|Year : 2020 | Volume
| Issue : 2 | Page : 71-75
Management of intussusception in the era of ultrasound-guided hydrostatic reduction: A 3-year experience from a tertiary care center
Mir Fahiem-Ul-Hassan1, Gowhar N Mufti1, Nisar A Bhat1, Aejaz A Baba1, Mudassir Buchh1, Sajad A Wani2, Shahid Banday1, Mudassir Magray1, Atif Nayeem1, Sikandar Iqbal1
1 Department of Pediatric Surgery, Sheri Kashmir Institute of Medical Sciences, Srinagar, Jammu and Kashmir, India
2 Department of Pediatric Surgery, Government Medical College, Srinagar, Jammu and Kashmir, India
|Date of Submission||17-Aug-2018|
|Date of Decision||17-Feb-2019|
|Date of Acceptance||07-Nov-2019|
|Date of Web Publication||28-Jan-2020|
Dr. Gowhar N Mufti
Sheri Kashmir Institute of Medical Sciences, Srinagar, Jammu and Kashmir
Source of Support: None, Conflict of Interest: None
| Abstract|| |
Introduction: Ultrasound-guided hydrostatic reduction (HSR) is currently the initial management tool in the treatment of intussusception. HSR is, however, confronted with failures besides there are still a number of patients who primarily undergo surgical intervention for the management of intussusception. We undertook this study to assess the efficacy of HSR and also to look for factors demanding the surgical exploration in patients with intussusception.
Materials and Methods: A total of 215 patients with intussusception from June 2014 to June 2017 were prospectively studied. HSR was carried out in 203 patients, which was successful in 187 and unsuccessful in 16. These two groups were compared using the Student's t-test. Significance was set at P < 0.05. Twelve patients undergoing surgery primarily were also assessed for the factors affecting the decision-making.
Results: HSR was successful in 187 and unsuccessful in 16. The failed group was more likely to have symptoms over 24 h, appearance of crescent, and ≥10-cm length on ultrasonography (USG). Two of these patients had ischemic bowel, two had ileoileal intussusception, and eight had pathological lead points, whereas no obvious cause could be identified in the rest of the four patients. Among the 12 patients who were primarily operated, four patients had peritonitis and other four patients were neonates. Laparoscopic reduction was done in four patients.
Conclusion: HSR is a safe and effective treatment modality for intussusception. However, it is met with higher failure rates in patients with risk factors such as delayed presentation, appearance of crescent on USG, and length >10 cm. The role of HSR is also dubious in situations such as neonatal intussusception, small-bowel intussusception, and multiple intussusceptions and also in preventing the future recurrence. Such patients ought to be managed by laparotomy or where feasible by laparoscopy. Furthermore, before embarking on HSR, peritonitis and bowel ischemia should be ruled out clinically and radiologically. In the suspicious cases of bowel ischemia, USG Doppler may be helpful.
Keywords: Intussusception, peritonitis, resection anastomosis, ultrasound-guided hydrostatic reduction
|How to cite this article:|
Fahiem-Ul-Hassan M, Mufti GN, Bhat NA, Baba AA, Buchh M, Wani SA, Banday S, Magray M, Nayeem A, Iqbal S. Management of intussusception in the era of ultrasound-guided hydrostatic reduction: A 3-year experience from a tertiary care center. J Indian Assoc Pediatr Surg 2020;25:71-5
|How to cite this URL:|
Fahiem-Ul-Hassan M, Mufti GN, Bhat NA, Baba AA, Buchh M, Wani SA, Banday S, Magray M, Nayeem A, Iqbal S. Management of intussusception in the era of ultrasound-guided hydrostatic reduction: A 3-year experience from a tertiary care center. J Indian Assoc Pediatr Surg [serial online] 2020 [cited 2020 Jul 11];25:71-5. Available from: http://www.jiaps.com/text.asp?2020/25/2/71/276937
| Introduction|| |
Intussusception is invagination of the proximal bowel into the distal bowel. It is one of the most frequent causes of intestinal obstruction in children. The cardinal features of intussusception are pain, vomiting, and rectal bleeding. However, this classical triad is present in <25% of patients. The diagnosis of intussusception is aptly made by ultrasonography (USG). Sonography diagnoses intussusception with an almost 100% accuracy. It has the advantage of being easily affordable, noninvasive, and radiation free. It is also valuable in excluding other pathological conditions  such as appendicitis and mesenteric adenitis, which is a common occurrence in this age group. In addition to its diagnostic value, it has achieved an indispensable role in the management of intussusception. Ultrasound-guided hydrostatic reduction (HSR) is currently the initial management tool in the treatment of intussusception. HSR is, however, confronted with failures besides there are still a number of patients who primarily undergo surgical intervention for the management of intussusception. We undertook this study to assess the efficacy of HSR and also to look for factors demanding the surgical exploration in patients with intussusception.
| Materials and Methods|| |
A total of 215 patients with intussusception presenting to the Department of Pediatric Surgery, Sheri Kashmir Institute of Medical Sciences, a sole tertiary care center in the region, from June 2014 to June 2017, were included in the study. Patients with age >4 years and those with a previous history of surgery were excluded from the study owing to the findings that HSR is least beneficial in such scenarios. Individuals with transient small-bowel intussusception <2.5 cm were also excluded from the study.
