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Intussusception: toward less surgery?
S H Ein1, S B Palder, D J Alton
1Division of General Surgery, Hospital for Sick Children, Toronto, Ontario.
Insights
Ileocolic intussusception can be successfully reduced using air enema, even without terminal ileum filling. This finding challenges traditional criteria for surgical intervention in pediatric cases.
Area of Science:
- Pediatric Radiology
- Gastroenterology
- Surgical Pediatrics
Background:
- Ileocolic intussusception is commonly treated with hydrostatic reduction using barium under fluoroscopic guidance.
- A historical criterion for successful reduction included adequate reflux into the distal ileum, with failure necessitating surgery.
- Spontaneous reduction occurs in approximately 10% of cases, highlighting potential for nonoperative management.
Purpose of the Study:
- To evaluate the efficacy of air enema reduction for ileocolic intussusception, particularly in cases lacking terminal ileum filling.
- To assess outcomes for pediatric patients treated with air enema reduction without meeting traditional criteria for complete reduction.
Main Methods:
- A retrospective review of 503 air contrast colon studies for suspected intussusception in children aged 2 days to 13 years (October 1985–March 1991).
- Analysis of reduction success rates and clinical outcomes, focusing on cases where terminal ileum filling was absent post-reduction.
Main Results:
- Of 241 identified intussusceptions, 196 (81%) were reduced. 45 cases proceeded to surgery.
- Three pediatric patients (4 months–2 years) experienced successful air enema reduction without terminal ileum filling and remained asymptomatic initially.
- These three patients were observed nonoperatively; two experienced recurrent pain but repeat air enemas were normal.
Conclusions:
- Air enema reduction of ileocolic intussusception can be successful even without observed terminal ileum filling.
- The absence of terminal ileum filling should not automatically mandate surgical intervention.
- Nonoperative management and observation may be appropriate in select cases of successful air enema reduction.
Abstract:
Since the 1950s, several large pediatric centers have used hydrostatic reduction with barium under fluoroscopic control as the treatment method of choice for ileocolic intussusception and have adopted rigid criteria for its management. One such rule has been that in order for an intussusception to be completely reduced, there must be adequate reflux of barium into the distal ileum. If this did not occur, it was assumed that the ileocolic intussusception had not been reduced, and the infant or child was taken straight to the operating room for laparotomy and surgical treatment. However, 10% of such intussusceptions were found to have reduced spontaneously. Needless to say, nonoperative management reduces morbidity and shortens hospitalization. From October 1985 through March 1991, 503 air contrast colon studies for suspected intussusception were performed on infants and children aged 2 days to 13 years (average, 16.8 months); 262 (52%) were normal, and 241 had an intussusception, 196 (81%) of which were reduced. The remaining 45 were operated on. In three patients (4 months to 2 years of age) the air enema reduced the intussusception from the colon without terminal ileum filling, but they all became asymptomatic immediately. For this reason they were not operated on; they were admitted and observed for 24 to 48 hours. Two of the three had recurrence of abdominal pain the next morning, but results of repeat air enemas were all normal (no intussusception observed, and normal terminal ileum filling).(ABSTRACT TRUNCATED AT 250 WORDS)