EL-MINIA MED. BULL. VOL. 20, NO. 1, JAN., 2009
Eissa & Moustafa
THE ROLE OF SURGERY AND AIR REDUCTION IN THE TREATMENT
OF INTUSSUSCEPTION IN YAMEN
By
Omar Eissa* and **Mostafa M Mostafa
Departments of *General Surgery, El-Minia Faculty of Medicine
and **Radiology, Assuit Faculty of Medicine
ABSTRACT:
Intussusception is the most common cause of bowel obstruction in children
under two years of age. The proximal part of the bowel and its mesentery (the
intussusceptum) enter within that part immediately beneath it (the intussuscipiens).
Being pulled by peristalsis the mesenterial vessels get compressed which result in
ishaemia of the bowel wall. Most intussusceptions are ileocolic. The diagnosis can be
confirmed by a contrast enema or ultrasound. Therapeutic reduction can be attempted
by a contrast enema (following diagnostic procedure) or by air, both under
fluoroscopic monitoring, or by normal saline under sonographic guidance. When
presentation is delayed, intussus-ceptions may be difficult to reduce using standard
enema regimens. Our endeavour to minimize the need for surgery in an environment
where failed reductions are common has led to the development of an aggressive,
non-operative method of reducing intussusceptions. Thirty patients with
intussusceptions were reviewed with the aim of evaluating a new method of reducing
intussusceptions suited to our Third World environment. Delayed presentation was
common, with 32% of patients presenting more than 48h after the onset of the
intussusception. On clinical grounds alone, 41% of patients required a primary
laparotomy. Standard barium and air reductions for intussusceptions were rarely
successful under these conditions i.e.13% and 22%, respectively. By using an air
enema under general anaesthesia in the operating theatre, the reduction rate has
improved to 53%. Air enema under anesthesia is suggested as a last attempt at
reducing an intussusception prior to laparotomy following failed standard enema
reduction, and as the first line of management in the attempted reduction in the patient
with delayed presentation without symptoms of peritonitis.
KEYWORDS:
Intussusception
Air reductions
INTRODUCTION:
Nonsurgical reduction has
paved the way for successful management of childhood intussusception. The
success rates have varied between 63%
and 95%1-24. Although the techniques
of nonsurgical reduction differed in
many earlier reports depending on the
instit-utional site, recently, the
reduction tech-nique most commonly
used seems to be an air enema performed under fluoro-scopic guidance
because the air is quick, less messy,
Delayed presentation
Surgical intervention
General anaesthesia
and safer than a liquid enema in bowel
perforation1-3. To the best of our
knowledge, there are only a few
published reports dealing with the use
of sonographic guidance in air enemas
for nonsurgical reduction of childhood
intussusceptions4.
The concerns of missing bowel
pathology, reduction of gangrenous
bowel with consequent shock, perforation of bowel and causing peritonitis
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EL-MINIA MED. BULL. VOL. 20, NO. 1, JAN., 2009
Eissa & Moustafa
have been adequately addressed by
adopting criteria for case selection and
delineation of pressures of 80-130 mm
Hg as effective and safe for reduction
of intussusceptions25,26. It has been
reported that successful hydrostatic
reduction may be less likely in patients
with symptoms for more than 48 hours,
and consequently patients with
prolonged symptoms are nowadays
likely to under-go operative reduction
as the first line treatment27-29.
advanced disease, an awareness of the
complications of Laparotomy32, and a
lack of paediatric radiologists, have
provided the impetus for an aggressive
non-operative managment protocol.
In a Third World environment,
where
delayed
presentation
of
intussusceptions is common and enema
reduce-tions are rarely successful,
operative
reductions
frequently
become the only option30,31. Local
circumstances, such as frequently seen
There were no exclusion
criteria for this study. On admission,
the diagn-osis of intussusception was
made on clinical and radiological
grounds figure (1) and was followed by
an aggressive period of resuscitation.
MATERIALS AND METHODS:
All 30 patients treated for
intussusception during a 2-year period
(Jane 2007 to Jane 2009) at the
Department of Surgery, Suady German
hospital and Yamen International
hosoital in Yamen.
