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an 5 years are much more likely to have a pathologic lead point and early surgical

intussusceptum and guide the aggressiveness

ith this diagnosis from. Patients aged greater

Journal of Pediatric Surgery 50 (2015) 647650

Contents lists available at ScienceDirect

Journal of Pedi

j ourna l homepage: www.e lsecomes so common that surgery is the best rst step? A classic pediatric with a diagnosis of ileocolic intussusception were included in the

study. The following data were extracted from electronic medical re-surgical textbook states that hydrostatic reduction should be attemptedpathological lead point. In adult patients, pathological lead points arean expected nding among patients with intussusception. The questionis: Is there an age at which the presence of a pathological lead point be-

than 12 years were excluded, because it was felt that they wouldshare the same characteristics as adult patientswith respect to this diag-nosis. Hospital charts were reviewed by three individuals. Only casesrather than a true pathological lead point.Increasing age is associated with a higher likelihood of nding a

tion. Electronic medical records of all patients wJanuary 2007 to December 2013 were reviewedmany studies, the success rate with this approach is very high withthe majority of patients avoiding the need for laparoscopy or laparoto-my to complete the reduction [13]. In the occasional patient wherethe intussusception cannot be reduced, resection is required. Theusual ndings are necrosis due to prolonged vascular compression,

1. Materials and methods

Hospital records from six regional hospitals within a singlehealthcare systemwere searched using the diagnosis code intussuscep- Corresponding author. Tel.: +1 323 783 5500.E-mail addresses: pooya.banapour@kp.org (P. Banapou

(R.M. Sydorak), donald.b.shaul@kp.org (D. Shaul).1 Tel.: +1 323 783 4857.2 Tel.: +1 323 783 4857; fax: +1 323 783 8747.

http://dx.doi.org/10.1016/j.jpedsurg.2014.09.0780022-3468/ 2015 Elsevier Inc. All rights reserved.of the reduction [1,2]. In termine how to best manage these patients.

used to determine the presence orYounger children (aged 02 years) with intussusception usually donot have a pathological lead point. In these cases, resection of the in-volved intestinal segment is not necessary, provided that the intussus-ception can be completely reduced, either radiologically or surgically.The management of intussusception in these younger children is wellestablished and begins with either hydrostatic or air reduction, some-times under ultrasound guidance. Ultrasound Doppler studies are also

absence of blood ow in the

in all patients regardless of age [4]. It was standard training in the seniorauthors institution to perform surgery on all pediatric patients with in-tussusception older than 2 years of age. Similarly, Van der Laan et al.found that all patients older than 2 years of agewith intussusception re-quired laparotomy with the majority requiring a bowel resection [5].

This study was performed to determine the characteristics of olderchildren (312 years old) with ileocolic intussusception, to determinethe incidence of pathological lead points and most importantly, to de-age group. 2015 Elsevier Inc. All rights reserved.intervention should be considered. In this study, enema reduction was safe but minimally benecial in thisdiverticula and 7 others.Conclusion: Children older thSurgical approach to intussusception in oldlead points

Pooya Banapour , Roman M. Sydorak 1, Donald ShaulKaiser Los Angeles Medical Center, Department of Surgery, 4760 Sunset Blvd., 3rd , Los Angele

a b s t r a c ta r t i c l e i n f o

Article history:Received 22 July 2014Received in revised form 2 September 2014Accepted 24 September 2014

Key words:Ileocolic intussusceptionIntussusceptionPediatricHydrostatic

Background: The likelihood oThis study looks at whetherMethods: 7 year multi-instituResults: Ileocolic intussuscep10612 years, respectively. Bbined hydrostatic and/or sup b 0.001. Enemas were saf(15 idiopathic, 14 lead pointand 5/10 aged 612 years (pr), roman.m.sydorak@kp.orgr children: Inuence of

