Pediatric Intussusception Surgery Treatment & Management
- Author: Michael S Irish, MD; Chief Editor: Harsh Grewal, MD, FACS, FAAP more...
Expeditious diagnosis and management are essential for achieving successful outcomes in infants with intussusception. Once the diagnosis is entertained, surgical personnel should be notified, an intravenous (IV) line inserted, and IV hydration started. A nasogastric tube should be inserted and placed to suction. If there is marked distention or a dilated bowel loop, an abdominal radiograph should be obtained. Antibiotics should be administered if there is clinical suspicion of peritonitis or infection (sepsis) or if the white blood cell (WBC) count is markedly elevated.
In the United States, if the intussusception can be reduced with an enema, the hospital stay typically lasts 3 days. 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 must be developed before it can become common practice.
Preoperatively, IV crystalloid resuscitation is begun (10 mL/kg × 2, plus 1.5 × maintenance fluid). A Foley catheter is placed to guide fluid resuscitation. A nasogastric tube is placed. Broad-spectrum IV 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.
The abdomen and bowel are typically explored through a transverse incision in the right lower quadrant (RLQ), though 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. After successful manual reduction, the involved bowel segment may appear edematous, hyperemic, or ischemic, but such findings do not necessarily mandate resection. An incidental appendectomy is often done, particularly if an RLQ incision was made for access to the abdomen; 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 with the open technique, intraoperative complications occurred only when bowel necrosis was present and resulted in a 12.5% (2/18) conversion-to-open rate. Postoperative complication rates were not significantly different in the open and laparoscopic groups. 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).
A major concern regarding the laparoscopic approach is the inability to reduce the intussusception in the standard retrograde fashion characteristic 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 should 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 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 in the two cases where laparoscopic reduction failed, open manual reduction failed as well, thus necessitating right hemicolectomy. Of the 12 reductions, five 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.
IV fluid resuscitation is continued and calculated, with consideration given to maintenance requirements and third-space losses. Upon resolution of ileus, diet is advanced at the discretion of the surgeon.
In older children and in cases of recurrent intussusception (three or four episodes) successfully reduced with an enema, consider evaluating the patient for a lead point (eg, upper gastrointestinal [GI] series, Meckel scan).
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 weeks) may occur within the length of intestine involved.
Outcome and Prognosis
Intussusception carries an overall mortality of 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 for nonoperative reduction:
Long duration of symptoms (>24 hours)
Raised neutrophils percentage
Failed reduction with barium at another institution
Age older than 2 years or younger than 3 months
Small-bowel obstruction on radiograph
Dehydration of greater than 5%
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%; after operative reduction, the risk is as high as 5%.
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