Non-operative Reduction Research Articles

Delayed repeat enemas are safe and cost-effective in the management of pediatric intussusception

Background/purposeThe purpose of the study is to compare outcomes between delayed repeat enema (DRE) and immediate surgery (IS) in children with ileocolic intussusception who fail initial enema reduction. MethodsRetrospective cohort study of children <6years-of-age from 2008 to 2012 in the Pediatric Health Information System (PHIS) database. Outcomes measured were bowel resection, length of stay (LOS), and adjusted hospital costs (AHC). Results4980 of 6889 (72.3%) children with intussusception were discharged without operation following a single successful enema. 1407 of 1909 (73.7%) remaining patients underwent IS while 502 (26.3%) had a DRE. Bowel resection was required in 372 of 1407 (26.4%) patients in IS group compared to 59 of 502 (11.8%) in the DRE group (p<0.001). The number of patients needed to treat by DRE to prevent a bowel resection was 7. In multivariable analysis, the IS patients had a 2.5 times greater likelihood of undergoing bowel resection than the DRE patients (adjusted odds ratio [OR] 2.50, 95% confidence interval [CI] 1.83–3.41, p<0.001). The DRE group had a mean LOS of 3.2days (95% CI 2.9–3.6) and mean AHC of $9205 (95% CI $7673–$10,735). The IS group had a longer LOS (4.4days, 95% CI 4.0–4.8, p≤0.001) and higher AHC ($14,422, 95% CI $12,631–$16,214, p<0.001). ConclusionDelayed repeat enemas for ileocolic intussusception increase the success of nonoperative reduction, decrease the rate of bowel resection and reduce mean hospital length of stay and costs.

A Pilot Survey of Pediatric Surgical Capacity in West Africa

While some data exist for the burden of pediatric surgical disease in low- and middle-income countries (LMICs), little is known about pediatric surgical capacity. In an effort to better plan and allocate resources for pediatric surgical care in LMICs, a survey of pediatric surgical capacity using specific tool was needed. Based on the previously published Surgeons OverSeas Personnel, Infrastructure, Procedure, Equipment, and Supplies (PIPES) survey, a pediatric PIPES (PediPIPES) survey was created. To ensure relevance to local needs and inclusion of only essential items, a draft PediPIPES survey was reviewed by nine pediatric surgeons and modifications were incorporated into a final tool. The survey was then distributed to surgeons throughout sub-Saharan Africa. Data from West Africa (37 hospitals in 10 of the 16 countries in the subregion) were analyzed. Fewer than 50 % (18/37) of the hospitals had more than two pediatric surgeons. Neonatal or general intensive care units were not available in 51.4 % (19/37) of hospitals. Open procedures such as appendectomy were performed in all the hospitals whereas less-invasive interventions such as non-operative intussusception reduction were done in only 41 % (15/37). Life-saving pediatric equipment such as apnea monitors were not available in 65 % (24/37) of the hospitals. The PediPIPES survey was useful in documenting the pediatric surgical capacity in West Africa. Many hospitals in West Africa are not optimally prepared to undertake pediatric surgery. Our study showed shortages in personnel, infrastructure, procedures, equipment, and supplies necessary to adequately and appropriately provide surgical care for pediatric patients.

Recurrent Intussusception in Infants

Background: The majority of intussusceptions, between 2 months and 2 years, are idiopathic. Indication of surgery in infants with recurrences is still matter for debate. The aim of our study was to review our experience to better define the management of recurrent intussusceptions (RIs). Methods: A retrospective study was conducted involving all patients treated for intussusception at the Department of Pediatric Surgery “A” of Tunis Children’s Hospital, over a 5-year period, going from 2008 through 2012. Patients admitted for more than one episode of intussusception were further investigated. Results: During the 5-year period, 170 infants and children younger than 2 years were diagnosed as having ileocolic intussusception. There were 10 patients with 12 recurrences. Overall recurrence rate was 6%. RI occurred in all cases following successful hydrostatic reduction. Nine infants underwent a second hydrostatic reduction of intussusception. The reduction was successful in all cases. The other infant was taken directly to the operating room because it was too sick to undergo enema. No lead point was found at surgery. The two patients who presented a second recurrence had a successful non-operative reduction. Subsequent laparoscopic exploration was normal in both cases. Conclusion: Based on our experience and on reviewing the literature, we recommend radiological reduction for more than the third episode of intussusceptions but we must take into consideration the socio-economic level of the parents. Surgery should be reserved for irreducible recurrences and in patients with a suspected pathologic lead point. Int J Clin Pediatr. 2014;3(4):105-107 doi: http://dx.doi.org/10.14740/ijcp175w