Figure 1. Ileocolic intussusception in a 2-year-old boy for which air enemas
failed. A, Transverse sonogram of the right upper abdomen shows intramural
gas (black arrowheads) peripherally located within the markedly swollen
returning limb of the intussusceptum (arrows).
When optimally resuscitated,
usually within 1–2 h, the patient was
transferred for either a reduction
attempt or a laparotomy.
The new method of reduction
required the patient to be transferred to
the operating theatre; a general anaesthetic was administered, followed by
the set-up for an air reduction. This
involved inserting a large Foley
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EL-MINIA MED. BULL. VOL. 20, NO. 1, JAN., 2009
catheter (30 FG) into the rectum and
partially inflating the balloon. The
catheter was joined via a Y-connection
to an inflation bulb and a pressure
monitor. Using the inflation bulb, a
steady pressure of air, not exceeding
120 mmHg for 3 min at a time, was
passed into the colon. The movement
of air was visualised using on-table
imaging, and an attempt at reducing
the intussusception was made.
When the procedure failed to
reduce the intussusceptions after three
attempts, or when a complication
occurred (e.g. a bowel perforation), the
child’s abdomen was prepared, draped,
and an immediate laparotomy was
done.
Intraoperative Details
The abdomen and bowel are
typically explored through a right
lower quadrant transverse incision,
although some advocate a right
transverse supraumbilical or even an
upper
midline
incision.
After
inspection for signs of perforation, the
intussusception is identified and
delivered into the wound. First, an
attempt is made at manual reduction by
retrograde milking of the intussusceptum. Although gentle pulling may
aid in reduction, avoid vigorous pulling
apart of the intussuscepted segment of
bowel.
Gentle finger pressure is necessary for reduction of intussusception.
This subjective "gentleness" is dependant on experience of the surgeon and
varies from person to person. Focal
pressure on the intussuscipient and
apex of the intussusceptum by the
finger during reduction may be more
damaging than the diffusely transmitted hydrostatic pressure even by a
less-experienced surgeon. This will
avoid the needless resection and
Eissa & Moustafa
anastomosis of the intestine on many
occasions33.
If manual reduction is unsuccessful, if a mass or pathologic lead point
is present, or if perforation has
occurred, segmental bowel resection is
necessary. After resection, a primary
anastomosis may be performed. Often
after succe-ssful manual reduction, the
involved segment of bowel appears
edematous, hyperemic, or ischemic.
These findings do not necessarily mandate resection. An incidental appendectomy is often performed, particularly if a right lower quadrant incision
was made for access to the abdomen,
as it may be presumed that the patient
has had an appendectomy.
Postoperative Details
IV fluid resuscitation is continued and calculated, taking into
consideration maintenance requirements and third-space losses. Upon
resolution of ileus, diet is advanced at
the discretion of the surgeon.
RESULTS:
Of the 30 patients diagnosed with
an intussusception, 16(53.3%) presented within the first 48 h of developing
features of this condition, and 10
(33.3%) presented later than 48 h
(range 3–7 days). The remaining 4
(13.4%) patients were admitted with no
indication of the duration of the
intussusception, as shown in Table 1.
Clinically, there was a palpable
abdominal mass in 18 (60%) patients,
of whom 8 (44.4%) had a left-sided or
rectal mass. Fifteen (50%) patients
were noted to have per-rectal bleeding.
There was no correlation between leftsided masses and duration of the
disease process.
The classical type of ileo-colic
intussusception was present in 24
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EL-MINIA MED. BULL. VOL. 20, NO. 1, JAN., 2009
Eissa & Moustafa
(80%) patients, colo-colic intussusceptions was seen in 3(10%), and the
remaining 3 (10%) patients had small
bowel intussusception. An associated
midgut malrotation was found in 6
patients with ileocolic intussusceptions
and in one patient who had a small
bowel intussus-ception.
important primary treatment method,
and many studies have reported it to be
a widely available and highly
successful technique with a low
incidence of complications34-61. Initial
diagnosis may be carried out by
contrast
enemas
controlled
by
fluoroscopy or by ultra-sonography62-64
The patients’ abdominal presenting features determined their
management. 12(40%) patients had a
surgically acute abdomen at presentation, and no attempts were made to
reduce their intussusceptions.One of
these patients died during the resuscitation period.
