Pediatric Intussusception Surgery Treatment & Management

  • Author: Michael S Irish, MD; Chief Editor: Harsh Grewal, MD, FACS, FAAP   more...
 
Updated: Apr 14, 2011
 

Medical Therapy

Expeditious diagnosis and management is essential to successful outcomes in infants with intussusception. Once the diagnosis of intussusception is entertained, surgical personnel should be notified, an intravenous line inserted, and intravenous hydration started. A nasogastric tube should be inserted and placed to suction. If the patient is markedly distended or has a dilated loop of bowel, an abdominal radiograph should be obtained. Antibiotics should be administered based on clinical suspicion of peritonitis or infection (sepsis) or in patients with a markedly elevated WBC count.

If the intussusception can be reduced with an enema, the hospital stay typically lasts 3 days in the United States. However, one small retrospective study in Canada evaluated 96 patients with a successfully reduced ileocolic intussusception and determined that a short observational stay in the emergency department could be used safely in 90% of patients. This approach would prevent an admission and save on costs; however, more evidence-based criteria need to be developed before it could become common practice.

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Preoperative Details

Preoperatively, intravenous crystalloid resuscitation is begun (10 mL/kg x 2, plus 1.5 x maintenance fluid). A Foley catheter is placed to guide fluid resuscitation. A nasogastric tube is placed. Broad-spectrum intravenous antibiotics are administered. Body temperature must be preserved in the operating room. A type and screen of the patient's blood should be obtained. As with any patient with a bowel obstruction, careful induction (ie, rapid sequence) of anesthesia should take place because of the risk of regurgitation and aspiration.

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Intraoperative Details

The abdomen and bowel are typically explored through a right lower quadrant transverse incision, although some advocate a right transverse supraumbilical or even an upper midline incision. After inspection for signs of perforation, the intussusception is identified and delivered into the wound. First, an attempt is made at manual reduction by retrograde milking of the intussusceptum. Although gentle pulling may aid in reduction, avoid vigorous pulling apart of the intussuscepted segment of bowel.

If manual reduction is unsuccessful, if a mass or pathologic lead point is present, or if perforation has occurred, segmental bowel resection is necessary. After resection, a primary anastomosis may be performed. Often, after successful manual reduction, the involved segment of bowel appears edematous, hyperemic, or ischemic. These findings do not necessarily mandate resection. An incidental appendectomy is often performed, particularly if a right lower quadrant incision was made for access to the abdomen, as it may be presumed that the patient has had an appendectomy.

Laparoscopy in the management of intussusception was initially limited to a diagnostic role. It was used to confirm unreduced bowel following an enema with prompt conversion to an open procedure. The laparoscope allowed the surgeons to avoid unnecessary open procedures in cases of spontaneous reduction following enema and enhanced the efficacy of hydrostatic or pneumatic reductions, reducing the need for an open procedure in approximately 30% of cases. Continued experience with laparoscopy and improved technology has led some centers to successfully utilize the technique for therapeutic reduction in confirmed cases of pediatric intussusception.

Several small series have been published demonstrating the laparoscopic approach as safe, effective, and cost efficient when compared to the open technique. In a retrospective analysis at the University of Michigan comparing laparoscopic treatment of intussusception to the open technique, intraoperative complications occurred only in the cases where bowel necrosis was present and resulted in a 12.5% (2/18) conversion to open rate. Postoperative complications between the open and laparoscopic groups were not significantly different in this study. The open group experienced one wound infection and one recurrence (2/25), and the laparoscopic group experienced one urinary tract infection and one recurrence (2/18).[23]

A major concern regarding the laparoscopic approach is the inability to reduce the intussusception using the standard retrograde fashion of the open technique. Some authors voice concern that a surgeon reducing an intussusception laparoscopically must apply pull and tension on an often friable segment of bowel, increasing the risk of bowel perforation.

Additionally, because most cases of intussusception in older children and adults are secondary to a pathologic lead point, the laparoscopic technique may not be appropriate in these patients. In order to minimize the rate of conversion to the open approach, the patient should be seen within 36 hours of the onset of symptoms and have no peritoneal signs.

The compromised tactile feedback for identifying a lead point laparoscopically and the potential need for an extended bowel resection for malignancy support an open approach in older children and adults. However, advances in laparoscopy have made intussusception reduction more safe and effective. Chui et al have developed a “Chinese fan spread” technique that utilizes an intracorporeal fulcrum to distribute the distraction forces more evenly as the surgeon does a push-pull on the intussusception. Overall, 12 of 14 intussusceptions were reduced successfully without a concurrent enema, and the 2 cases in which laparoscopic reduction failed also failed open manual reduction, thus requiring right hemicolectomy. Of the 12 reductions, 5 had lead points that were managed laparoscopically or through a transumbilical incision.

The role of laparoscopy in intussusception is evolving and will be better defined as technology progresses and experience with the minimally invasive approach to this disease grows.

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Postoperative Details

Intravenous fluid resuscitation is continued and calculated, taking into consideration maintenance requirements and third-space losses. Upon resolution of ileus, diet is advanced at the discretion of the surgeon.

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Follow-up

In older children and in cases of recurrent intussusception (after 3-4 episodes) successfully reduced with an enema, consider evaluating the patient for a lead point (eg, upper GI series, Meckel scan).

