Pediatr Surg Int DOI 10.1007/s00383-015-3726-8
ORIGINAL ARTICLE
Intussusception patients older than 1 year tend to have early recurrence after pneumatic enema reduction Zhe Wang1 • Qiu-ming He1,2 • Hong Zhang3 • Wei Zhong1 • Wei-qiang Xiao1 Lian-wei Lu1 • Jia-kang Yu1 • Hui-min Xia1,2
•
Accepted: 23 June 2015 Ó Springer-Verlag Berlin Heidelberg 2015
Abstract Purpose To identify age risk factors of early recurrent intussusception after pneumatic enema reduction. Management opinions are proposed. Methods Two thousand two hundred and ninety-five intussusception patients’ medical records from January 2009 to December 2011 were retrospectively reviewed and analyzed. Results Of the 2295 patients, the intussusception of 1917 of them was initially reduced by pneumatic enema, with 127 cases recurring within 72 h. The early recurrence rate is 6.62 %. The early recurrence rate of patients younger than 1 year old is 2.1 % (22/1032), while the rate for those older than 1 year is 11.9 % (105/885). The difference is significant (P = 0.0001). There were no significant differences between age groups older than 1 year. One hundred and seventeen cases of recurrence happened within 48 h, which accounted for 92.1 % of all early recurrence. Recurrence patients were treated again with pneumatic enema, with a successful reduction in 93.7 %. They were Q. He is co-first author.
followed up for 2–4 years; the long-term recurrent rate was 11.8 % (14/119). No patient had poor prognosis because of delayed treatment. Conclusion Intussusception patients older than 1 year tend to have greater early recurrence rate after pneumatic enema reduction; 92.1 % of the early recurrent cases happened in 48 h. There is no need to hospitalize patients after pneumatic enema reduction. A repeat pneumatic enema is a good choice before surgical approach. Keywords Early recurrence Intussusception Children Pneumatic enema
Introduction Acute intussusception is one of the most important pediatric surgery emergency conditions of infants and young children. The majority of the cases were found idiopathic, the incidents of intussusception presenting a pathologic lead point accounts for 6 % of the cases [1]. Ultrasonography has been widely adopted to screen and diagnose
& Jia-kang Yu [email protected]
Wei-qiang Xiao [email protected]
& Hui-min Xia [email protected]
Lian-wei Lu [email protected]
Zhe Wang [email protected]
1
Guangzhou Women and Children’s Medical Center, Guangzhou, People’s Republic of China
Qiu-ming He [email protected]
2
Southern Medical University, No. 9 Jinsui Road, Tianhe District, Guangzhou 510623, Guangdong, People’s Republic of China
3
Guangzhou Medical University, Guangzhou, People’s Republic of China
Hong Zhang [email protected] Wei Zhong [email protected]
123
Pediatr Surg Int
intussusception. Most of the time, idiopathic intussusception can be easily managed nonoperatively by hydrostatic or pneumatic enema, only a small portion needs surgical management eventually. Fluoroscopy-guided pneumatic enema became popular rapidly after it was first introduced. The rate of successful reduction of pneumatic enema was reported around 80–92 % [2]. Intussusception is more likely to recur after nonoperational reduction [3]. Overall recurrence rates after pneumatic enema was around 7.9–8.5 % as previously reported [2, 4, 5], among them, approximately one-third were early recurrences within 72 h after the reduction [5]. Previous studies have failed to identify consistent risk factors for intussusception recurrence and the characteristic of early recurrence are rarely reported. This retrospective study was designed to inspect the important age characteristic of early recurrent intussusception and provide information to guide clinical practice.