Although the intussusceptions
seen in children of the Third World are
similar to those in children in developed countries, there are some
important differences: the frequent
delays in presentation of patients30,32,
the high incidence of colocolic
intussusce-ptions66, and the frequently
noted association between intussusception and midgut malrotation, called
Waugh’s syndrome67. The reasons for
these differences and their primary
causes are unknown, but they do make
the diag-nosis and simple reduction of
intussus-ception more difficult.
The remaining 11 (36.6%)
patients went for laparotomy, at which
9 (75%) patients were found to have
ischaemic bowel requiring resection.
The 18 (60%) patients with no
features of an acute abdomen at admission were all managed with an attempted enema reduction.
Patients with intussusception
and a nonacute abdomen had an
attempted reduction in the operating
theatre once they were optimally
resuscitated and anaesthetised. This
resulted in 10 (55.5%) successful and 8
(44.5%) failed reductions. The latter 8
patients were further managed with
laparotomy, at which 4 (22.25%)
patients had bowel necrosis and one
(5.5%) patients were found to have
bowel perforations.
Three (10%) of the 30 patients
died. The deaths were among the acute
surgical group of patients and occurred
either during resuscitation or subsequently from overwhelming sepsis.
DISCUSSION:
Nonsurgical
reduction
for
pediatric intussusception has been an
Regarding the delayed presentations in our study of 30 patients, at
least 33% presented more than 48 h
after the onset of the intussusception.
The effects of this delay were manifest
in the progression of the condition and
the development of complications. In
all, 10% of patients died. A further
40% of patients had a distended,
peritonitic abdomen warranting a
laparotomy, a decision that proved to
be justified because 75% of this acute
group required a bowel resection.
In the 18 patients meaningful
improvement was seen with the introduction of air enema reductions in
theoperating theatre under a general
anaes-thetic, achieving a success rate
of 55.5%.
Failed reduction of intussusceptions is seen in developed and
underdeveloped nations alike65,68, but
is a common feature and of particular
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EL-MINIA MED. BULL. VOL. 20, NO. 1, JAN., 2009
concern in our Third World environment. In such patients we perceive
distinct advantages to attempting a
reduction in the operating theatre on an
anaesthetised child who is fully
resuscitated. The child is totally
relaxed and pain-free during the
procedure, which thereby abolishes the
unhelpful effects of a straining
abdomen. This allows the intraluminal
forces of the air in the bowel, at
pressures not exceeding 120 mmHg for
more than 3 min at a time, to act
unopposed, giving this method a
greater chance of success.
ception in children under fluoroscopic
guidance. The results of reduction with
the device were equal to those by
saline enema reduction under ultrasound guidance69.
It was of note that the patient
profile for age, as well as site and
duration of the intussusception, was the
same for both the successful and failed
groups of the 18 patients in whom a
reduction was attempted under
anaesthesia.
Bowel perforations are a major
concern when attempting to reduce an
intussusception. In two patients there
was leakage of gas into the peritoneal
cavity following perforation during
failed air reduction.
Reju and Syam have developed
a portable device for insufflation of air
reliably at pressures accepted as safe
for effective reduction of intussus-
The findings at laparotomy for
the 8 failed reductions showed the
presence of bowel pathology in 5
(62.5% of this group) patients as a
possible cause. This finding is of
particular significance, as the clinical
features of compromised bowel were
not present in these patients prior to the
attempted reduction.
It has been previously noted
that although air reductions are more
likely to perforate, air is safer than
barium in the peritoneal cavity70.
Table (1): Management versus duration (GA general anaesthetic)
Duration Patients Primary
surgery
<48hrs
16
5
>48hrs
10
6
unknown
4
1
Total
30
12
Attempted
Reduction air with GA
11
4
3
18
Conclusion:
In a population group in which
33.3% of patients have a delayed
presentation and in which a high
incidence of ‘‘hidden’’ bowel ischaemia exists, we have improved the
success rate of non-operative reduction
of intussusceptions.
