JOURNAL OF LAPAROENDOSCOPIC & ADVANCED SURGICAL TECHNIQUES Volume 25, Number 0, 2015 ª Mary Ann Liebert, Inc. DOI: 10.1089/lap.2014.0283
2014 IPEG Paper
LAHRI: Laparoscopic-Assisted Hydrostatic Reduction of Intussusception Cristina B. Geltzeiler, MD,1 Thomas L. Sims, MD,2 and Andrew F. Zigman, MD1,3
Abstract
Background/Purpose: Intussusception is the most common cause of bowel obstruction in children from 3 months to 3 years of age. In the absence of peritonitis, initial treatment is either hydrostatic or pneumatic reduction. If these measures fail, operative intervention is required. In nonreducible cases, we propose the use of intraoperative hydrostatic enema to achieve or confirm reduction. In this study we describe a cohort of patients who have undergone laparoscopic-assisted hydrostatic reduction of intussusception (LAHRI). Materials and Methods: This is a retrospective cohort study of all patients undergoing LAHRI from the years 2011 to 2013. We performed LAHRI in seven children 4 months to 2 years of age. All patients had ileocolic intussusception that failed initial reduction by radiographic enema. With the patient under general anesthesia, saline enema reduction was facilitated by direct laparoscopic visualization. Results: In 2 of the 7 cases, intussusception reduction was visually confirmed in real time, and only a laparoscopic camera port was required. In 1 patient, the bowel was extensively dilated, requiring mini-laparotomy for visualization. The enema, however, reduced the intussusception without any need for manual reduction. In the remaining 4 cases, minimal laparoscopic manipulation was required after the enema failed to completely reduce the intussusceptum, but enema was used to confirm reduction. No child required bowel resection. Conclusions: In cases of failed reduction by contrast enema, we have demonstrated LAHRI to be a successful treatment modality. The technique has the advantage of little to no bowel manipulation and has evolved into one performed via a single umbilical port.
enema is performed within 12 hours after the onset of symptoms.13 If enema reduction measures are not successful, operative intervention is required.6,15 Approximately 25% of patients with intussusception will ultimately require an operation, and of those, approximately 27% will require a bowel resection.15 Recently, attempts at laparoscopic management have been determined to be safe and effective with an approximately 10%–30% conversion rate to an open procedure.16–19 Laparoscopic management reduces the length of hospital stay and hospital costs without a change in postoperative complications.15,16,19 We propose the use of laparoscopic-assisted hydrostatic reduction of intussusception (LAHRI) to achieve and confirm reduction of intussusception in cases that are nonreducible by radiologic enema.
Introduction
I
ntussusception is the most common cause of bowel obstruction in children 3 months to 3 years of age.1–4 It is a common disease process faced by pediatric surgeons. The most common etiology of intussusception in this age group is idiopathic.1,3,5 In the absence of a lead point such as Meckel’s diverticulum, preceding viral infection with prominent lymphoid follicles is proposed as the most likely inciting illness.1,5 Diagnosis of intussusception is usually confirmed by ultrasound, which has a high sensitivity and specificity.6,7 In the absence of peritonitis or a known lead point, initial treatment is either hydrostatic or pneumatic reduction under radiographic guidance.2 This initial treatment has been well established for decades.8 Enema reduction is successful 61%–90% of the time.9–15 The success rate of the procedure is improved if a diagnosis of intussusception is prompt and 1 2 3
Materials and Methods
We propose a unique technique for reduction of pediatric ileocolic intussusception that has failed radiographic reduction.
Department of Surgery, Oregon Health and Science University, Portland, Oregon. Department of Surgery, Nemours Children’s Clinic Jacksonville, Jacksonville, Florida. Division of Pediatric Surgery, Northwest Permanente, Portland, Oregon.
1
2
GELTZEILER ET AL.
