1. Victoria V. Lao PEDIATRIC INTUSSUSCEPTION

2.  The triad (1/3 of patients)  Colicky abdominal pain  Bloody stools  Emesis  Signs and Symptoms  Episodic crying, alternating with appearing normal  Drawing up legs  Small dark mucoid stools  Preceding viral illness  Progress to obstruction—emesis, abdominal distension  Dehydration, lethargy and shock  Physical Exam  Sausage shaped mass  “Empty” right lower quadrant  Can have normal physical exam PRESENTATION Robb A. (2008) Paediatric

3.  Viral illness (hypertrophy of Peyer’s Patches)  Idiopathic  6mo – 2 years  Lead points  Polyps  Meckel’s diverticulum  Lymphoma  Duplication cyst  Ectopic pancreas  Intramural hemorrhage (Henoch Schonlein Purpura)  Location  Ileocolic most common  Ileoileal  Cecocolic, colocolic ETIOLOGY McKinney et al (2000)

4.  Plain film  Absence of cecal air  Obstructive bowel pattern  Right upper quadrant soft tissue mass IMAGING

5.  Air or Contrast Enemas  Diagnostic and therapeutic IMAGING www.radiologyinfo.org

6.  Ultrasound  Target sign aka donut sign (transverse)  Pseudokidney sign (longitudinal) IMAGING www.radiologyinfo.org

7. ENEMA REDUCTION

8.  Randomized controlled trial air vs liquid contrast for diagnosis and reduction, 101 patients  Rates of diagnosis: Air 49% vs contrast 54% (p = 0.62)  Rates of reduction: Air 76% vs contrast 63% (p = 0.31)  Air enemas resulted in shorter fluoroscopic times with no difference in rates of diagnosis or reduction  Retrospective study, 1340 patients, 1448 episodes of intussusception with 108 recurrent episodes in 75 patients  Recurrence rate after air enema 11.4% vs contrast enema 15.8% ( p= 0.08) AIR VS CONTRAST ENEMAS Meyer JS (1993) Radiology 188, 507-511 Niramis R, (2010) Journal of Pediatric Surgery 45, 2175-2180

9.  Textbooks recommend pre-enema reduction antibiotics  Retrospective cohort study, 2 centers, January 2005- December 2010, 118 patients  No difference post-reduction fever between the two groups PRE-ENEMA REDUCTION ANTIBIOTICS Al-Tokhais T (2012) Journal of Pediatric Surgery 47, 928-930

10. PRE-ENEMA REDUCTION ANTIBIOTICS Al-Tokhais T (2012) Journal of Pediatric Surgery 47, 928-930

11.  Standard practice is to admit for 24-48 hours of observation after enema reduction  Retrospective chart review 2002-2008  98 children with successful enema reduction  10 episodes of recurrence in 7 patients (7.1%)  3 patients with 2 recurrences each  Early recurrences ( <48 hrs) seen at 3h and 5h – 2%  Late recurrences ( > 48hrs) – 8.2%  Suggest 6hr observation in ED  Discussion of other studies reporting lower early recurrence rates, and at < 6hrs HOSPITAL VS HOME AFTER ENEMA REDUCTION Chien M et al, Journal of Emergency Medicine (2013) 44, 53-57

12.  Retrospective review 405 episodes of intussusception over 10 years  371 attempts at enema reduction  285 successful reductions  Failed enema group  Over 24hr of symptoms before presentation (P = 0.006)  Bloody diarrhea (P < 0.001)  Lethargy (P < 0.001)  Colonic extent of intussusception (< 0.001)  Right colon - 88% success  Transverse colon - 73% success  Left colon - 43% success  Rectal - 29% success PREDICTORS OF FAILED ENEMA REDUCTION Fike FB et al, Journal of Pediatric Surgery (2012) 47, 925-927

13.  Retrospective review 361 intussusceptions in 333 patients in 11 years  Identification of risk factors leading to surgical reduction ( p < 0.001) —early identification important to decrease need for resection  Duration of symptoms > 24hrs  Presence of triad  Positive pathologic lead point  Radiologic finding of obstruction PREDICTORS OF FAILED ENEMA REDUCTION Chung JL et al, J Formos Med Assoc (1994) 93, 481-485

14. SURGICAL REDUCTION

15.  Meta-analaysis of 10 studies, total 276 cases  Laparoscopy  Save and effective  Propose that laparoscopy be considered the primary intervention technique as opposed to laparotomy LAPAROSCOPIC VS OPEN Apelt, N et al, Journal of Pediatric Surgery (2013) 48, 1789-1793

16.  Meta-analaysis of 3 studies providing internal primary laparotomy control group  Shorter length of stay compared to open (4 vs 7 days P < 0.0001) LAPAROSCOPIC VS OPEN Apelt, N et al, Journal of Pediatric Surgery (2013) 48, 1789-1793

17.  Retrospective, 10 year review of experience, single institution  72 patients, 2 subgroups  under 3 years old n=65, surgery in 35 of which 19 required resection  over 3 years old n=7, surgery in all, 6 of which required surgery  Patients 3 years old or older will likely not benefit from the laparoscopic approach as they are more likely to need resection LAPAROSCOPIC VS OPEN Van der Laan M (2001) Surg Endosc 15, 373-376

18. RECURRENT INTUSSUSCEPTION

19.  Rates  Overall recurrence ~7-10%  Enema reduction ~10-15%  Surgical reduction ~1-3%  Adhesions  Resection 0%  Factors  Age of child  Lead points more common in children older than 2 years RECURRENCE

20.  Previous recommendations were after first of second recurrence (Sarason 1955, Soper 1964, Beaseley 1987)  Retrospective study, January 1995-May 2010, 686 cases of intussusception, 86 recurrences  Surgery in 177/686 (146 during first episode, 31 during recurrences)  Probability of recurrence  First episode: 15.7%  Second episode: 37.7%  Third episode: 68.4%  Fourth episode: 100%  Surgical intervention should be considered at the third episode of intussusception RECURRENT INTUSSUSCEPTION: WHEN TO OPERATE Hsu W (2012) Pediarics and Neonatology 53, 300-303

21.  Retrospective, single institution, 17 years, 278 children  Compared incidence of recurrent intussusception shows no significant difference between the groups  Manual reduction 67 (24.1%), recurrence 3 (4%)  Manual reduction with ileopexy 186 (66.9%), recurrence 8 (4%)  Segmental resection 25 (9.0%), No recurrence RECURRENCE AFTER SURGICAL PROCEDURES Koh CC (2006) Pediatr Surg Int 9, 725-728

22.  No real difference in air and contrast enemas with regard to reduction, however there is less radiation and time involved with air enema  No evidence either way for pre-enema antibiotics  Benefit of laparoscopic reduction when possible is decreased length of stay  Surgical intervention should be considered after third episode of recurrence  No evidence the ileopexy will prevent recurrence SUMMARY

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