Methods Medical records of 2295 intussusception patients treated by the pediatric surgery department of the Guangzhou Women and Children’s Medical Center from January 2009 to December 2011 were collected with the approval of the institution’s Research Ethics Board. Clinical data were retrospectively analyzed. Patients were followed up for 2–4 years. When patients presented suspicious symptoms and signs, either an ultrasonography or a low-pressure diagnostic fluoroscopy-guided pneumatic enema was performed. When the diagnosis of intussusception was confirmed, initial pneumatic enema reduction was attempted in most of the situations. Pneumatic enema was performed with continuous manometric monitoring. Pressure was accumulated to 120 mmHg in young children and 140 mmHg in select older patients in order to achieve reduction. Vital signs were closely monitored during the procedure. The criteria for successful reduction were lead point disappearance and air perfusion into the ileum [6]. If reduction failed or unstable vital signs were observed, enema was discontinued and surgical management was proposed. If intussusception recurrence was confirmed, pneumatic enema would be performed again whenever possible. The patients for whom pneumatic reduction was successful were routinely treated as outpatients in the emergency room. These patients were fasted for 3–6 h, electrolytes and smooth muscle relaxants were given orally or intravenously depending on the patients’ situation. If severe dehydration and/or septic shock was observed or complications were suspected after the enema reduction, patients were admitted in the inpatient department for further treatment. Before the patients and parents
123
were sent home, they were educated about the important information of recurrence intussusception. Patients with recurrence were documented during the follow-up. The number of patients who had early recurrence in 24, 24–48 and 48–72 h were compared with total recurrent population. The early recurrence rate was compared between different age groups. The data were abstracted by the first and second author separately in order to ensure the accuracy. Results were analyzed with Fisher’s exact test.
Results There were 2295 patients who were diagnosed and treated from January 2009 to December 2011. One thousand nine hundred and seventeen cases were initially reduced by pneumatic enema. During the follow-up, 127 patients were found to have a recurrence within 72 h after reduction. The overall early recurrence rate was 6.62 % (127/1917) (Table 1). In the patients younger than 1 year, the recurrence rate was 2.1 % (22/1032), in those older than 1 year the rate was 11.9 % (105/885), the difference between the two age groups was statistically significant (P = 0.0001) (Table 2). There were no significant differences between age groups older than 1 year. There were 80 episodes of recurrence within 24 h (63.0 %, 80/127), 37 episodes were found between 24 and 48 h (29.1 %, 37/127), and the remaining 7.9 % (10/127) of recurrences occurred within 48–72 h. All the 127 recurrence patients were treated again with pneumatic enema and 119 of them were again successfully reduced. Pneumatic enema reduction failed in Table 1 Age groups associated with early-recurrent Age
Early-recurrent Yes
(%) No
0–1
22
1010
2.1
1–2
45
409
9.9
2–3
37
208
15.1
3–4 4–5
8 7
85 36
8.6 16.3
8
42
16.0
127
1790
6.6
[5 Total
Table 2 Age groups associated with early-recurrent Age (year)
Early-recurrent Yes
(%)
P value
No
B1
22
1010
2.1
[1
105
780
11.9
0.0001
Pediatr Surg Int Fig. 1 A flow chart showing the management of earlyrecurrent intussusceptions
Intussusception 2009-2011 (n=2295)
Successful pneumatic reduction (n=1917)
Early-recurrent (n=127)
Successful pneumatic reduction (n=119)
Follow-up 2-4 years Multiple-recurrence (n=14)
Successful pneumatic reduction (n=13)
Follow-up 2-4 years No recurrent (n=105)
Failed pneumatic reduction (n=1)
Failed pneumatic reduction (n=378)
No early-recurrent (n=1790)
pathologic lead point: (n=9)
Failed pneumatic reduction (n=8)
Pathologic lead point
Meckel diverticulum (n=1)
idiopathic (n=6)
Colonic polyp (n=1)
pathologic lead point: Meckel diverticulum (n=1)
eight cases in which surgical treatment was finally needed. The presence of a pathologic lead point was confirmed in two patients, one with colon polyps and the other with Meckel’s diverticulum. The 119 early recurrent and reduced cases were followed up for 2–4 years, among them, 11.8 % (14/119) experienced long-term recurrent episodes, one case needed surgical treatment (pathologic lead point was confirmed as Meckel’s diverticulum) while the other 13 cases were reduced by pneumatic enema successfully and incident-free until the end point of the study (Fig. 1). No patient had unsatisfactory outcome because of delayed medical attention.
