| HOME | HELP | FEEDBACK | SUBSCRIPTIONS | ARCHIVE | SEARCH | TABLE OF CONTENTS |
|
|
|
|||||||
|
|||||||||
1 All authors: Department of Diagnostic Imaging, Hospital for Sick Children, University of Toronto, 555 University Ave., Toronto, ON M5G 1X8, Canada.
Received August 27, 2003;
accepted after revision November 6, 2003.
Address correspondence to O. M. Navarro
(oscar.navarro{at}sickkids.ca).
Abstract
 Top Abstract IntroductionMaterials and MethodsResultsDiscussionReferences |
|---|
MATERIALS AND METHODS. We performed a retrospective analysis of all intussusception cases seen at the Hospital for Sick Children, Toronto, Canada, a tertiary pediatric hospital, from May 1999 to December 2002.
RESULTS. There were 163 children with a total of 219 intussusceptions. Enema reduction was attempted in 211 (96%). Reduction rate with air enema was 90.2%. Delayed reduction attempts were used in 25 patients (15.3%) in 26 intussusceptions (12.3%) and were successful in 50% of the cases. Lead points were documented in 13 children (8%); sonography depicted the lead points in seven (53.8%) of the 13. The reduction rate of intussusceptions due to lead points was 63.6% (14/22).
CONCLUSION. Air enema associated with the use of delayed, repeated reduction attempts is a safe and effective approach for intussusception reduction with a high success rate. Delayed, repeated reduction attempts should be considered when the initial attempt manages to move the intussusceptum and the patient remains clinically stable. The management of intussusceptions due to lead points remains a challenge. Sonography does not depict all lead points, and the indication for other imaging studies should be tailored according to each particular patient. We recommend attempted enema reduction in all patients with lead points.
|
TopAbstractIntroductionMaterials and MethodsResultsDiscussionReferences |
|---|
|
TopAbstractIntroductionMaterials and MethodsResultsDiscussionReferences |
|---|
At our institution, sonography is used to document the presence or absence of intussusception. All confirmed cases are evaluated by the pediatric surgeons. If there is no evidence of peritonitis or signs of dehydration or shock, all intussusceptions, even if a lead point has been detected, undergo an enema reduction attempt, usually within 1 hr of diagnosis. The reduction technique most commonly used is air enema performed under fluoroscopic guidance, with the exception of one of our newer staff radiologists who prefers to use hydrostatic enema with diatrizoate (Hypaque-M 18%, Amersham Health) performed under fluoroscopic guidance. This first enema reduction attempt may comprise one or several consecutive attempts with a minimal time interval between them. If this first enema reduction attempt is not successful, a decision is made in consultation with the pediatric surgeons as to whether the patient should proceed to surgical reduction or undergo one or several delayed, repeated reduction attempts.
Delayed, repeated reduction attempts are only considered when partial reduction has been achieved with the first attempt and the patient is clinically stable. Sonography is performed before each delayed, repeated reduction attempt to rule out interval spontaneous reduction. For the purpose of this study, we have considered an attempt as delayed when there is an interval of 15 min or more between the reduction attempts. Surgery is again considered each time that delayed, repeated reduction attempts are unsuccessful. Between the delayed reduction attempts, the patients do not receive any antibiotics or sedation, and they are kept under close observation in the surgical ward.
|
TopAbstractIntroductionMaterials and MethodsResultsDiscussionReferences |
|---|
Of the total 219 intussusceptions, enema reduction was attempted in 211 (96%). The remaining eight (4%) did not have a reduction attempt because of spontaneous reduction of the intussusception, which was documented on sonography prior to enema reduction attempt in two cases and during the air enema in the remaining six. In these latter six, the spontaneous reduction was further confirmed on sonography. The overall reduction rate with air enema and hydrostatic enema was 90.5%. All seven enema reduction attempts with Hypaque-M 18% were successful. If only the air enema reduction attempts were considered, the reduction rate was 90.2%.
Delayed, repeated reduction attempts were used in 25 patients (15.3%) in a total of 26 intussusceptions (12.3%). The interval between attempts ranged between 18 min and 12 hr 10 min (mean, 3 hr 23 min). The number of delayed attempts ranged from 1 to 4 with a mean of 1.5 (14 children with 15 intussusceptions had one delayed attempt, nine children had two delayed attempts, one child had three delayed attempts, and one child had four delayed attempts). Delayed, repeated reduction attempts were successful in 13 intussusceptions (50%), of which eight had one delayed attempt, four had two delayed attempts, and one had four delayed attempts. The mean age of those children with successful reduction after delayed, repeated reduction attempts was 24 months, not significantly different from the mean age of those whose intussusceptions were reduced with only one attempt (25 months).
