Pediatric Intussusception Surgery

Updated: Jun 30, 2017
  • Author: Michael S Irish, MD; Chief Editor: Harsh Grewal, MD, FACS, FAAP  more...
  • Print
Overview

Background

Intussusception, which is defined as the telescoping or invagination of a proximal portion of intestine (intussusceptum) into a more distal portion (intussuscipiens), is one of the most common causes of bowel obstruction in infants and toddlers.

Intussusception was first described by Barbette in 1674, and it was first successfully treated surgically by Wilson in 1831. In 1876, Hirschsprung first reported the technique of hydrostatic reduction, [1] and in 1905, after monitoring a series of 107 cases, he reported a 35% mortality attributable to intussusception.

Vascular compromise and subsequent bowel necrosis are the primary concerns with intussusception. Among patients who undergo operative reduction of intussusception, as many as 10% may require bowel resection.

Next:

Anatomy

Intussusception is the telescoping or invagination of a proximal portion of intestine into a more distal portion (see the first image below). Intussusception may be ileoileal (see the second image below), colocolic, ileoileocolic, or ileocolic (the most common type; see the third image below).

Diagram illustrating anatomy of intussusception. Diagram illustrating anatomy of intussusception.
Intraoperative appearance of ileoileal intussuscep Intraoperative appearance of ileoileal intussusception.
Intraoperative appearance of ileocolic intussuscep Intraoperative appearance of ileocolic intussusception.
Previous
Next:

Pathophysiology

Intussusception results in bowel obstruction, followed by congestion and edema with venous and lymphatic obstruction. This progresses to arterial obstruction and subsequent necrosis of the bowel. Ischemia and then necrosis results in fluid sequestration and bleeding from the gastrointestinal (GI) tract. If untreated, the bowel may perforate, resulting in sepsis.

Previous
Next:

Etiology

Intussusception is ileocolic in 80% of cases but may also be ileoileal, colocolic, or ileoileocolic. Most infants and toddlers (95%) with the condition do not have an identifiable specific lead point. In these idiopathic cases, careful examination may reveal hypertrophied mural lymphoid tissues (Peyer patches), which are due to adenovirus or rotavirus infection. Intussusception has also been found to increase the risk of tonsillar disease (ie, chronic or acute tonsillitis) and tonsillectomy in children. [2]

A specific lead point that draws the proximal intestine and its mesentery inward and propagates it distally through peristalsis is identified in only 5% of cases and is most commonly found in cases of ileoileal intussusception. Specific lead points are more commonly found in children older than 3 years and almost always in adults with intussusception. Meckel diverticulum (see the image below) is the most common lead point, followed by polyps, such as are seen with Peutz-Jeghers syndrome, and intestinal duplications. [3]

Intraoperative appearance of ileocolic intussuscep Intraoperative appearance of ileocolic intussusception due to Meckel diverticulum.

Other lead points described include lymphomas, lymphangiectasias, [4] submucosal hemorrhage with Henoch-Schönlein purpura, trichobezoars with Rapunzel syndrome, [5] caseating granulomas due to abdominal tuberculosis, [6] hemangiomas, and lymphosarcomas. Intussusception associated with pathologic lead points may be more likely to recur. [7]

Children with cystic fibrosis (CF) may present with intussusception due to inspissated meconium in the terminal ileum. Although intussusception is generally observed as a complication in older children with CF, neonatal intussusception with meconium plug syndrome associated with CF has been reported.

Postoperative jejunoileal or ileoileal intussusception, which has no specific lead point in most cases, accounts for approximately 1% of intussusceptions in children of all ages. [8] When a lead point is present with postoperative intussusception, several cases have been reported after appendectomy with stump inversion. [9] Other rare reported types of intussusception include retrograde jejunojejunal intussusception following duodenal atresia repair [10] and an ileoileal type resulting from blunt abdominal trauma. [11]

Although the vast majority of intussusception cases are idiopathic, Oshio et al in Japan reported a familial anatomic tendency that may predispose to the condition in the face of viral infection. Of 554 families who had at furthest a third-degree relative with an idiopathic case of intussusception, the authors found an incidence of approximately 7%, or 1 per 14.2 cases. The family history may help in the workup, and further genetic testing may eventually identify the gene responsible for this predisposition. [12]

Previous
Next:

Epidemiology

The incidence of intussusception is 1.5-4 cases per 1000 live births, with a male-to-female ratio of 3:2. The highest incidence of idiopathic intussusception is in infants aged 9-24 months. A seasonal incidence has been described, with peaks in the spring, summer, and the middle of winter. These periods correspond to peaks in the occurrence of seasonal gastroenteritis and upper respiratory tract infections.

Previous
Next:

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:

  • Ileoileocolic intussusception
  • Long duration of symptoms (>24 hours)
  • Raised neutrophil percentage
  • Rectal bleeding
  • Failed reduction with barium enema at another institution
  • Age older than 2 years or younger than 3 months
  • Small-bowel obstruction on radiography
  • 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%; after operative reduction, the risk is as high as 5%.

Previous