Discussion Recurrence of reduced intussusception is a problem that cannot be ignored. It is believed that when intussusception recurs, parents are usually able to notice the symptoms
earlier than the first time the condition occurred, because they are more aware of the situation. But delayed treatment of recurrence remains one of the reason of unfavorable outcomes, the idea of treating intussusception patients reduced by pneumatic enema at home is still not being wildly accepted. Despite the improvement of modern medicine, we still know little about the recurrence of intussusception, as there are no consistent data about the pattern of it in previous studies and the characteristics of early recurrence were scarcely reported. In our study, intussusception patients who were reduced by pneumatic enema were divided into groups by each year of their age. Early recurrence in each age group was documented during follow-up, and the early recurrence rates were compared between groups. It was interesting to find that the group of those under 1 year had the lowest early recurrence rate of 2.1 %, while it was 8.6–16.3 % in other age groups. The difference between patients younger than 1 year old and older than 1 year was statistically
123
Pediatr Surg Int
significant, and there were no significant differences between age groups older than 1-year-old. Solomon ChihCheng Chen and colleagues reported a decreasing total recurrence rate by age in their large sample retrospective study. In the study, 43.6 % recurrences happened within 3 days of previous admission date and remaining 56.4 % recurred later [4]. Combining this result with our study, it seemed patients younger than 1 year had a lower early recurrent risk but were more likely to have at least one recurrent episode later during their lifetime. Or they tend to be free from early recurrence but will not be safe until they have over grown their high-risk age, while older patients are likely to have recurrence earlier but will be safer after overcoming the early reduction period. We believe a certain number of early recurrences in older patients could be due to incomplete ileum-ileum intussusception, because older patients have more developed Peyer’s patches. Peyer’s patches affected by lymphadenopathy is the most commonly seen lead point in open reduction procedures. These lead points always lead to ileum intussusceptions, and these ileum types usually were not so sensitive during enema reduction. Special attention should be given to this age group after reduction. When patients were reduced by pneumatic enema, their parents should be alerted to the risk of early recurrence before they are sent home, especially the parents of patients older than 1 year. Meanwhile, we found 63.0 % of early recurrences happened within 24 h and 92.1 % within 48 h, which suggested that a close monitoring for 48 h on those age groups at risk after initial pneumatic reduction also should be recommended to the parents. In the long-term follow-up of our study, the longterm recurrence rate is 11.8 % (14/119). A repeat pneumatic enema achieved reduction in 13 cases, and only one case needed surgery. These patients were symptom-free after the last recurrent episode until the end point of the study. No patient had an unsatisfactory outcome because of delayed medical attention. This suggested that pneumatic enema is a safe, efficient, and repeatable way in the management of recurrent intussusception, and surgical approach should be the last consideration. Sending the
123
patients home for further observation after thorough parental education is a safe practice.
Conclusion This retrospective study showed intussusception patients older than 1 year tend to have a greater early recurrence rate than other age groups after pneumatic enema reduction. Most of the episodes happened within 48 h. Special attention is recommended for patients older than 1 year for at least 48 h after pneumatic enema reduction. A repeat pneumatic enema seems a good choice before surgery approach. The long-term recurrence rate of the early recurrent patients is low; the prognosis is favorable. Sending the patients home for further observation after targeted parental education is a safe practice.