Patients with peritonitis and X-ray evidence of gas under the diaphragm were taken for immediate exploration after a session of resuscitation. Those patients who had USG-diagnosed intussusception and were clinically stable were subjected to ultrasound-guided HSR.
Hydrostatic reduction procedure
Patients satisfying the inclusion criteria were resuscitated and then shifted to the radiological suite where they were laid down on a couch in a left lateral position. A well-lubricated, 18–20 French Foley's catheter was introduced 6–9 cm into the rectum, its balloon was inflated with 15–20 ml of distilled water, and its position was checked by USG. The buttocks were strapped together, and the catheter was connected to the intravenous fluid column about 100–150 cm from the level of the pubis of the patient. HSR was carried out under USG guidance, with normal saline flowing freely into the rectum without application of any external force to the saline bag. HSR was performed by the surgical team in the presence of a sonologist to monitor the reduction of intussusception on ultrasound. Each sitting of saline reduction was carried out for a maximum of 20–25 min after which the procedure was abandoned. Three such attempts, 4–6 h apart, were made prior to subjecting the patient to surgery. Repeat attempts were undertaken only in clinically stable patients where the initial attempt achieved at least partial reduction. Successful reduction was defined by disappearance of intussusception and flooding of terminal ileum with saline and passage of flatus. The procedure was carried out in awake patients without sedation and held in position by staff.
The patients were assessed for clinical signs of peritonitis and shock every 2 hourly before and every 4 hourly after a successful reduction. The patients were observed for 24 h after successful reduction or till they tolerated orals and discharged thereafter.
| Results|| |
A total of 215 patients of intussusception were studied over a period of 3 years. There were 135 males and 80 females (male:female ratio 1.7:1). The average age at presentation was 8 months ± 6 months. The oldest patient was 4 years old and the youngest was 21 days old. Most of the patients (185 [86%]) presented with pain and irritability followed by vomiting (172 [80%]). Other clinical parameters are summarized in [Table 1]. USG was the main modality used for diagnosis. The average size of intussusception on USG was 4.2 ± 1.2 cm, with the largest one being 18.2 cm and the smallest being as small as 3.3 cm. Out of the 215 patients, 12 patients underwent primary surgical intervention [Figure 1]. There were four patients who had features suggestive of peritonitis at presentation and were hence taken for surgery immediately after resuscitation. Other four patients were neonates. As neonatal intussusceptions are rare and at present no water enema reduction protocol for neonates is adhered to by our institute, all these patients were managed surgically. However, three out of these four patients were subjected to water-soluble contrast enema for diagnostic purpose. Diagnosis was clinched in one patient by contrast enema and another by ultrasound. Other two patients were initially treated for necrotizing enterocolitis and were explored for intestinal obstruction. All the four patients of neonatal intussusception underwent exploration followed by resection anastomosis.
Parents of two patients preferred laparoscopic reduction over HSR. Laparoscopic reduction was carried out in two more patients: one, a case of multiple small-bowel intussusceptions and another was a case of Peutz–Jeghers syndrome with ileoileal intussusception and severe recurrent colics.
HSR was carried out in 203 patients after an initial session of resuscitation. It was successful in 187 (92.1%) patients and unsuccessful in 16 (7.9%) patients who were subjected to surgical exploration. These two groups were assessed, and their clinicoradiological features were compared [Table 2]. On statistical analysis, it was observed that the patients presenting late (after 24 h of their first symptoms) had more likelihood of a failed HSR. Appearance of crescent sign and length of intussusceptum on USG also significantly predicted the failure of HSR. Patients with intussusceptum length of ≥10 cm had more chances of failure on HSR. Other parameters such as bleeding per rectum (PR), abdominal mass, and bilious vomiting did not seem to influence the success of HSR. We did not experience any event of intestinal perforation with HSR.
|Table 2: Comparison of clinical features and ultrasound findings of successful and unsuccessful hydrostatic reduction groups|
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Among the 16 patients who underwent surgery, two had ileoileal intussusception and other two had ischemic bowel. Pathological lead points were found in eight patients. Severely hypertrophied Payer's patches were seen in six patients. One patient had a Meckle's diverticulum and another had polyp. Pathological lead points could not be traced in other eight patients.
Successful HSR was achieved in 187 (92.1%) patients. Nine (4.8%) patients developed recurrence of intussusception following successful HSR. Seven patients developed early recurrence within 24 h, which was again reduced by water enemas. Two patients who developed late and multiple recurrences were taken for diagnostic laparoscopy and caecopexy. Both of these patients had free and mobile cecum.