90027

ead point as the cause of ileocolic intussusception increases as children get older.fferent management strategy should be employed in older patients.al retrospective study of intussusception in patients aged b12 years.with complete data was found in 153 patients: 109 02 years, 34 35 years, anddy stools occurred in 42/143 of 05 years and 0/10 of 612 years, p b 0.001. Com-al reduction was successful in 113/143 05 year olds vs 5/10 612 year olds,t reduced only 1 patient over age 5. Resections were required in 29 patientsead points were found in 4/109 children under 3 years, in 5/34 aged 35 years.04 vs 35 years and p b0.001 vs 05 years). Lead points consisted of 7Meckels

atric Surgery

v ie r .com/ locate / jpedsurgcords: demographics, date of birth, age at diagnosis of intussusception,symptoms at presentation (emesis, grossly bloody stool, fever), lengthof symptoms, and date of last followup. Feverwas dened as oral or rec-tal temperature greater than 100.6 F. Radiology reports were reviewedfor the following information: date of contrast enema, number of con-trast enema studies, presence of radiologic lead point, level of

intussusception at start of enema, level of intussusception at end ofenema and date(s) of repeat enema(s). Operative notes were reviewedfor the following: type of operation (laparoscopic, laparoscopic convert-ed to open, open), presence of pathological lead point, reduction of in-tussusception and resection. Pathology reports were reviewed for allndings including the location and presence of any pathology whichserved as the lead point for the intussusception. We dened pathologi-cal lead point as the nding of a pathologic abnormality in the resectedspecimen which served as the lead point for the intussusception. Thending of ischemia and/or necrosis without a co-existing lead pointwas not considered a pathological lead point. Cases involving smallbowel-small bowel intussusception (n = 10) and patients who had no

clinically, the emergency department physician may have ordered anabdominal CT scan. In other cases, where the diagnosis of intussuscep-tion was suspected, an ultrasound or a contrast enema was obtainedas the initial study. When intussusception was diagnosed by CT scan,the attending surgeon made a decision on whether to proceed with anattempt at hydrostatic reduction or proceed with surgical intervention.If this study suggested a small bowel to small bowel intussusception thepatient may have been taken to surgery without an attempt at enemareduction. In some cases, primarily early in the study period, the lackof an experienced radiologist may have prompted the surgeon to pro-ceed directly to the operating room, rather than attempt a hydrostaticreduction. This was more likely to be true in older patients. Of the 153

esis

mbe

0

648 P. Banapour et al. / Journal of Pediatric Surgery 50 (2015) 647650follow up and/or had insufcient hospital records were excluded(n = 12). Patients were grouped into the following age categories: 0,1, 2, 3, 4, 5, 612 years old before statistical analyses were performed.

The general radiological approach was to use the hydrostatic enemawith the bag 3 feet above the level of the rectum, infusingwater solublecontrast up to 3min at a time or until no further reductionwas evident.Inmost cases the colonwas drained and the infusionwas repeated up tothree additional times until no further progress was made.

Analyses of length of symptoms, presence of emesis, bloody stools,fever at diagnosis, hydrostatic enema reduction attempts, hydrostaticenema reductions, surgical reductions, surgical resections and presenceof pathological lead points were performed based on age groups. UsingGraphPadQuickCalcs Software (2014, GraphPad Software, Inc, La Jolla,CA), the statistical signicance of differences between age groups 05and 612 years was calculated. Fishers exact test was used for categor-ical data and students t test was used for continuous data. A 5% level ofsignicance was used for all cases. The study was approved by our re-gional institutional review board, approval number 10251.

2. Results

A total of 153 cases of ileocolic intussusception were identiedamong the ages of 012 years from January, 2007 to December, 2013.Of these patients, 55 were age b12 months, 37 were age 1 year, 17were age 2 years, 34 were age 35 years and 10 were age 612 years(Table 1). Examination of the data revealed a natural break betweenages 5 and 6 years, rather than an anticipated break between ages 2and 3 years. For this reason, comparisons were made between groupsaged 05 years and 612 years, respectively. Average length of symp-toms for the different age groups was 1.9, 2.1, 2.4, 2.2 and 3.3 days, re-spectively. There was a signicant difference in length of symptomsbetween children of age 612 (3.3 days) and 05 (2.1 days, p b 0.001).In children aged 05 years, 56% presented with emesis whereas only40% presented with emesis in children aged 612 years (p b 0.001).Similarly, 29% of children aged 05 years presented with bloody stoolswhereas none of the children aged 612 years presented with bloodystools (p b 0.001). Only 9% of patients aged 05 presented with feverwhereas 30% of patients aged 612 years had a fever upondiagnosis (p b 0.001).

Inmany cases, the patients initial presentationwas to the emergen-cy department. If the diagnosis of intussusception was not suspected

Table 1Patient characteristics.