References 1. Blakelock RT, Beasley SW (1998) The clinical implications of non-idiopathic intussusception. Pediatr Surg Int 14(3):163–167 2. Ramachandran P, Gupta A, Vincent P, Sridharan S (2008) Air enema for intussusception: is predicting the outcome important? Pediatr Surg Int 24(3):311–313 [Epub 2007 Dec 21] 3. Rattanasuwan T, Wongtapradit L, Tongsin A (2010) Management of recurrent intussusception: nonoperative or operative reduction? J Pediatr Surg 45(11):2175–2180. doi:10.1016/j.jpedsurg.2010.07. 029 4. Chen SC, Wang JD, Hsu HY, Leong MM, Tok TS, Chin YY (2010) Epidemiology of childhood intussusception and determinants of recurrence and operation: analysis of national health insurance data between 1998 and 2007 in Taiwan. Pediatr Neonatol 51(5):285–291. doi:10.1016/S1875-9572(10)60055-1 5. Gray MP, Li SH, Hoffmann RG, Gorelick MH (2014) Recurrence rates after intussusception enema reduction: a meta-analysis. Pediatrics 134(1):110–119. doi:10.1542/peds.2013-3102 6. Shiels WE 2nd, Maves CK, Hedlund GL, Kirks DR (1991) Air enema for diagnosis and reduction of intussusception: clinical experience and pressure correlates. Radiology 1(1):169–172 (PubMed PMID: 1887028)
ORIGINAL ARTICLE
Intussusception patients older than 1 year tend to have early recurrence after pneumatic enema reduction Zhe Wang1 • Qiu-ming He1,2 • Hong Zhang3 • Wei Zhong1 • Wei-qiang Xiao1 Lian-wei Lu1 • Jia-kang Yu1 • Hui-min Xia1,2
•
Accepted: 23 June 2015 Ó Springer-Verlag Berlin Heidelberg 2015
Abstract Purpose To identify age risk factors of early recurrent intussusception after pneumatic enema reduction. Management opinions are proposed. Methods Two thousand two hundred and ninety-five intussusception patients’ medical records from January 2009 to December 2011 were retrospectively reviewed and analyzed. Results Of the 2295 patients, the intussusception of 1917 of them was initially reduced by pneumatic enema, with 127 cases recurring within 72 h. The early recurrence rate is 6.62 %. The early recurrence rate of patients younger than 1 year old is 2.1 % (22/1032), while the rate for those older than 1 year is 11.9 % (105/885). The difference is significant (P = 0.0001). There were no significant differences between age groups older than 1 year. One hundred and seventeen cases of recurrence happened within 48 h, which accounted for 92.1 % of all early recurrence. Recurrence patients were treated again with pneumatic enema, with a successful reduction in 93.7 %. They were Q. He is co-first author.
followed up for 2–4 years; the long-term recurrent rate was 11.8 % (14/119). No patient had poor prognosis because of delayed treatment. Conclusion Intussusception patients older than 1 year tend to have greater early recurrence rate after pneumatic enema reduction; 92.1 % of the early recurrent cases happened in 48 h. There is no need to hospitalize patients after pneumatic enema reduction. A repeat pneumatic enema is a good choice before surgical approach. Keywords Early recurrence Intussusception Children Pneumatic enema
Introduction Acute intussusception is one of the most important pediatric surgery emergency conditions of infants and young children. The majority of the cases were found idiopathic, the incidents of intussusception presenting a pathologic lead point accounts for 6 % of the cases [1]. Ultrasonography has been widely adopted to screen and diagnose
& Jia-kang Yu [email protected]
Wei-qiang Xiao [email protected]
& Hui-min Xia [email protected]
Lian-wei Lu [email protected]
Zhe Wang [email protected]
1
Guangzhou Women and Children’s Medical Center, Guangzhou, People’s Republic of China
Qiu-ming He [email protected]
2
Southern Medical University, No. 9 Jinsui Road, Tianhe District, Guangzhou 510623, Guangdong, People’s Republic of China
3
Guangzhou Medical University, Guangzhou, People’s Republic of China
Hong Zhang [email protected] Wei Zhong [email protected]
123
Pediatr Surg Int
intussusception. Most of the time, idiopathic intussusception can be easily managed nonoperatively by hydrostatic or pneumatic enema, only a small portion needs surgical management eventually. Fluoroscopy-guided pneumatic enema became popular rapidly after it was first introduced. The rate of successful reduction of pneumatic enema was reported around 80–92 % [2]. Intussusception is more likely to recur after nonoperational reduction [3]. Overall recurrence rates after pneumatic enema was around 7.9–8.5 % as previously reported [2, 4, 5], among them, approximately one-third were early recurrences within 72 h after the reduction [5]. Previous studies have failed to identify consistent risk factors for intussusception recurrence and the characteristic of early recurrence are rarely reported. This retrospective study was designed to inspect the important age characteristic of early recurrent intussusception and provide information to guide clinical practice.