Lead points were documented in 13 patients (8%) who had a total of 22 intussusceptions (10%). The mean age of the children with lead points was 44 months compared with a mean age of 22 months of those without lead points. Lead points were documented in seven patients who had no recurrent intussusception (5.3%) and in six patients who had a total of 15 recurrent intussusceptions (19.4% of the children with recurrences and 26.3% of the recurrences). Table 1 lists the type of lead points and the accuracy of sonography in the depiction of the lead points. Figures 1A, 1B, 2A, 2B, 2C, 2D, 3A, 3B depict examples of sonographic appearances of the more common lead points. Successful reduction was achieved in 14 (reduction rate, 63.6%) of 22 intussusceptions in seven patients.
|
|
|
|
|
|
|
|
|
Twenty intussusceptions (9.8%) were not reducible with air enema and required surgery (Table 2). Seven of these intussusceptions (35%) had only one enema reduction attempt, which involved four patients with a lead point and one patient who had a perforation during the air enema procedure. The remaining 13 (65%) were considered irreducible after one to three delayed, repeated reduction attempts (one delayed attempt in seven intussusceptions, two delayed attempts in five, and three delayed attempts in one).
|
Of the 20 intussusceptions irreducible with air enema, six (30%) were also irreducible at surgery, requiring bowel resection. These included three intussusceptions due to lead points, two that had bowel necrosis (Fig. 4A, 4B), and one in which no other abnormality was found. The remaining 14 irreducible intussusceptions (70%) were manually reduced at surgery. These included five intussusceptions due to lead points, one in the patient who had the perforation during the air enema, and eight intussusceptions in which no other abnormality was found. In these eight, delayed, repeated reduction attempts were used in seven (one to three attempts), and in only one, a delayed, repeated reduction attempt was not used.
|
|
In this series, there was only one complication attributable to the use of air enema. This was a bowel perforation during the air enema reduction in a 7-month-old boy with an ileocolic intussusception and secondary bowel obstruction (Fig. 5A, 5B, 5C). This patient underwent only one air enema reduction attempt, in which air was introduced at a maximal pressure of 80 mm Hg. The apex of the intussusception was encountered in the midtransverse colon. This intussusception was reduced easily to the hepatic flexure, but at this point, intraperitoneal air was noted on fluoroscopy. The procedure was immediately discontinued, and the patient remained stable. At laparotomy, the intussusception was manually reduced, and a small right colonic perforation was found, which was oversewn. No bowel resection was required. The patient recovered uneventfully.
|
|
|
|
TopAbstractIntroductionMaterials and MethodsResultsDiscussionReferences |
|---|
The high rate of reduction achieved in this series is in part due to the use of delayed, repeated reduction attempts. In our series, delayed, repeated reduction attempts were used in 12% of the patients and were successful in 50% of these. An increase in our reduction rate by 6.4% from 83.8% to 90.2% can therefore be attributed to the use of delayed, repeated reduction attempts. This approach was brought about by previous observations that 10–14% of the radiologically irreducible intussusceptions have undergone spontaneous reduction at the time of laparotomy [12, 13] and that 51–66% of those still present at laparotomy are manually reduced without the need for bowel resection [13]. The rationale behind the use of delayed, repeated reduction attempts is that the partial reduction achieved with the first enema improves the venous drainage from the residual intussusception and the interval before a repeated enema allows the congestion and swelling to subside, facilitating the subsequent reduction attempt [14, 15].
The use of delayed, repeated reduction attempts is mentioned in several series, but a more thorough evaluation of its use and impact in larger groups of patients has been reported only by a few authors [15–18]. In 1984, Mortensson et al. [19] reported that in two of eight patients, a second attempt at hydrostatic reduction, 1 to several hours after the first attempt, was successful after premedication with morphine before surgery. In 1989, Collins et al. [14] reported that the use of a second reduction attempt while the patient was under general anesthesia in the operating room increased the reduction rate of the hydrostatic enema from 50% to 84%. In 1986, Guo et al. [1] presented a series of 6,396 cases of intussusception treated with air enema with a reduction rate of 94%. These authors specified that almost 50% of the cases required a second reduction attempt, repeated 2–3 hr after the initial attempt. In 1994, Rohrschneider and Tröger [20] reported their experience with hydrostatic reduction technique under sonographic guidance and recommended that if a complete reduction was not achieved, a repeated enema should be attempted after a 20-min rest phase; with this approach of delayed attempts used in 40% of their patients, they obtained a reduction rate of 91%. In 1999, González-Spínola et al. [18] showed that the use of delayed, repeated reduction attempts increased the rate of successful reductions with sonographically guided saline enema in their series by 15%. Also in 1999, a survey of the European Society of Pediatric Radiology revealed that nearly 17% of the respondents were using at least a 15-min delay between two attempts [21].