A Rare Cause of Acute Abdominal Obstruction in an Adult Due to Intestinal Intussusception from a Fibroblastic Polyp

Purpose: Colonic intussusception is often associated with childhood disease; however, adult intussusception only consists of 5% of all intussusceptions. Frequently, the clinical presentation is with chronic intermittent abdominal pain, nausea, vomiting, and, less often, with acute obstruction. Non-operative reduction (barium enema) is not successful, due to underlying pathology in adult patients with a pathological lead point that requires surgical intervention. We present a rare case of acute abdominal obstruction secondary to benign fibroblastic polyp. A 54-year-old African-American female without any significant past medical history presented with acute onset of diffuse abdominal pain associated with nausea and vomiting. Initial x-rays revealed air fluid levels consistent with bowel obstruction. CT scan showed colo-colonic intussuception of the right colon. A subsequent CT with contrast enema was utilized, and the patient reported relief of her symptoms. With the resolution of obstipation, the patient developed significant diarrhea. She was transferred to a tertiary care center for further evaluation and treatment. A colonoscopy was performed to evaluate the etiology of the colonic intussuception. A large submucosal mass with intussusception of small bowel into the colon was seen in the terminal ileum. The patient was taken to the operating room and a right hemicolectomy was performed, removing a 6x5-cm mass that had intussucepted into the ascending colon again. Pathology was consistent with a benign fibroblastic polyp (positive for Vimentin and CD34 and negative for CD 117 and SMA) with edematous changes secondary to acute and chronic inflammation. Adult colonic intussuception is often linked to malignant tumors, however, 30% of cases are due to benign disease. Typically clinical symptoms are associated with a chronic course; however, patients can have acute presentation with bowel obstruction. This patient had a large fibroblastic polyp in the terminal ileum, which served as the intussuscipiens, resulting in acute colonic obstruction. Although the barium enema temporarily reduced the obstruction, definitive management can only be achieved with resection of the underlying pathology leading to intussusception. This case underlies the need for consideration of intussusception in the differential diagnosis of acute bowel obstruction in adult patients.

English

INTRODUCTION: Intussusception is a common cause of childhood intestinal obstruction, occurring more frequently in children aged 6 months to 2 years and in more males than in females. When this condition occurs in neonates and in children older than 2 years, there is a high incidence of associated bowel abnormality that serves as an initiating lead point for intussusception. Intussusception is a common abdominal emergency in infants and children. A lot of debate exists regarding the best method for diagnosis and treatment. In our set up, most children with intussusception come to us late and only a few satisfy the criteria for non-operative hydrostatic reduction. Whenever hydrostatic reduction of intussusception is feasible, barium enema has been considered the gold standard. However recently, alternative methods using air, oxygen and ionic water soluble iodinated contrast media have been reported. US have occasionally been used for the past five years in our institution to diagnose intussusception when the clinical features were not clear cut. Having gained experience with US in diagnosing intussusception, we tried hydrostatic reduction of childhood intussusception using water under US guidance, with the idea of reducing exposure to radiation, lessening absorption of radiation by the contrast media and decreasing potential peritoneal contamination in the event of iatrogenic perforation during attempted reduction

Reduction of intussusception: defining a better index of successful non-operative treatment

The reported non-operative reduction rate for intussusception is usually the proportion of attempted non-operative (radiological) reductions that succeed, which we term the "selective reduction rate." This value shows wide variation that may result from selection bias that is difficult to quantify because data regarding primary operative treatment are frequently lacking. The proportion of patients with late clinical presentation or pathological lead points can also distort the apparent efficacy of non-operative treatment. We found no definitions of outcome measures in the literature or practice guidelines to inform analysis. Based on analysis of our own audit data we derived a "composite reduction rate" from first principles that can account for variations in radiological and surgical treatment thresholds that might bias other measures of successful non-operative treatment. This index is the proportion of intussusceptions not requiring resection that are successfully reduced non-operatively. We propose that the composite reduction rate be used as a key component of standardised multidisciplinary outcome reporting for intussusception rather than the selective reduction rate. The reduced bias and confounding would allow fairer comparisons and lead to better outcome standards.