Methods Medical records of 2295 intussusception patients treated by the pediatric surgery department of the Guangzhou Women and Children’s Medical Center from January 2009 to December 2011 were collected with the approval of the institution’s Research Ethics Board. Clinical data were retrospectively analyzed. Patients were followed up for 2–4 years. When patients presented suspicious symptoms and signs, either an ultrasonography or a low-pressure diagnostic fluoroscopy-guided pneumatic enema was performed. When the diagnosis of intussusception was confirmed, initial pneumatic enema reduction was attempted in most of the situations. Pneumatic enema was performed with continuous manometric monitoring. Pressure was accumulated to 120 mmHg in young children and 140 mmHg in select older patients in order to achieve reduction. Vital signs were closely monitored during the procedure. The criteria for successful reduction were lead point disappearance and air perfusion into the ileum [6]. If reduction failed or unstable vital signs were observed, enema was discontinued and surgical management was proposed. If intussusception recurrence was confirmed, pneumatic enema would be performed again whenever possible. The patients for whom pneumatic reduction was successful were routinely treated as outpatients in the emergency room. These patients were fasted for 3–6 h, electrolytes and smooth muscle relaxants were given orally or intravenously depending on the patients’ situation. If severe dehydration and/or septic shock was observed or complications were suspected after the enema reduction, patients were admitted in the inpatient department for further treatment. Before the patients and parents
123
were sent home, they were educated about the important information of recurrence intussusception. Patients with recurrence were documented during the follow-up. The number of patients who had early recurrence in 24, 24–48 and 48–72 h were compared with total recurrent population. The early recurrence rate was compared between different age groups. The data were abstracted by the first and second author separately in order to ensure the accuracy. Results were analyzed with Fisher’s exact test.
Results There were 2295 patients who were diagnosed and treated from January 2009 to December 2011. One thousand nine hundred and seventeen cases were initially reduced by pneumatic enema. During the follow-up, 127 patients were found to have a recurrence within 72 h after reduction. The overall early recurrence rate was 6.62 % (127/1917) (Table 1). In the patients younger than 1 year, the recurrence rate was 2.1 % (22/1032), in those older than 1 year the rate was 11.9 % (105/885), the difference between the two age groups was statistically significant (P = 0.0001) (Table 2). There were no significant differences between age groups older than 1 year. There were 80 episodes of recurrence within 24 h (63.0 %, 80/127), 37 episodes were found between 24 and 48 h (29.1 %, 37/127), and the remaining 7.9 % (10/127) of recurrences occurred within 48–72 h. All the 127 recurrence patients were treated again with pneumatic enema and 119 of them were again successfully reduced. Pneumatic enema reduction failed in Table 1 Age groups associated with early-recurrent Age
Early-recurrent Yes
(%) No
0–1
22
1010
2.1
1–2
45
409
9.9
2–3
37
208
15.1
3–4 4–5
8 7
85 36
8.6 16.3
8
42
16.0
127
1790
6.6
[5 Total
Table 2 Age groups associated with early-recurrent Age (year)
Early-recurrent Yes
(%)
P value
No
B1
22
1010
2.1
[1
105
780
11.9
0.0001
Pediatr Surg Int Fig. 1 A flow chart showing the management of earlyrecurrent intussusceptions
Intussusception 2009-2011 (n=2295)
Successful pneumatic reduction (n=1917)
Early-recurrent (n=127)
Successful pneumatic reduction (n=119)
Follow-up 2-4 years Multiple-recurrence (n=14)
Successful pneumatic reduction (n=13)
Follow-up 2-4 years No recurrent (n=105)
Failed pneumatic reduction (n=1)
Failed pneumatic reduction (n=378)
No early-recurrent (n=1790)
pathologic lead point: (n=9)
Failed pneumatic reduction (n=8)
Pathologic lead point
Meckel diverticulum (n=1)
idiopathic (n=6)
Colonic polyp (n=1)
pathologic lead point: Meckel diverticulum (n=1)
eight cases in which surgical treatment was finally needed. The presence of a pathologic lead point was confirmed in two patients, one with colon polyps and the other with Meckel’s diverticulum. The 119 early recurrent and reduced cases were followed up for 2–4 years, among them, 11.8 % (14/119) experienced long-term recurrent episodes, one case needed surgical treatment (pathologic lead point was confirmed as Meckel’s diverticulum) while the other 13 cases were reduced by pneumatic enema successfully and incident-free until the end point of the study (Fig. 1). No patient had unsatisfactory outcome because of delayed medical attention.
