Original article 219

Intussusception Complicated by Bowel Perforation During Hydrostatic Reduction ]. A. M. Reijnen J, M. Mravunac 2 , C. Festen 3 1Department of General Surgery, University Hospital S1. Radboud, 2Department of Pathology, S1. Canisius-Wilhelmina Hospital, and 3Department of Paediatric Surgery, University Hospital St. Radboud, Nijmegen, The Netherlands

Most perforations of the bowel during attempt at hydrostatic red uction of intussusception oceur in an area of localised infarction in the normal transverse or left colon. An animal model of intussuseeption was used to find indications for the cause of this phenomenon. We submitted the intussuscipiens of 10 strangulated intussusceptions in 6 dogs to a histological examination. In 6 of 10 intussusceptions we found ischaemic changes in the mueosa of the intussuscipiens. In 3 eases these lesions were multiple. Alllesions were found in loeations where there was a close contact between the intussusceptum and the intussuscipiens. We did not find signs of impaired circulation of the whole intussuscipiens. We conclude that our findings give an indication that perforation of the intussuscipiens during attempt at hydrostatic reduction occurs through areas of localised ischaemie infarction on the basis of direct pressure by the intussusceptum.

Keywords Intussusceptum - Complication - Pathology

Invagination kompliziert durch Perforation des Kolon während hydrostatischer Reposition Den meisten Darmperforationen während der hydrostatischen Reposition einer Invagination liegt ein lokal infarziertes Gebiet im Bereich des Colon transversum oder descendens zugrunde. Wir suchten anhand eines Tiermodells nach Hinweisen für die Ursache dieses Phänomens. Das Intussuscipiens von 10 strangulierten Invaginationen wurde einer histologischen Untersuchung unterworfen. In 6 Fällen wurden ischämische Veränderungen der Schleimhaut des Intussuscipiens gefunden. In 3 Fällen handelte es sich um multiple Läsionen. In allen Fällen bestand ein enger Kontakt zwischen Invaginat und Intussuscipiens an der SteIle der ischämischen Veränderungen. Zeichen einer reduzierten Durchblutung der Intussuseipienswand wurden nicht gefunden. Unsere Schlußfolgerung läßt vermuten, daß Perforationen des Intussuscipiens während hydrostatischer Repositionsversuche an Stellen lokaler ischämischer Infarzierung stattfinden, die durch direkten Druck des Invaginats verursacht werden.

Schlüsselwörter Invagination - Komplikation - Pathologie

Introduction Fortunately, perforation of the bowel during attempt at hydrostatic reduction of intussusception is uncommon. The incidence is under 1 % (7, 9). Recently in our clinic we encountered the first perforation during hydrostatic reduction in aseries of 105 attempts over aperiod of 20 years. This prompted us to review the literature on this subjeci. Among other aspects it was striking that, as in our case, most perforations described were in an area of localised haemorrhagic infarction in the apparently normal transverse or left colon (1, 2, 5, 6, 7, 9, 11). The explanations given forthis phenomenon are prolonged direct pressure on the intussuscipiens by the swollen intus-

susceptum (6, 7, 9, 10), sequential involvement of the blood supply of the distal bowel (7, 10), excessive intraluminal pressure in young infants together with the usual enema pressure (1, 6, 10), kinking of the bowel wall or mesentery (6), colitis, anomalous blood supply and shock (1). To study the effect of strangulated intussusception we adopted and modified an animal model, earlier described by Ravitch (15). In these experiments, after laparotomy of a dog, intussusception was produced instrumentally and strangulation was achieved by selective ligation of veins. We examined the specimens of 6 ileocolic and 4 ileoileal intussusceptions in 6 dogs with special interest in ischaemic changes of the intussuscipiens.

Case report Received July 28, 1989 Z Kinderchir 45 (1990) 219-221 ~ Hippokrates Verlag Stuttgart

A 17-month-old female child was transferred from another hospital for inexplicable vomiting, abdominal pain and diarrhoea that existed for i 1 days. At surgical consultation she was pale and listless but afebrile. Examination of the abdomen revealed distension,

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Intussusception complicated by bowel perforation during hydrostatic reduction.

Most perforations of the bowel during attempt at hydrostatic reduction of intussusception occur in an area of localised infarction in the normal trans...
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