External manual reduction of paediatric idiopathic ileocolic intussusception with US assistance: a new, standardised, effective and safe manoeuvre

The ultimate goal in the management of paediatric ileocolic intussusception is to achieve non-operative reduction and therefore patient cure. The standard non-surgical treatment consists of enema (air or liquid media). The purpose of this study is to present external manual reduction for paediatric ileocolic intussusception. We present a new manoeuvre that is standardised, simple, safe and effective for the radiologist in the non-surgical management of this pathology. External manual reduction is performed under sedation. Execution of the manoeuvre is detailed and illustrated. The procedure was carried out 15 times in 13 paediatric patients with idiopathic ileocolic intussusception. Complete reduction exclusively by external manual reduction was accomplished on 12 occasions (80%). In the remaining three procedures, partial reduction to the cecum was obtained. Subsequent enema achieved complete reduction in two. Overall non-surgical reduction rate was 93%. External manual reduction is a radiation-free, safe and effective procedure. In case of incomplete reduction, it facilitates enema performance. External manual reduction incorporates and additional initial step in the non-surgical reduction of intussusception and should be considered a first-line procedure.

The second trial pneumatic reduction for idiopathic intussusception

Purpose To study the therapeutic effect of the second trial pneumatic reduction on patients with idiopathic intussusception. Patients and methods A prospective study was carried out on patients with idiopathic intussusception presenting to our unit, between August 2009 and January 2010. We excluded patients older than 2 years of age, neglected cases with signs of peritonitis, and recurrent cases. All patients were subjected to the first trial pneumatic reduction, which was performed in three successive attempts (3 min each) under fluoroscopic guidance with pressure ranging from 80 to 100 mmHg. Patients with incomplete reduction but with satisfactory movement of the intussusceptum in the first trial were subjected to a second trial pneumatic reduction after 3 h. Results Fifty patients underwent first trial pneumatic reduction, which was successful in 33 patients, representing an overall reduction success rate of 66%. Of the remaining 17 patients, nine immediately underwent surgery rather than undergoing a second trial of pneumatic reduction because of minimal movement of the intussusceptum during the first trial. A second trial pneumatic reduction was offered to the remaining eight patients and was successful in six (75%), increasing the overall success rate from 66 to 78%. There were no bowel perforations among all the attempts at pneumatic reduction (first or second trials). Conclusion In a selected group of patients, delayed repeated air enema can increase the nonoperative reduction rate of idiopathic intussusception; however, careful attention should be paid towards decreasing exposure to radiation. Keywords : intussusception, pneumatic reduction, radiation dose

Colonic Volvulus

Management approaches for colonic volvulus are infrequently described in the literature in the United States, and many studies only report operative cases. The aim of this study was to define the demographics, diagnostic and treatment approaches, and outcomes for patients with this disorder in the United States. This study is a retrospective review. The study was conducted at a 7-hospital health system. All patients diagnosed with colonic volvulus by International Classification of Diseases, Ninth Revision code were included. The primary outcomes measured were recurrence, complications, and mortality. One hundred three cases of volvulus (50 sigmoid, 53 cecal) were identified in 92 patients. Compared with cecal volvulus, sigmoid volvulus was more common in men, patients with neurologic diagnoses, and residents of skilled nursing home. Eighty-five percent of the cases presented were acutely obstructed. The diagnosis was established by abdominal x-ray (17%), contrast enema study (27%), CT scan (35%), or laparotomy (17%). Abdominal x-rays were insufficient for definitive diagnosis in 85% of cecal and 49% of sigmoid cases (p = 0.002). All patients with cecal volvulus were treated surgically. Seventy-nine percent of patients with sigmoid volvulus underwent successful nonoperative reduction, of whom 38% had subsequent surgery. Fifty-eight percent of patients with sigmoid volvulus were treated operatively. Resection with primary anastomosis was chosen in most cases (78%). Resection with end ostomy (10%), reduction and pexy (7%), and reduction alone (4%) were other approaches. The mortality rate was 5% (cecal 0%, sigmoid 10%; p = 0.012). There were no readmissions for recurrent cecal volvulus. Nonoperative treatment for sigmoid volvulus often failed (48%). Complication rates were higher in sigmoid volvulus cases (cecal 17%, sigmoid 34%; p = 0.047). This study was limited by its retrospective, nonexperimental design. Although incidences of cecal and sigmoid volvulus are similar in the present series, sigmoid volvuli are more common in men, individuals with neurologic disease, and residents of nursing homes. Plain radiograph is insufficient to confirm cecal volvulus. The diagnosis is most often made with CT scans. The nonoperative management of sigmoid volvulus is associated with a high recurrence rate.