Table 3 identifies five series, including ours, that have analyzed with greater detail the use of delayed, repeated reduction attempts and shows that independent of the technique used, the time delay between attempts varies considerably not only from series to series but also within each series. It would appear from the success of these series that there might not be a specific interval between attempts that enables one to achieve a successful reduction because the window of opportunity appears to be quite wide. Only the protocol by Gorenstein et al. [16] proposes a more fixed interval of 45–60 min between these delayed attempts with a success comparable to that in the other series. With regards to the number of delayed attempts to be considered in each patient, the series by Saxton et al. [15] and by González-Spínola et al. [18] describe only the use of a single delayed reduction attempt, and the series of Gorenstein et al. [16] includes the use of two delayed attempts. Only in two other series [17, 22] and in this series, were more than two delayed attempts used.
|
This approach is based on our criteria that as long as the intussusception moves and the patient is clinically stable, delayed, repeated reduction attempts are preferable to surgery. However, the use of delayed, repeated reduction attempts and the risks of an increased radiation dose if one uses fluoroscopy have to be weighed against the risks of emergency surgery and anesthesia in sick children and the long-term risks of postoperative adhesions [8]. The fluoroscopy units must be properly configured to decrease the radiation delivered to the patient and should be combined with measures such as careful coning and intermittent and pulsed fluoroscopy to reduce the radiation dose to the patient to a minimum [8].
In our series, the percentage of patients that underwent delayed, repeated reduction attempts (12.3%) and the success rate of these attempts (50%) were similar to the series of Saxton et al. [15] (14.7% and 52.4%, respectively) (Table 3). The higher percentage of patients (> 50%) that had delayed, repeated reduction attempts in the series of Gorenstein et al. [16] may be due to a less aggressive approach with their first attempt, which also would explain the higher success rate of their delayed attempts. However, the overall success rate in this latter series of 90.9% is similar to ours.
Bowel perforation during delayed, repeated reduction attempts has been reported in only one patient in the five series described in Table 3 [17]. This perforation occurred in a third attempt that was performed 10 hr after the first attempt. This incident prompted the recommendation to perform all delayed, repeated reduction attempts within 2–4 hr of the initial attempt [17]. This guideline, however, has not been followed at our institution because we believe that the clinical assessment of the patient is more relevant to prevent perforation than the absolute interval between delayed attempts. In this series, we had no perforation while performing delayed, repeated reduction attempts.
The incidence of lead points in our series of 8% and the types of lead points found correspond to those described in the literature [23, 24]. We could diagnose the presence of a lead point in 53.8% of the cases with proven lead points (Table 1). However, when analyzing the role of sonography in the diagnosis of lead points, one should place more emphasis on the detection of focal lead points, such as Meckel's diverticulum (Fig. 1A, 1B), duplication cyst (Fig. 2A, 2B, 2C, 2D), and lymphoma (Fig. 3A, 3B). In the presence of lead points that involve the bowel more diffusely, such as cystic fibrosis or Henoch-Schönlein purpura, sonography usually depicts nonspecific bowel wall thickening and often the diagnosis of the lead point has already been established on clinical grounds. If we only consider focal lead points, our depiction rate on sonography is 60%, which emphasizes that sonography is the cornerstone technique in the search for lead points, especially when it is used routinely for diagnosis of intussusception. However, there remain cases in which the lead point may not be identified on sonography, particularly intestinal polyps and some Meckel's diverticula [24], and they will only be diagnosed at surgery if the intussusception cannot be reduced with enema.
In our series, 19% of the patients had recurrent intussusceptions, which is a percentage slightly higher than those reported in the recent literature (0–14.3%) [8, 18, 20, 25–30]. Recurrence of an intussusception may arouse the suspicion of the presence of a lead point. However, most recurrent intussusceptions are not due to lead points but are considered to be the result of lymphoid hyperplasia [7, 27]. There is little discussion in the literature regarding the incidence of lead points in recurrent intussusceptions; the reported incidence varies from 0% to 33% [8, 25, 27, 29]. In our series, the incidence of lead points in recurrent intussusceptions was 26.3% (19.4% of the patients) compared with 5.3% of the intussusceptions and patients with no recurrence. These figures indicate that although lead points are more common in recurrent intussusceptions, they still account for only a minority of these recurrences. Therefore, although one may be more concerned about the presence of lead points in recurrent intussusceptions, one has to be vigilant for their presence in any intussusception.