Em

Age (years) N Average days of Symptoms (mean SD) Nu

0 55 1.9 1.1 451 37 2.1 1.5 242 17 2.4 1.5 1135 34 2.2 1.5 20Total 05 143 2.1 0.2 80612 10 3.3 2.2 4Total 153 2.1 1.2 18

p b 0.001 for 612 vs 05.patientswith intussusception, contrast enema reductionwas attempted168 times in 130 patients and successfully reduced the intussusceptionin 67 patients (Table 2).There were 6 patients in whom a CT scanshowed ileocolic intussusception but the intussusception was sponta-neously reduced by the time the patient underwent a contrast enemaor surgical exploration. These cases were counted as spontaneous re-ductions. There were also 10 patients in whom the CT scan showedsmall bowel to small bowel intussusception (6 reduced spontaneously,3 underwent open or laparoscopic reduction, and one patient withPeutzJeghers syndrome underwent resection of a polyp that hadserved as the lead point). These patients were excluded from the overallanalysis. The number of delayed repeated enemas ranged from 0 to 2times per patient. A total of 80 patients underwent laparoscopic oropen surgical intervention. Of the surgical cases, 51were reduced intra-operatively whereas 29 intestinal resections were performed. Changesconsistent with ischemia and necrosis were seen in 15 patients, noneof which had a pathological lead point, and all of whom were lessthan three years of age. 14 patients had a pathological lead point. Specif-ically among the patients aged 6 and above, 10 patients were diagnosedwith ileocolic intussusception. Hydrostatic reduction was attempted infour patients and was successful in one. The other 3 went to the operat-ing room, one was reduced and the other two underwent resection of apathological lead point. It was the surgeons choice to take the other 6patients directly to the operating room, without attempting hydrostaticreduction. Of these 6 patients whowent to the operating room, one hadreduced spontaneously, two were reduced surgically without discover-ing a pathological lead point and the remaining 3 had lead points re-moved. Pathological lead points were found in 9/143 (6%) ofchildren aged 5 and younger and in 5/10 (50%) of children aged612 years (p b 0.001).

The pathologic ndings in the patientswith lead points are shown inTable 3. Of the patients aged 612 years, the lead points included 2 pa-tients with Meckels diverticulum, 1 patient with a metastasis from aEwings sarcomaprimary, 1 patientwith appendicealmass and cystic -brosis and 1 patient with a hyperplastic mesenteric lymph node, whichserved as the lead point. In patients aged 35 years, 11 patients weretaken to the operating room. Lead points were present in 5 patientsand 5 patients were reduced intraoperatively. The remaining intussus-ception reduced spontaneously. Of the 8 patients aged 2 years whowere taken to the operating room, one had a pathologic lead point. All3 of the resected specimens had pathologic ndings consistent with

Bloody stools Fever

r Percent Number Percent Number Percent

82 29 53 6 1165 12 32 6 1665 1 6 1 659 6 18 7 2156 42 29 13 940 0 0 3 30

90 33

was not helpful, or even harmful. This question has not been specicallyaddressed in other reports in the literature. This is a hard question to an-swer given the relatively low prevalence of intussusception within this

Table 2Therapeutic intervention.

Hydrostatic Enema Operations

Age (years) N Number of patients (%) Number reduced (%) Number of patients (%) Number reduced (%) Resected (%) Lead Point (% of N)

0 55 45 (82) 17 (38) 39 (71) 25 (64) 14 (36) 1 (1.8)1 37 34 (92) 20 (59) 13 (35) 11 (85) 2 (15) 2 (5.4)2 17 15 (88) 10 (67) 8 (47) 5 (63) 3 (38) 1 (5.9)35 34 32 (94) 19 (59) 11 (32) 6 (55) 5 (45) 5 (14.7)Total 05 143 126 (88) 66 (52) 71 (50) 47 (69) 24 (34) 9 (6.3)612 10 4 (40) 1 (25) 9 (90) 4 (44) 5 (56) 5 (50)Total 153 130 (85) 67 (52) 80 (52) 51 (51) 29 (36) 14 (18)

p b 0.001 for 612 vs 05.