Only 74 (39.5%) patients with HSR were rescanned before discharge. All the other patients were discharged once they were colic free and moved bowels. The average hospital stay was 28 ± 6 h for the patients in the HSR group. Patients who were treated surgically had an average hospital stay of 3.5 ± 1.5 days.
| Discussion|| |
USG-guided HSR has become a popular and effective treatment modality for the reduction of intussusception. It is a simple, easy, rapid, and radiation-free method of treatment of intussusception with minimal complications. Studies have shown a high success rate (76%–95%) with HSR. In our study, HSR was successful in 92.1% (187 out of 203) of patients. However, unlike other studies, late presenting cases were not excluded from our study.
Like any other procedure, HSR is associated with failures. In the recent past, many studies have been conducted to predict the failure of HSR with considerably variable results. McDermott et al. demonstrated that the length of duration of symptoms, rectal bleeding, and radiological features of small-bowel obstruction significantly predict the failure of reduction. However, Menor et al. did not find any significant association of duration of symptoms and radiological features of small-bowel obstruction with failure of reduction. Similarly, Gorenstein et al. concluded that age and rectal bleeding do not influence the successful reduction of intussusception. Our study revealed that the duration of the presence of symptoms and length of intussusceptum significantly affected the outcome of HSR, with patients presenting later than 24 h and those having an intussusceptum length of 10 cm or above having more failure rates than the other patients. Appearance of crescent on USG, due to trapped fluid within intussusceptum also predicted the failure of hydrostatic reduction. Our findings were similar to the observations made by other authors., Although these factors may predict failure, their presence does not necessarily form a contraindication to a trial of HSR. A well-monitored, gentle attempt of HSR may still be attempted even in the presence of these risk factors provided there are no features suggestive of peritonitis. Patients who fail three genuine attempts of HSR are subjected to surgical intervention. In our study, HSR failed in 16 (7.9%) patients who were subsequently operated. Among the 16 patients, ileoileal intussusception was found in two patients and ischemic bowel in two patients. Ileoileal intussusception has been associated with more chances of resection anastomosis, which has been reported by other studies also. Two patients were found to have ischemic bowel on exploration. Viability of bowel in both of these patients could not be assessed with certainty on clinical assessment and routine USG. Color Doppler may be more beneficial in such cases to assess the bowel viability although it is also confronted by limitations. Obvious lead points could be identified in 50% (8 out of 16) of our surgical patients. Six patients had hypertrophied Peyer's patches and two other patients had a Meckel's diverticulum and a polyp. In most of the cases, hypertrophied Peyer's patches are thought to cause intussusception, especially in young children. However, presence of diverticula, duplication cysts, and polyps as the pathological lead points is well documented in literature.
The recurrence of intussusception following successful HSR in our series was 4.8% (9 out of 187), which is similar to 2.7%–6.6% as reported by other studies. Recurrences were managed again by HSR. Two patients continued to have multiple late recurrences and hence were taken for laparoscopic reduction. Both of these patients had mobile cecum on laparoscopy, and cecopexy was done in them. Whether mobile cecum was a cause of their recurrent symptoms was not evident, but both of these patients remained symptom free following cecopexy. Mobile cecum is present in a good number of patients (25%–64%) and can rarely lead to intussusception.
Some authors recommend a routine follow-up scan 24 h after a successful HSR; however, follow-up scans were done only in 74 (39.5%) patients in our study. Rescanning was not deemed to be necessary in patients who were free of symptoms, who were feeding, and those moving bowels. Patients were discharged once they were colic free and tolerated orals. As the post-reduction complications and recurrences are rare, patients can be safely discharged once they are pain-free and have resumed oral feeds.,,
In our study, primary surgical interventions were carried out in 12 patients. Four patients had peritonitis on presentation and had to undergo resection anastomosis. Other four patients were neonates who were also managed by resection and anastomosis. Most specialist pediatric surgical units have reported an incidence of bowel resection ranging from 1.4% to 9%., Neonatal intussusception is very rare and difficult to diagnose as it closely mimics necrotizing enterocolitis. Closed reduction has a very limited role in neonatal intussusception which is usually managed by surgery.
Recently, laparoscopic reduction of intussusception has emerged as a new treatment modality for the management of intussusception. We instituted laparoscopic reduction in six patients, and all of them were managed successfully without any significant complications. Laparoscopic reduction of intussusception is especially useful in patients who fail HSR or develop recurrence after HSR. Laparoscopy offers a minimally invasive approach in managing intussusception, especially in cases where the diagnosis is not clear.
| Conclusion|| |
HSR is the initial management tool for intussusception in children. It is safe, effective, simple, and radiation free. However, it is met with higher failure rates in patients with risk factors such as delayed presentation, appearance of crescent on USG, and length >10 cm. The role of HSR is also dubious in situ ations such as neonatal intussusception, small-bowel intussusception, and multiple intussusceptions and also in preventing the future recurrence. Such patients ought to be managed by laparotomy or where feasible by laparoscopy. Before embarking on HSR, peritonitis and bowel ischemia should be ruled out clinically and radiologically. In the suspicious cases of bowel ischemia, USG Doppler may be helpful.
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Conflicts of interest
There are no conflicts of interest.
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[Table 1], [Table 2]