This method is suggested as a
last attempt at reducing intussusceptions prior to laparotomy and
Failed
Succeful
reduction reduction
5
6
2
2
1
2
8
10
should be used in all patients following
a failed standard enema reduction. It
should also be used as the first line of
management in the attempted reduction
in the patient with delayed presentation
without symptoms of an acute
abdomen.
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EL-MINIA MED. BULL. VOL. 20, NO. 1, JAN., 2009
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Eissa & Moustafa
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Roentgenol 1993; 160:363–366.
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Beasley SW. Intussusception: a repeat
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nonoperative reduction rate. J Pediatr
Surg 1994; 29:588–589.
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Chae A. Intussusception: the use of
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intussusceptions due to pathologic lead
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Roentgenol 2004; 182: 1169–1176.
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and enema reduction. Radiographics
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Paik TW, Choi SO. Childhood
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hydrostatic reduction. Radiology 1992;
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511.
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Hydrostatic
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Intussusception in infants and children:
diagnosis and therapy. Radiology
1988; 168:141–143
35. Gu L, Alton DJ, Daneman A,
et al. Intussusception reduction in
children by rectal insufflation of air.
AJR Am J Roentgenol 1988;
150:1345–1348.
36. Stein M, Alton DJ, Daneman
A. Pneumatic reduction of intussusception: 5-year experience. Radiology
1992; 183: 681–684.
37. Yoon CH, Kim HJ, Goo HW.
Intussusception in children: US-guided
pneumatic
reduction—initial
experience. Radiology 2001; 218:85–
88.
38. Guo JZ, Ma XY, Zhou QH.
Results of air pressure enema reduction
of intussusception: 6,396 cases in 13
years. J Pediatr Surg 1986; 21:1201–
1203.
39. Shiels WE II, Maves CK,
Hedlung GL, Kirks DR. Air enema for
diagnosis and reduction of intussusception: clinical experience and
pressure
correlates.Radiology
1991;181:169–172.
40. Tamanaha K, Wimbish K,
Talwalkar YB, Ashimine K. Air reduction of intussusception in infants and
children. J Pediatr 1987; 111:733–736.
41. Zheng JY, Frush DP, Gui JZ.
Review of pneumatic reduction of
intussusception: evolution not revolution. J Pediatr Surg 1994; 29:93–97.
___________________________________________________________________________________
317
EL-MINIA MED. BULL. VOL. 20, NO. 1, JAN., 2009
42. de Campo JF, Phelan E. Gas
reduction of intussusception. Pediatr
Radiol 1989; 19:297–298.
43.
Kirks
DR.
Air
intussusception reduction: "the winds
of change." Pediatr Radiol 1995;
25:89–91.
44. Glover JM, Beasley SW,
Phelan
E.
Intussusception:
effectiveness of gas enema. Pediatr
Surg Int 1991; 6:195–197.
45. Katz M, Phelan E, Carlin JB,
Beasley SW. Gas enema for the
reduction
of
intussusception:
relationship between clinical signs and
symptoms and outcome. AJR Am J
Roentgenol 1993; 160:363–366.
46. Saxton V, Katz M, Phelan
W, Beasley SW. Intussusception: a
repeat delayed gas enema increases the
nonoperative reduction rate. J Pediatr
Surg 1994; 29:588–589.
47. Navarro OM, Daneman A,
Chae A. Intussusception: the use of
delayed, repeated reduction attempts
and
the
management
of
intussusceptions due to pathologic lead
points in pediatric patients. AJR Am J
Roentgenol 2004; 182: 1169–1176.
48. del-Pozo G, Albillos JC,
Tejedor D, et al. Intussusception in
children: current concepts in diagnosis
and enema reduction. Radiographics
1999; 19:299–319.
49. Woo SK, Kim JS, Suh SJ,
Paik TW, Choi SO. Childhood
intussus-ception:
US-guided
hydrostatic reduction. Radiology 1992;
182:77–80.
50. Riebel TW, Nasir R, Weber
K. US-guided hydrostatic reduction of
intussusception in children. Radiology
1993; 188: 513–516.
51. Meyer JS, Dangman BC,
Buonomo C, Berlin JA. Air and liquid
contrast agents in the management of
intussusception: a controlled, randomized trial. Radiology 1993; 188:507–
511.
