Intussusception Treatment & Management

From a clinical perspective, using a cutoff age of 3 years is helpful for dividing patients with intussusception into 2 groups. Patients aged 5 months to 3 years who have intussusception rarely have a lead point (ie, idiopathic intussusception) and are usually responsive to nonoperative reduction. Older children and adults more often have a surgical lead point to the intussusception and require operative reduction.

A decreased rate of operative intussusception management is noted in specialized pediatric hospitals compared with nonpediatric hospitals. This is attributed to the increased experience with and use of the various radiologic reduction techniques. ^[30]

Intussusception seen in patients older than age 2-3 years may be associated with various medical conditions or situations. The intussusception in these patients is usually small bowel to small bowel; therefore, therapeutic enemas are less helpful and are usually unsuccessful.

A few hours after nonoperative reduction, start the infant on a regular age-appropriate diet as tolerated. If operative reduction was performed, advance the diet as with any postoperative patient.

The only limitations on activity after the treatment of intussusception are those imposed by the postoperative state.

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Tailor treatment of the child with intussusception to the stage at presentation. For all children, start intravenous fluid resuscitation and nasogastric decompression as soon as possible.

The presence of peritonitis and any evidence of perforation revealed on plain radiographs are the only 2 absolute contraindications to an attempt at nonoperative reduction with a therapeutic enema. Therapeutic enemas can be hydrostatic, with either barium or water-soluble contrast, or pneumatic, with air insufflation. Therapeutic enemas can be performed under fluoroscopic or ultrasonographic guidance. The technique chosen is not important as long as the radiologist performing the enema is comfortable with the method. Preferably, the pediatric surgeon involved is present at the reduction. Enema reduction is more likely to be successful if initiated early (eg, within 4 hours of hospitalization). ^[31]

A study by Flaum et al presented their experience in intussusception reductions using saline enema under ultrasound control and concluded that it is an efficient and safe procedure. ^[32]

Since Harald Hirschsprung’s description of a systematic approach to hydrostatic reduction of intussusception, the reported success rate of this nonoperative intervention has widely varied (< 40% to >90%). This variability in outcome attests to the various factors involved in successful hydrostatic reduction. Among these are factors that are individual to the patient (age, duration of symptoms, presence of lead points) and others that depend on the technique used. Paramount among the latter category is the availability of a team of pediatric surgeons and radiologists with the necessary expertise, determination, and dedication. Even among pediatric radiologists, consensus has been lacking on methodologic issues, including the choice of reducing agent, the type of catheter, the role of the external manipulation of the abdomen, the use of medications, and the establishment of guidelines for pressure limits and number of attempts.

Air enema is the treatment of choice in many institutions. The risk of major complications with this technique is small. Its success is decreased, as with other reducing agents, in patients with small bowel intussusceptions and in those with prolapsing intussusceptions. When performing a therapeutic enema, the recommended pressure of air insufflation should not exceed 120 cm of water. When using barium or water-soluble contrast, the column of contrast should not exceed 100 cm above the level of the buttocks.

Traditionally, an attempt was not considered successful until the reducing agent, whether air, barium, or water-soluble contrast, was observed refluxing back into the terminal ileum, but evidence has shown that this is not entirely necessary. Most intussusceptions that failed to show reflux into the ileum were due to either an edematous or competent ileocecal valve. When these patients were explored, they displayed a completely reduced intussusception. According to this study, a patient who becomes asymptomatic after nonoperative reduction that fails to show reflux of the reducing agent into the ileum can safely be observed. ^[29]

The value of repeated attempts at nonoperative reduction, if the first attempt is unsuccessful, has not been determined. Some clinicians recommend taking the patient to surgical care if the first attempt fails, and other clinicians advocate 1 or 2 subsequent attempts within a few minutes to a few hours after the first attempt. ^[33] Delay between the reduction attempts may place the patient in the "window" of spontaneous resolution, which has been reported with an incidence of 5-6%. In addition, the first attempt can reduce the intussusception partially, making the intussusceptum less edematous, with improved venous drainage.

Some reports have postulated that reduced bowel edema with improved venous drainage is one of the reasons why the success rate of hydrostatic reduction increases with the administration of a second enema. If repeated attempts are unsuccessful, any progress in pushing back the intussusceptum toward the ileocecal valve during operative reduction is advantageous. Delay in performing surgery because of additional attempts at nonoperative reduction has been demonstrated to have no adverse effects on the rates of success of operative reduction and patient morbidity.

When therapeutic enema is successful, the results are immediate and extremely gratifying. The infant falls asleep almost immediately, and the obstruction is relieved, allowing the resumption of a normal diet. A short period of overnight observation usually is warranted before discharge.

Therapeutic enema is of no value in patients with small bowel–to–small bowel intussusception, which usually occurs in older children who have other associated diseases (eg, HSP, hemophilia, Peutz-Jeghers syndrome, malignancies).

Intussusception in the first month of life is rare. Most of these patients are found to have a surgical lead point; therefore, enemas are rarely successful and are potentially dangerous.

If nonoperative reduction is unsuccessful or if obvious perforation is present, promptly refer the infant for surgical care.

Traditional entry into the abdomen is through a right paraumbilical incision. Deliver the intussusception into the wound and attempt nonoperative reduction. Milking the intussusceptum out of the intussuscipiens is important. Sustain gentle manual pressure rather than pulling out the intussusceptum to avoid risk of iatrogenic perforation. If operative reduction is successful, appendectomy is often performed if the blood supply of the appendix is compromised. A cecopexy is not necessary. Risk of recurrence of the intussusception after operative reduction is less than 5%. ^[18]

If manual reduction is not possible or perforation is present, perform a segmental resection with an end-to-end anastomosis. A diligent search for any lead points is warranted, especially if the patient is older than 2-3 years.

Laparoscopy has been added to the surgical armamentarium in the treatment of intussusception. ^{[2, 3]} Laparoscopy can be performed in all cases of intussusception. Reduction of the intussusception, confirmation of radiologic reduction, and detection of lead points have all been reported.

Laparoscopy is associated with faster recovery times, decreased length of stay, decreased time to full feeds, and lower requirements of pain medication. (See the image below.)

Laparoscopic view of a jejuno-jejunal intussusception.

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With toleration of diet, patients treated with nonoperative reduction are usually discharged 12-18 hours after the therapeutic enema. After operative reduction, postoperative progress dictates the length of stay.

Some have proposed patient discharge from the emergency department after a short period of observation. Their recommendation is based on the fact that hospitalized children after enema-reduced intussusceptions often require minimal interventions and often have no serious enema-related complications. ^{[34, 35]} Obviously, the decision of where to observe the patient must be made on an individual basis, keeping in mind the small, but significant, recurrence rate.

Involve a pediatric surgeon as early as possible to help coordinate the care and resuscitation of the child. The availability of a pediatric radiologist enhances the chances of successful nonoperative reduction.

Patients treated with nonoperative reduction usually do not require any specific follow-up care unless problems exist. Postoperatively, patients require 1-2 visits to the pediatric surgeon to check on the progress of healing.

Radiologic reduction is best performed with the surgeon on standby, because complications may develop and require immediate surgery. This may require transfer to a facility with a pediatric surgeon. The benefit of transfer must be weighed against the delay in reduction.