ 0.006), and the postoperative complication rate was higher in the OS group (P ≤ 0.021).

DISCUSSION

Laparoscopy is a screening tool to determine the need for OS in surgical intussusception patients. Laparoscopy reduces the incidence of OS and its complications.

Reduction of intussusception under general anesthesia by hydrostatic technique: the RIGHT technique

Background

Intussusception is the one of the commonest causes of intestinal obstruction requiring urgent attention in early childhood. There is no gold standard of non-operative reduction. We report our 6 years’ experience in non-operative reduction using our “RIGHT” (Reduction of Intussusception under General anesthesia using Hydrostatic Technique) technique, emphasizing the need to perform the procedure in the operating room (OR) under general anesthesia. This prospective observational study covering the period from July 2014 till May 2020 included patients diagnosed with intussusception. Hydrostatic reduction was performed in the OR under general anesthesia by infusing a saline enema and the reduction was confirmed by ultrasound.

Results

Forty-eight patients underwent reduction using the RIGHT technique. Successful reduction was achieved in 44 (91.6%) patients. Four (8.3%) patients needed surgery, three (6.2%) due to failed reduction and one (2.0%) due to perforation. One (2.2%) patient developed a recurrence.

Conclusions

The “RIGHT” technique is a combination of the best available techniques of reduction of intussusception. It ensures patient safety by being performed in the OR, being pain free, avoiding radiation, avoiding the risk of aspiration associated with sedation, and also being able to immediately address a failure of reduction or a complication by surgical exploration.

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.