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Complications

Intussusception results in bowel obstruction; thus, complications such as dehydration and aspiration from emesis can occur. Ischemia and bowel necrosis can cause bowel perforation and sepsis. Necrosis of a significant length of intestine can lead to complications associated with short bowel syndrome. Whether treated by operative or radiographic reduction, late stricture (4-8 wk) may occur within the length of intestine involved.

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Outcome and Prognosis

The overall mortality rate of intussusception is less than 1%. Recurrence rates following nonoperative reduction and surgical reduction are approximately 5% and 1%-4%, respectively.

The following criteria are associated with a higher failure rate of nonoperative reduction:

  • Ileoileocolic intussusception
  • Long duration of symptoms
  • Raised neutrophils percentage
  • Rectal bleeding
  • Failed reduction with barium at another institution
  • Age older than 2 years or younger than 3 months
  • Duration of symptoms longer than 24 hours
  • Small-bowel obstruction on radiograph
  • Dehydration of greater than 5%
  • Inexperienced radiologist

Factors significantly predictive of bowel perforation are younger age and a longer duration of symptoms. The risk of postoperative adhesive small-bowel obstruction following nonoperative reduction is 0%; for operative reduction, it has been reported in as many as 5% of patients.

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Contributor Information and Disclosures
Author

Michael S Irish, MD  Adjunct Clinical Assistant Professor, Department of Surgery, University of Iowa, Roy J and Lucille A Carver College of Medicine; Consulting Pediatric Surgeon, Department of Pediatric Surgery, Blank Children's Hospital and Children's Hospital Physicians Group

Michael S Irish, MD is a member of the following medical societies: International Pediatric Endosurgery Group and Sigma Xi

Disclosure: Nothing to disclose.

Coauthor(s)

Jason K Shellnut, MD  Staff Physician, Department of Surgery, Iowa Methodist Hospital

Disclosure: Nothing to disclose.

Philip M Bovet, DO, MPH  Resident Physician in Family Medicine, University of Wisconsin Health Clinic

Philip M Bovet, DO, MPH is a member of the following medical societies: American Academy of Family Physicians, American Medical Association, American Osteopathic Association, and Wisconsin Medical Society

Disclosure: Nothing to disclose.

Specialty Editor Board

Rebeccah Brown, MD  Associate Director of Trauma Services, Associate Professor, Department of Clinical Surgery and Pediatrics, Cincinnati Children's Hospital Medical Center and University of Cincinnati Hospital

Rebeccah Brown, MD is a member of the following medical societies: American College of Surgeons, American Medical Association, and American Medical Women's Association

Disclosure: Nothing to disclose.

Mary L Windle, PharmD  Adjunct Associate Professor, University of Nebraska Medical Center College of Pharmacy; Pharmacy Editor, eMedicine

Disclosure: Nothing to disclose.

Deborah F Billmire, MD  Associate Professor, Department of Surgery, Indiana University Medical Center

Deborah F Billmire, MD is a member of the following medical societies: Alpha Omega Alpha, American Academy of Pediatrics, American College of Surgeons, American Pediatric Surgical Association, Phi Beta Kappa, and Society of Critical Care Medicine

Disclosure: Nothing to disclose.

H Biemann Othersen Jr, MD  Professor of Surgery and Pediatrics, Emeritus Head, Division of Pediatric Surgery, Medical University of South Carolina

H Biemann Othersen Jr, MD is a member of the following medical societies: Alpha Omega Alpha, American Academy of Pediatrics, American Association for the Surgery of Trauma, American Burn Association, American Cancer Society, American College of Surgeons, American Medical Association, American Pediatric Surgical Association, American Society for Parenteral and Enteral Nutrition, American Surgical Association, American Thoracic Society, British Association of Paediatric Surgeons, Society for Surgery of the Alimentary Tract, Society of Critical Care Medicine, South Carolina Medical Association, Southeastern Surgical Congress, Southern Medical Association, Southern Society for Pediatric Research, and Southern Thoracic Surgical Association

Disclosure: Nothing to disclose.

Chief Editor

Harsh Grewal, MD, FACS, FAAP  Professor of Surgery and Pediatrics, Temple University School of Medicine; Chief, Section of Pediatric Surgery, Temple University School of Medicine

Harsh Grewal, MD, FACS, FAAP is a member of the following medical societies: American Academy of Pediatrics, American College of Surgeons, American Pediatric Surgical Association, Association for Surgical Education, Children's Oncology Group, Eastern Association for the Surgery of Trauma, International Pediatric Endosurgery Group, Society of American Gastrointestinal and Endoscopic Surgeons, Society of Laparoendoscopic Surgeons, and Southwestern Surgical Congress

Disclosure: Nothing to disclose.

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Diagram illustrating the anatomy of intussusception.
Intraoperative appearance of ileoileal intussusception.
Intraoperative appearance of ileocolic intussusception.
Intraoperative appearance of ileocolic intussusception due to Meckel diverticulum.
This is an abdominal plain radiograph of a 14-week-old patient with intussusception. Note the nonspecific appearance of bowel obstruction.
Transverse ultrasonographic view (target sign) of intussusception.
Longitudinal ultrasonographic view (pseudo-kidney sign) of intussusception.
Appearance of intussusception on CT scan.
This ileocolic intussusception is observed using air-contrast enema. Intussusception has been reduced to the level of the cecum.
This ileocolic intussusception is observed using barium contrast enema. Intussusception has been reduced to the level of the proximal transverse colon.
 
 
 
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