Discussion Recurrence of reduced intussusception is a problem that cannot be ignored. It is believed that when intussusception recurs, parents are usually able to notice the symptoms
earlier than the first time the condition occurred, because they are more aware of the situation. But delayed treatment of recurrence remains one of the reason of unfavorable outcomes, the idea of treating intussusception patients reduced by pneumatic enema at home is still not being wildly accepted. Despite the improvement of modern medicine, we still know little about the recurrence of intussusception, as there are no consistent data about the pattern of it in previous studies and the characteristics of early recurrence were scarcely reported. In our study, intussusception patients who were reduced by pneumatic enema were divided into groups by each year of their age. Early recurrence in each age group was documented during follow-up, and the early recurrence rates were compared between groups. It was interesting to find that the group of those under 1 year had the lowest early recurrence rate of 2.1 %, while it was 8.6–16.3 % in other age groups. The difference between patients younger than 1 year old and older than 1 year was statistically
123
Pediatr Surg Int
significant, and there were no significant differences between age groups older than 1-year-old. Solomon ChihCheng Chen and colleagues reported a decreasing total recurrence rate by age in their large sample retrospective study. In the study, 43.6 % recurrences happened within 3 days of previous admission date and remaining 56.4 % recurred later [4]. Combining this result with our study, it seemed patients younger than 1 year had a lower early recurrent risk but were more likely to have at least one recurrent episode later during their lifetime. Or they tend to be free from early recurrence but will not be safe until they have over grown their high-risk age, while older patients are likely to have recurrence earlier but will be safer after overcoming the early reduction period. We believe a certain number of early recurrences in older patients could be due to incomplete ileum-ileum intussusception, because older patients have more developed Peyer’s patches. Peyer’s patches affected by lymphadenopathy is the most commonly seen lead point in open reduction procedures. These lead points always lead to ileum intussusceptions, and these ileum types usually were not so sensitive during enema reduction. Special attention should be given to this age group after reduction. When patients were reduced by pneumatic enema, their parents should be alerted to the risk of early recurrence before they are sent home, especially the parents of patients older than 1 year. Meanwhile, we found 63.0 % of early recurrences happened within 24 h and 92.1 % within 48 h, which suggested that a close monitoring for 48 h on those age groups at risk after initial pneumatic reduction also should be recommended to the parents. In the long-term follow-up of our study, the longterm recurrence rate is 11.8 % (14/119). A repeat pneumatic enema achieved reduction in 13 cases, and only one case needed surgery. These patients were symptom-free after the last recurrent episode until the end point of the study. No patient had an unsatisfactory outcome because of delayed medical attention. This suggested that pneumatic enema is a safe, efficient, and repeatable way in the management of recurrent intussusception, and surgical approach should be the last consideration. Sending the
123
patients home for further observation after thorough parental education is a safe practice.
Conclusion This retrospective study showed intussusception patients older than 1 year tend to have a greater early recurrence rate than other age groups after pneumatic enema reduction. Most of the episodes happened within 48 h. Special attention is recommended for patients older than 1 year for at least 48 h after pneumatic enema reduction. A repeat pneumatic enema seems a good choice before surgery approach. The long-term recurrence rate of the early recurrent patients is low; the prognosis is favorable. Sending the patients home for further observation after targeted parental education is a safe practice.
References 1. Blakelock RT, Beasley SW (1998) The clinical implications of non-idiopathic intussusception. Pediatr Surg Int 14(3):163–167 2. Ramachandran P, Gupta A, Vincent P, Sridharan S (2008) Air enema for intussusception: is predicting the outcome important? Pediatr Surg Int 24(3):311–313 [Epub 2007 Dec 21] 3. Rattanasuwan T, Wongtapradit L, Tongsin A (2010) Management of recurrent intussusception: nonoperative or operative reduction? J Pediatr Surg 45(11):2175–2180. doi:10.1016/j.jpedsurg.2010.07. 029 4. Chen SC, Wang JD, Hsu HY, Leong MM, Tok TS, Chin YY (2010) Epidemiology of childhood intussusception and determinants of recurrence and operation: analysis of national health insurance data between 1998 and 2007 in Taiwan. Pediatr Neonatol 51(5):285–291. doi:10.1016/S1875-9572(10)60055-1 5. Gray MP, Li SH, Hoffmann RG, Gorelick MH (2014) Recurrence rates after intussusception enema reduction: a meta-analysis. Pediatrics 134(1):110–119. doi:10.1542/peds.2013-3102 6. Shiels WE 2nd, Maves CK, Hedlund GL, Kirks DR (1991) Air enema for diagnosis and reduction of intussusception: clinical experience and pressure correlates. Radiology 1(1):169–172 (PubMed PMID: 1887028)