Our study and the literature do not provide data on how to continue the investigation of patients with recurrent intussusceptions in whom sonography does not reveal a lead point. However, in our series that was a rare event. In only two patients with recurrence and proven lead points, sonography did not depict the lead point, and one of them had a known diagnosis of cystic fibrosis.
It is well documented that intussusceptions due to lead points can be successfully reduced with enema [12, 23, 24], and this was confirmed by our reduction rate of 63.6% in our group. We, therefore, believe that because of this success rate, imaging-guided reduction should be attempted in all intussusceptions with lead points as long as there is no clinical contraindication to performing the enema as described. This recommendation also applies to those lead points that will eventually require surgical management because even if the reduction attempt is not completely successful, it may facilitate surgery. The technique chosen for reduction varies depending on the expertise and experience of each radiologist. However, lead points still accounted for 40% of those intussusceptions that were irreducible with air enema and for 50% of those irreducible at surgery. The question remains as to how aggressive one should be with delayed, repeated reduction attempts if it is known that a lead point is present. In our series, awareness of the presence of a lead point probably explains why four patients with irreducible intussusception due to a lead point had only one reduction attempt.
When analyzing the surgical findings of those intussusceptions that were irreducible with air enema (Table 2), we believe that attention should be focused on the 14 cases that were manually reduced at surgery. These, at least theoretically, could have been amenable to nonoperative reduction. In this group, if we exclude the five patients with lead points and the patient who had a perforation, we are left with eight patients in whom no other abnormality was found. Of these eight patients, seven had two to four delayed, repeated reduction attempts, which we felt exhausted our approach in these particular patients. The eighth had no delayed reduction attempt because sonography had shown a large amount of trapped and septate fluid within the limbs of the intussusceptum, a sign that has been associated with irreducibility [31]. We question whether the use of delayed, repeated reduction attempts could have been of benefit to this patient.
In conclusion, we have shown that air enema associated with the use of delayed, repeated reduction attempts is a safe and effective technique for intussusception reduction with a high success rate. The use of delayed, repeated reduction attempts was not complicated with bowel perforation. Delayed, repeated reduction attempts should be considered when the initial attempt manages to move the intussusceptum and the patient remains clinically stable. There does not appear to be a fixed optimal timing between attempts because success can be achieved with a great variability of intervals, but it is imperative to maintain strict clinical observation of the patient during the intervals between attempts. There are not enough data in our review or in the literature to propose a specific number of attempts that may be tried. This number should be weighed against the risk from increased radiation.
The management of intussusceptions due to lead points remains a challenge. Sonography does not depict all lead points, and there are no data available on how to continue the investigation of those patients in whom sonography does not depict a lead point but in whom there is a high index of suspicion for its presence. The indication for other imaging studies should be tailored according to each particular patient. Moreover, sonography cannot predict which intussusceptions due to lead points will be irreducible. We recommend attempted enema reduction in all patients with lead points if there is no contraindication to nonoperative reduction.
|
TopAbstractIntroductionMaterials and MethodsResultsDiscussionReferences |
|---|
CiteULike 
Complore 
Connotea 
Del.icio.us 
Digg 
Reddit 
Technorati What's this?
This article has been cited by other articles:
|
|
 |
|
  H Williams Imaging and intussusception Arch. Dis. Child. Ed. Pract., February 1, 2008; 93(1): 30 - 36. [Full Text] [PDF]
|
|
|
|
 |
|
 M. Buettcher, G. Baer, J. Bonhoeffer, U. B. Schaad, and U. Heininger Three-Year Surveillance of Intussusception in Children in Switzerland Pediatrics, September 1, 2007; 120(3): 473 - 480. [Abstract] [Full Text] [PDF]
|
|
|
|
 |
|
 J. H. Lee, S. H. Choi, Y. K. Jeong, W. J. Kwon, A. K. Jeong, B. S. Kang, and S. H. Shin Intermittent sonographic guidance in air enemas for reduction of childhood intussusception. J. Ultrasound Med., September 1, 2006; 25(9): 1125 - 1130. [Abstract] [Full Text] [PDF]
|
|
|
|
 |
|
 K. E. Applegate Clinically Suspected Intussusception in Children: Evidence-Based Review and Self-Assessment Module Am. J. Roentgenol., September 1, 2005; 185(3_supp): S175 - S183. [Abstract] [Full Text] [PDF]
|
|
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
| HOME | HELP | FEEDBACK | SUBSCRIPTIONS | ARCHIVE | SEARCH | TABLE OF CONTENTS |