649P. Banapour et al. / Journal of Pediatric Surgery 50 (2015) 647650ischemia and necrosis while the remaining 5 intussusceptions were re-duced intraoperatively. There were 2 lead points seen in the 14 patientsaged 1 yearwhowere taken to the operating room and 12 patients whohad their intussusception reduced intraoperatively. Although therewere a total of 39 patients aged 012monthswhowere taken to the op-erating room, only 1 patient had a pathologic lead point (Meckels diver-ticulum). In total the pathologist identied 4 patients with follicularhyperplasia or lymphoid hyperplasia large enough to serve as the leadpoint for the intussusception. There may not be substantial differencesbetween this diagnosis and an enlarged Peyers patch, which is felt torepresent a potential lead point in younger children with intussuscep-tion. However, the focus population in this study is the 612 year oldage group, and lymphoid hyperplasia was only diagnosed in one ofthese patients.

The prevalence of pathological lead points in various age groups isshown in Fig. 1. The overall prevalence of lead points in the differentage groups 0, 1, 2, 35 and 612 was 1.8%, 5.4%, 5.9%, 14.7% and 50%, re-spectively. To determine if any clinical parameters (other than age)could predict the presence of a pathological lead point, additional anal-yses were performed. For example, emesis was present in 50% of pa-tients with a pathological lead point and in 70% of patients without apathological lead point. Similarly, bloody stools were present in only21% of patients with a pathological lead point and in 33% of patientswithout a pathological lead point, all non-signicant. Total follow-upfor this study ranged from 1 to 199 months with a mean of 78 months.months. Patient charts were reviewed to determine the length of followup while looking for recurrent intussusception. If present, this wouldhave suggested that intussusception caused by a pathological leadpoint may have been reduced. In this specic patient population(reduced intussusception), follow-up ranged from 1 to 130 months,mean 74 months. Within this time frame, 9 patients were encounteredwho came back with a recurrent intussusception, however, none werefound to have a surgically proven pathological lead point.

3. Discussion

The objective of this study was to determine if there is an age atwhich attempted hydrostatic reduction of an ileocolic intussusceptionTable 3Pathologic ndings in patients with lead points.

Age (years) Patients w/leadpoints

Meckelsdiverticulum

LymphoidHyperplasia+

Other

0 1 1 0 01 2 1 1 02 1 0 1 035 5 3 1 1612 5 2 1 2Total 14 7 4 3

+ includes patients with follicular hyperplasia. Pathologic ndings included raised vascular lesion (35 age group), 2 cm small

bowel metastasis from primary Ewings sarcoma and inspissated appendiceal mass(612 age group).older age group. This study utilizes a patient database with access toover 4 million patients within a single healthcare system spread outover a seven year interval. Some of the providers were adult radiologistsand adult general surgeons, especially for the older patients. Other pro-viders were pediatric radiologists and pediatric surgeons. As such, thesuccess rate for hydrostatic reduction was lower than is generally quot-ed in the pediatric radiology literature. This fact no doubt inuenced asurgeons decision to either attempt a hydrostatic reduction or proceeddirectly to surgery. It is retrospective and there was no specic protocolutilized by the various facilities. In view of these important limitations,no rm conclusions can be reached about whether contrast enemasshould be obtained in older patients. Hydrostatic reduction was onlyattempted in four patients aged 612 years. One of these was success-fully reduced. Five of the ten patients in this age group were unable tohave their intussusceptions surgically reduced and underwent surgicalresection of a pathological lead point. If hydrostatic reduction hadbeen attempted in all 10 patients, it is unlikely that these 5 patientswould have been reduced, giving at most a 50% success rate. Therefore,only a 50% success rate should be expected, due to the higher incidenceof pathological lead points in this age group. This study does suggestthat attempted hydrostatic reduction appears safe in older patients, asno perforations were observed. It also showed that a pathological leadpoint is unlikely to be reduced using standard surgical or radiologicaltechniques. Based upon these data it is recommended that a therapeuticenema reduction be attempted in all patients with suspected or provenintussusception aged 5 years and below, who do not have a contraindi-cation to the enema. This study can not say that hydrostatic reductionshould not be performed in older patients, only that it is less likely tobe successful in this older age group. The decision to attempt a contrastenemamust bemade by the surgeon based upon the patients presenta-tion and the skill level of their radiology department.

6010

0

20

30

40

50

0 yr 1 yr 2 yrs 3 yrs 4 yrs 5 yrs 6-12 yrs

number of patients without lead point

number of patients with lead point

Fig. 1. Pathologic lead points by age group.