Clinical Analysis, Management and Outcome of Intussusception in Children

Introduction: Intussusception is the commonest cause of bowel obstruction in infancy and childhood. Early diagnosis and management is essential to reduce morbidity and mortality. The objective was to To review the diagnostic criteria of intussusception in infants and children to increase awareness of attending personnel for effective management decrease the rate of operative treatment and complications. Materials and Methods: The data collected of all 38 patients admitted in Kanti Childrens Hospital between 2008 September to 2009 September were studied prospectively. Each patient was evaluated in regard to age at presentation, sex, signs and symptoms, diagnostic method, treatment (operative, non-operative). Results: During study period of one year there were a total of 20 (52%) males and 18 (48%) females of age 3 months to 6 years. Pain abdomen was seen in 25(66%), vomiting 16(42%), diarrhea 15(40%), blood mixed with stool 10(26%). These symptoms were seen in different combination. X-ray erect abdomen was done in 15 and ultrasound in all 38 cases. Ten out of 15 (66.6%) patients with early presentation and diagnosis had successful barium enema reduction.10 (66.6%) had successful reduction and admitted to our hospital. 28(74%) patients were undergone laparatomy. Among 28 (74%) patents that had lapartotomy, manual reduction was successful in 18 and 10 required bowel resection and anastomosis. Conclusion: The awareness of early features of intussusception is important for early referral to tertiary centers for successful non-operative barium reduction and reduce the need of laparotomies in children. Key words: Barium enema reduction; Children; Intussusception; Laparatomy DOI: http://dx.doi.org/10.3126/jnps.v32i1.5347 J. Nepal Paediatr. Soc. Vol.32(1) 2012 9-13

Çocukluk Çağında Kolon Volvulusu

A 12-year-old boy with mental retardation and epilepsy was admitted with a 2-day history of vomiting, abdominal pain, constipation and severe abdominal distension. Physical examination showed a marked abdominal distention and generalized tenderness. Plain X-rays of the abdomen showed a markedly dilated loop of large intestine with multiple air-fluid levels. Surgical exploration revealed presence of a 180º counterclockwise volvulus of the transverse colon. A 15-year-old boy was admitted with the history of abdominal pain, constipation and abdominal distension. Non-operative reduction was performed with decompression of rectum and all the symptoms disappeared. The patient was discharged from the hospital. He was admitted with the same complaints seven days later. Surgical exploration revealed presence of a 720º counterclockwise sigmoid volvulus. Large intestinal volvulus is a rare surgical problem in childhood and it may be due to congenital or acquired anatomical variations. In this report, two cases of colon volvulus in childhood were presented and etiology and management were discussed.

Percutaneous Fixation of Geriatric Acetabular Fractures

The treatment of acetabular fractures in geriatric patients provides a unique set of challenges to the orthopaedic surgeon. Treatment strategies often differ from those employed to treat younger patients with acetabular fractures in order to minimize morbidity and mortality following these injuries. Treatment strategies to address these injuries include a repertoire of innovative methods for percutaneous or limited-open reduction and fixation in addition to traditional non-operative or open reduction and internal fixation methods. The purpose of this article is to discuss the challenges associated with the management of acetabular fractures in geriatric patients and to highlight current surgical techniques that can be applied to treat these patients.

