Pediatric Intussusception Surgery Treatment & Management

Updated: Jul 18, 2019
  • Author: Amulya K Saxena, MD, PhD, DSc, FRCS(Glasg); Chief Editor: Harsh Grewal, MD, FACS, FAAP  more...
  • Print
Treatment

Approach Considerations

Stable patients in whom the index of suspicion for intussusception is high but who do not have evidence of ischemic bowel, perforation, or sepsis may undergo immediate contrast enema for diagnosis and treatment of suspected intussusception. Contraindications for enema reduction include evidence of bowel perforation and peritonitis.

Immediate surgery is indicated for unstable patients, patients who have peritonitis, and patients with bowel perforation during attempted enema reduction. Elevated temperature and white blood cell (WBC) counts have also served as relative indicators for surgery. Patients requiring surgery must be aggressively resuscitated with fluids, and care must be taken to preserve body temperature preoperatively, intraoperatively, and postoperatively.

Next:

Medical Therapy

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 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. [32] This approach would prevent an admission and save on costs; however, more evidence-based criteria must be developed before it can become common practice.

Previous
Next:

Surgical Therapy

Preparation for surgery

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 in any patient with a bowel obstruction, careful rapid sequence induction of anesthesia should be carried out because of the risk of regurgitation and aspiration.

Operative details

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. Bowel resection is more likely to be required in older children and those with longer duration of symptoms. [33] 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. [34]

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. [35]  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. [36]

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. [37]  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. [38]

There are differences in ileocolic and small bowel intussusception  with regard to spontaneous reductions, and bowel resection, and age with regard to surgery and bowel resection. Treatment efficacy depends on time of presentation, intussusception type, pathologic lead points, US/color Doppler interpretation, and expertise in reduction techniques. [39]

Previous
Next:

Postoperative Care

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.

Previous
Next:

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 weeks) may occur within the length of intestine involved.

Previous
Next:

Long-Term Monitoring

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).

Previous