What this study does clearly show is that pathological lead points aremore likely at increasing ages, with a cutoff noted at age 6 years andabove. It was also unable to identify any clinical parameters (otherthan age) that indicated the high likelihood that a pathologic leadpoint is present. The exact reason why older patients (612 years) hadless emesis and bloody stools than their younger counterparts is notclear. They did tend to present later than the younger patients. Perhapsthis is because many parents are more anxious about younger childrenand infantswho are not able to talk and bring them to the doctor sooner.The higher incidence of fever in the older children may be due to thehigher likelihood of compromised intestine and/or a later presentation.

The overall incidence of pathological lead points in children with in-tussusception has been reported to be 1.5%12% [6]. In this study, path-ological lead points were found to be more prevalent in older patients.Pathological lead points occurred in 50% of patients aged 612 years,but in only 4% of 02 year olds and in 15% of 35 year olds. Other studiesof intussusception had similar results. In a study of 1340 children aged3 months to 12 years with recurrent intussusceptions, 3 of 7 patientswith pathological lead points were aged greater than 6 years and 1 pa-tient was 4 years old [7]. Saxena and colleagues found 2 pathologicallead points in a study of over 100 children with intussusception agedup to 16 years; both lead points were in children greater than 6 yearsold [8]. Many other studies have shown an increased frequency of path-ological lead points in children greater than 6 years old [911]. A radio-logic study of patients aged 014 years with intussusception found anequal distribution of radiological lead points among age groups [12].However, these were lead points seen on imaging, not proven at sur-gery. In this study, every child with a pathological lead point eventuallyunderwent resection of the pathological lead point due to failed reduc-

Early in the study period, patients with a possible diagnosis of intus-susception were evaluated in a variety of ways, and sometimes withoutthe involvement of a pediatric surgeonuntil after the diagnosiswasmade.In many cases, CT scans were done, in spite of the potential radiation ex-posure. Beginning in 2012 a regional protocolwas established to expeditethe evaluation and treatment of childrenwith suspected intussusception.It begins with a plain abdominal X-ray and an abdominal ultrasound, asthis has been shown to be highly sensitive in diagnosing intussusception[12]. It discourages the use of CT scans. Once imaging suggesting that anintussusception is found the patients are transferred to facilities withon-site pediatric surgeons and radiologists for denitive management.

References

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[2] Gonzlez-Spinola J, Pozo GD, Tejedor D, et al. Intussusception: the accuracy ofultrasound-guided saline enema and the usefulness of a delayed attempt at reduc-tion. J Pediatr Surg 1999;34:101620.

[3] Lee JH, Choi SH, Jeong YK, et al. Intermittent sonographic guidance in air enemas forreduction of childhood intussusception. J Ultrasound Med 2006;25:112530.

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[6] Blakelock RT, Beasley SW. The clinical implications of non-idiopathic intussuscep-tion. Pediatr Surg Int 1998;14:1637.

[7] Niramis R, Watanatittan S, Kruatrachue A, et al. Management of recurrent intussus-ception: nonoperative or operative reduction? J Pediatr Surg 2010;11:217580.

[8] Saxena AK, Hollwarth ME. Factors inuencing management and comparison of out-comes in pediatric intussusceptions. Acta Paediatr 2007;96:1199202.

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650 P. Banapour et al. / Journal of Pediatric Surgery 50 (2015) 647650have their intussusception reduced. However, in this study, no patientwhose intussusception was initially reduced was subsequently foundto have a pathological lead point. One of the strengths of this study isthe long-term follow-up of patients who remain within our system. Itis unlikely that a lead point was missed given this length of follow up.[10] Eklof DA, Johanson L, Lohr G. Childhood intussusception: hydrostatic reducibilityand incidence of leading points in different age groups. Pediatr Radiol 1980;10:836.

[11] Schuh S, Wesson DE. Intussusception in children 2 years of age or older. Can MedAssoc J 1987;136:26972.

[12] Navarro O, Dugougeat F, Kornecki A, et al. The impact of imaging in themanagementof intussusception owing to pathologic lead points in children: a review of 43 cases.Pediatr Radiol 2000;30:594603.tion. It is possible for a patient with a minor pathological lead point to

Surgical approach to intussusception in older children: Influence of lead points1. Materials and methods2. Results3. DiscussionReferences