Does the length of the history influence the outcome of pneumatic reduction of intussusception in children?

Intussusception is the most common cause of acute abdomen in infants and preschool children. Nonoperative reduction using air enema is an established treatment in children with intussusception. The aim of this study was to determine whether length of the history influences the outcome of pneumatic reduction of intussusception in children? The medical records of 256 consecutive children with intussusception between July 1998 and June 2010, who underwent air enema reduction regardless of the length of the history were reviewed. In all 256 patients, intussusception was confirmed by ultrasound before proceeding to air enema. The length of history ranged from 2 to 240 h with median time of 18.5 h. The median age in 256 patients was 7 months (range 1 day to 12 years). The presenting clinical features included irritability/abdominal pain (77%), vomiting (80%), bleeding per rectum (36%) and palpable abdominal mass (50%). Air enema reduction was successful in 234 (91.5%) of the 256 patients. In 22 (8.5%) patients, air enema failed to reduce the intussusception and 3 (1.1%) of these patients had colonic perforation during the procedure. All 22 patients required surgery. The duration of symptoms did not influence the outcome of pneumatic reduction. 37 (14%) patients developed recurrence after successful pneumatic reduction of intussusception, with 58% presenting within 48 h of the initial procedure. Our data suggest that pneumatic reduction should be first-line treatment in all children with intussusception regardless of the length of the history.

Treatment of Recurrent Sigmoid Volvulus with Percutaneous Endoscopic Sigmoidopexy

Purpose: In the United States, sigmoid volvulus is second only to cancer and diverticulitis as a cause of colonic obstruction. Prompt endoscopic decompression followed by surgical correction has become the accepted treatment method in most patients. There is, however, a small subset of patients in which comorbidities preclude the possibility of surgical intervention. Recurrence rates in these patients after nonoperative reduction are as high as 70%, with a resultant mortality rate of 21%. Percutaneous endoscopic sigmoidopexy has been proposed as a safe and effective treatment option in this population. We present a case of one such patient. Methods: A 93 year old female nursing home patient with a history of advanced Alzheimer's dementia, Parkinson's disease, CHF, PEG tube, and eight previous episodes of sigmoid volvulus within the prior year presented with a two day history of abdominal pain and distention. Abdominal X-ray confirmed the presence of sigmoid volvulus. The patient underwent directly visualized endoscopic reduction of volvulus with no evidence of gangrenous bowel wall or other pathology. As the patient was deemed a poor surgical candidate (ASA score 4), percutaneous endoscopic sigmoidopexy was considered as an alternative therapy. The patient received intensive bowel prep, conscious sedation and premedication with IV antibiotics prior to the procedure. On colonoscopy, a massively dilated rectum and sigmoid colon were noted. An area of the sigmoid with good 1:1 and transillumination was identified as the likely apex of the volvulus. Two 16 French PEG tubes were placed via pull technique per rectum and confirmed endoscopically at 40 cm and 55 cm from the anal verge. There were no immediate complications noted. Results: Diet was advanced after two days. The patient remained afebrile, and was subsequently transferred back to her nursing home with instructions on tube maintenance. No further episodes of confirmed revolvulus have occurred 12 months post procedure. Conclusion: A small number of reports of percutaneous endoscopic sigmoidopexy have appeared in the literature, most notably from the U.K., where the National Health Service has issued guidelines for its use in the treatment of sigmoid volvulus. To our knowledge, PES use has only been reported once prior in the United States. As surgical correction is the accepted modality in the majority of patients, PES is suggested as an alternative to expectant management in patients too ill to undergo general anesthesia or surgical intervention. As so few cases have thus been reported, many questions pertaining to methodology and outcomes must be answered prior to this procedure becoming a well accepted tool in the treatment of sigmoid volvulus.