Eissa & Moustafa
52. Grasso SN, Katz ME,
Presberg
HJ,
Croitoru
DP.
Transabdominal manually assisted
reduction of pediatric intussusception:
reappraisal of this historical technique.
Radiology 1994; 191:777–779.
53. Choi SO, Park WH, Woo
SK. Ultrasound-guided water enema:
an alternative method of nonoperative
treatment
for
childhood
intussusception. J Pediatr Surg 1994;
29: 498–500.
54. Rohrschneider WK, Tröger J.
Hydrostatic
reduction
of
intussusception under US guidance.
Pediatr Radiol 1995; 25: 530–534.
55. Peh WCG, Khong PL, Chan
KL, et al. Sonographically guided
hydrostatic reduction of childhood
intussusception using Hartmann’s
solution. AJR Am J Roentgenol 1996;
167:1237–1241.
56. Koumanidou C, Vakaki M,
Pitsoulakis G, Kakavakis K, Mirilas P.
Sonographic detection of lymph nodes
in the intussusception of infants and
young children: clinical evaluation and
hydro-static reduction. AJR Am J
Roentgenol 2002; 178:445–450.
57. Wang GD, Liu SJ. Enema
reduction of intussusception by hydrostatic pressure under ultrasound guidance: a report of 377 cases. J Pediatr
Surg 1988; 23:814–818.
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‫‪Eissa & Moustafa‬‬
‫‪EL-MINIA MED. BULL. VOL. 20, NO. 1, JAN., 2009‬‬
‫عالج االنسداد المعوى عند االطفال الناتج من تداخل االمعاء جراحيا‬
‫او بحقن الهواء تحت مخدر عام‬
‫عمر عيسى ‪ -‬مصطفى محمد مصطفى‬
‫أقسام *الجراحة العامة ‪.‬كلية طب المنيا‬
‫و**االشعة ‪.‬كلية طب اسيوط‬
‫*اجرى البث فى اليمن فىى مستشىىى الىيمن الىى لى مستشىىى السىد ىى املمى فى فىى الىتىر مىن‬
‫ي في ‪ 2007‬الى ي لي ‪2009‬‬
‫*شىىما الب ىىث ‪ 30‬طىىىا تتىىرا م اهم ى رشه مىىن شى ر الىىى ىىخث سىىف اش تىىه تش ي ى ه ب مشىىد‬
‫الكشف امكليفيكى ب بت ه ب فسىاى مد ى ف تج هن تىا ا اممد ء بدض ببدض‬
‫*أ ضىىر ش ى مء امطى ى ا بدض ى ه بدىىى‪ 48‬س ى ه مىىن ىىى ث المىىرض ك ف اهشىىر اطى ى ا تىىه‬
‫اسد ف ه يث ى ا مف ه ‪ 6‬الى الجرا مب شر بدى الت ضير الجيىى اجريىش الم لى بضى ط‬
‫ال اء ت ش الم ىر الد ه فجح فى شذ الم ل لتين ال لتين ام ريين اجريىش ل مى همليى‬
‫جرا ي‬
‫*ام من أ ضىر للطى ارىء لبىا ‪ 48‬سى ه فكى ن هىىىشه ‪ 16‬مريضى أجىرى ا‪ 5‬مىف ه همليى ش‬
‫جرا ي ه جل لمف بم ل ض ط ال اء ت ش م ىر ه ه ا‪ 11‬مريض فج ىش الم لى فىى‬
‫‪ 6‬مش لجأف للجرا فى اا‪ 5‬مش ام رى‬
‫*مجم ع مش الب ث ‪ 30‬اجريش م ل فى اممدى ء هىن طريىط ضى ط ال ى اء ت ىش م ىىر‬
‫ه ه ا‪ 18‬فج ش الم ل فى ‪ 10‬اجريش الجرا ا‪ 8‬مىف ه بىذل يكى ن هىىالمرضىى التىى‬
‫اجريىىش ل ىىه هملي ى ش جرا ي ى ‪ 20‬ت ى فى مىىف ه ‪ 3‬مرضىىى ا ىىىشه لبىىا الجرا ى ام ىىرين بدىىى‬
‫الدملي فتيج التل ث الشىيى لبا بدى الدملي‬
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