Intussusception in adult and pediatric patients: Two different entities

Intussusception is one of the most common abdominal emergencies in pediatrics, but adult intussusception is an uncommon entity and most surgeons have only limited experience in treating this disease. The purpose of this study was to highlight the differences between pediatric and adult intussusception. The records of 40 patients during 14 years were reviewed retrospectively. The symptoms, diagnosis, sites of intussusception, associated pathologies, and treatment methods of each patient were analyzed. A total of 31 pediatric and 9 adult patients were included in the study. In the pediatric group, bloody stool and vomiting were the most common symptoms whereas adult patients commonly presented with abdominal pain. The physical examination was diagnostic in a remarkable proportion of the pediatric patients but the diagnosis was suggested based on imaging techniques in the adults, and preoperative diagnosis was more successful in the pediatric group. Intussusception was more often associated with an underlying pathology in adults and no adult patient underwent nonoperative reduction, whereas pediatric patients were managed either with hydrostatic reduction or surgery. Although intussusceptions occur at all ages, there are major differences in the clinical presentation, diagnostic approach, and management between pediatric and adult populations. Intussusception is remarkably different in these two age groups and it must be approached from a different clinical perspective.

Lipoma as a Pathological Lead Point in a Child With Ileocolic Intussusception

Lipoma as a Pathological Lead Point in a Child With Ileocolic Intussusception

Intestinal Intussusception

Intussusception is defined as the invagination of one portion of the bowel into an immediately adjacent portion. Etiology, symptoms, diagnosis, and treatment are different in the pediatric and adult populations. In the pediatric population, most cases are idiopathic and result in the common scenario of ileocolic intussusception. Factors involved in causation include anatomic features of the developing gastrointestinal tract and infectious influences. In adults, the intussusceptum is typically the result of a mucosal, intramural, or extrinsic lead point that acts as a focal area of traction pulling the proximal portion of bowel into the peristalsing distal portion. The diagnosis and management in the pediatric population is relatively standardized with nonoperative reduction via air or contrast enemas attempted first. In the adult population, intussusception presents a preoperative diagnostic challenge; although surgical intervention is mandatory, intraoperative management remains controversial.

Risk Factors for the Failure of Non-operative Reduction of Intussusceptions

Risk Factors for the Failure of Non-operative Reduction of Intussusceptions

MINIMALLY INVASIVE APPROACH IN THE MANAGEMENT OF CHILDHOOD INTUSSUSCEPTION

Intussusception is one of the most common causes of intestinal obstruction in infancy. Non-operative reduction using air enema or other hydrostatic reduction methods has been the standard treatment in most cases. However, if the non-operative method is not indicated or fails, open surgery is still necessary. With the tremendous development of the minimally invasive approach in handling surgical conditions in children in the last decade, this has been applied recently for the reduction of intussusception in children. We herein reviewed our experience of using the combined approach, namely, pneumatic reduction and, if failed, laparoscopic reduction in the management of childhood intussusception. We carried out a retrospective analysis of all children with intussusception managed at Prince of Wales Hospital between December 1998 and December 2004. The minimally invasive approach was used as far as possible. The method of reduction, success rate and the incidence of complication were analysed. Over a 6-year period, there were 146 patients with 167 episodes of intussusception. Pneumatic reduction was carried out in 160 occasions and was successful in 134 (83.8%). In 33 patients, operative reduction was required. Of these, laparoscopic reduction was attempted in 15 and was successful in 13 (86.7%). In those with either pneumatic or laparoscopic reduction, no procedure-related complication was encountered and they had a significant shorter hospital stay (median 3.0 day) than those requiring laparotomy (median 8.0 day) (t-test, P < 0.0001). The minimally invasive approach, that is, pneumatic and/or laparoscopic reduction, was successful in reducing intussusception in 88% of patients with minimal morbidity and shorter hospital stay.

Intestinal obstruction caused by intraoperative mass reduction of an incarcerated inguinal hernia—Report of a case

Now that inguinal hernia repair is a feasible and safe procedure, mass reduction of an incarcerated inguinal hernia, usually resulting from forceful taxis during non-operative manual reduction, has became a rare occurrence. We present an even rarer complication: intraoperative mass reduction of an incarcerated inguinal hernia. Following herniorrhaphy, the patient was initially well, but symptoms of intestinal obstruction appeared gradually, and he presented with intestinal obstruction 2 weeks after herniorrhaphy. Imaging studies aroused suspicion of mass reduction and surgery confirmed the diagnosis. We highlight some peculiar physical findings and remind readers of the existence of such a rare complication, which can occur following herniorrhaphy, and be masked by a short period of symptomatic relief.