FIG. 1. (Left) Ileocolic intussusception visualized laparoscopically with ileum (intussusceptum) into cecum (intussuscipiens). (Right) Reduction of intussusception confirmed by ileum distended with hydrostatic enema fluid (arrow). A single staff pediatric surgeon at two separate children’s hospitals in Portland, OR performed all of the operations. We report a case series of seven children who ranged in age from 4 months to 2 years who underwent the procedure over a 25-month period, from the years 2011 to 2013. All 7 patients had a history and examination consistent with idiopathic intussusception. Patients presenting with a suspected pathologic lead point were not candidates for the LAHRI procedure. The diagnosis of intussusception was confirmed by ultrasound in all children. The pediatric surgery team evaluated all patients on presentation. With the exception of the youngest child, all children had symptoms of abdominal discomfort lasting for more than 48 hours prior to consultation with a surgeon. The youngest child was reported to have had noticeable abdominal discomfort for approximately 14 hours. In addition to abdominal pain, all children were reported to have episodes of emesis. Three of the seven children were reported to have bloody stools. The first attempt at reduction of intussusception was by radiologic enema, as per standard of care in this age group. The contrast material of choice for the radiologic enema was at the discretion of the attending radiologist. One child underwent barium enema, three children underwent watersoluble contrast enemas, and the remaining three underwent air enema. All intussusceptums on radiographic enema were visualized to extend distally to the hepatic flexure or midtransverse colon. All preoperative enemas were at least partially successful in reducing the intussusceptum, either to the ascending colon (2 of 7 cases) or to the ileocecal valve but without reflux into the small bowel (5 of 7 cases). Three of the seven children underwent two radiographic enemas prior to surgical intervention. One child had already undergone attempted reduction enema at a referring facility prior to radiographic enema performed at our institution. One child had incomplete reduction of intussusceptum at our facility. A decision in collaboration with the pediatric surgery team and the attending radiologist was made to repeat radiographic enema, which in this case failed again. The third child had what appeared to be a complete reduction at completion of the radiographic enema, but symptoms recurred a few hours later, at which time a second enema was unsuccessful. Following final failed radiographic enema reduction, all children went to the operating room urgently. All patients had general anesthesia. After induction of anesthesia, a large-bore (16–24 French) Foley catheter was placed into the anus and advanced a few centimeters to ensure positioning above the
anal sphincters, well within the rectum. The Foley catheter balloon was then inflated with 10 mL of sterile water. The catheter was pulled back gently against the anorectal junction to maintain a seal and taped in place, secured to the buttocks. A 3-L bag of normal saline was connected to cystoscopy tubing. The tubing was then connected to the Foley catheter that was in the child’s rectum. At this time, the tubing was clamped, and the bag of saline was hung 3 feet above the bed of the patient. The abdomen was prepared and draped. An umbilical incision was made. When this technique was first developed, a 5-mm incision was made, and a laparoscope was placed into the abdominal cavity. As the technique evolved, a single 12-mm port was placed at the umbilicus in order to use a coaxial operating scope (27-cm · 10-mm operating endoscope with a 6-mm working channel; Karl Storz Endoscopy Inc., El Segundo, CA). Diagnostic laparoscopy was used to identify the origin of the intussusceptum. Intraoperative hydrostatic enema was then performed. The bowel was visualized distending with saline, and the intussusception reduction was watched in real time. Small bowel distention with saline assisted in identifying a successful reduction (Fig. 1). If the hydrostatic enema fails to immediately reduce the intussusception, gentle manipulation with an atraumatic grasper pulling the intussusceptum out of the intussuscipiens is performed. There may be a need for the placement of one or two more ports in order to accomplish this. If bowel manipulation is successful, the reduction can then be confirmed using repeat saline hydrostatic enema. If laparoscopic reduction is not successful, then an open reduction or resection can be performed. All patients are admitted following reduction for observation. Patients are observed for a minimum of 24 hours postoperatively. Prior to discharge, patients must be able to tolerate a regular diet, and pain must be well controlled with oral medication. To assess for re-admission and or recurrence, charts were reviewed for all encounters at the two major pediatric hospitals in the Portland area, with a median follow-up time of 15 months (range, 9–36 months). The institutional review boards at both hospitals in which the patients were treated approved this study. Results
A summary of patient results is listed in Table 1. In 2 of the 7 cases, intussusception reduction was visually confirmed in
LAPAROSCOPIC ENEMA TREATMENT FOR INTUSSUSCEPTION
3
Table 1. Summary of Patients with Enema Reduction of Intussusception
Patient 1 2 3 4 5 6 7
Age/gender
Number of ports
Conversion to open
Enema alone achieved reduction
Bowel manipulation necessary to reduce
Postoperative discharge day
8 months/M 9 months/F 2 years/M 9 months/F 4 months/F 2 years/F 10 months/M
1 3 1 3 3 1 1
No Yes No No No No No
Yes Yes Yes No No No No
No No No Yes Yes Yes Yes
2 2 2 2 2 1 1
F, female; M, male.
real time without need for any bowel manipulation. In these 2 cases only a laparoscopic camera port was required. In 1 case, the bowel was extensively dilated, requiring mini-laparotomy for visualization. However, the enema reduced the intussusception without any need for manual reduction. In the remaining 4 cases, minimal laparoscopic manipulation was required after enema failed to completely reduce the intussusceptum, but enema was used not only to assist with the reduction, but also to confirm the reduction. No child required bowel resection. Patients 2 and 3 did present again to the emergency department postdischarge (20 and 17 days postoperatively, respectively) with recurrent abdominal discomfort. Both children had repeat ultrasounds, both without evidence of recurrence. Both children were observed uneventfully for 24 hours. No child has had any known recurrence of disease. Discussion
In our small case series, we have demonstrated that in cases of idiopathic intussusception that fail radiographic enema reduction, LAHRI is a safe and valuable addition to laparoscopic reduction of intussusception. We advocate that in the absence of a pathologic lead point or peritonitis, nonoperative, radiologic enema reduction should always be attempted first as standard of care where such expertise is available.4,12,20 Radiologic reduction is successful 75%–90% of the time and is confirmed by reflux of air and/or contrast into the small bowel.11,15,21,22 If these measures fail, we propose LAHRI. In the cases in which intraoperative reduction was successful after failed standard reduction, it seems likely that the general anesthetic played a role. Performance of reduction enema with the patient under general anesthesia is not a new concept. It has been advocated by certain authors with the theoretical benefit of relaxing the abdominal wall to allow for ease of reduction.10,13,23 Collins et al.10 advocated a repeated attempt at radiologic enema within the operating room when a patient was under general anesthesia; however, they did not use direct visualization to confirm this reduction. Chandrasekharam et al.24 proposed LAHRI as a safe and feasible option, yet these patients did not receive an initial attempt at radiologic reduction prior to going to the operating room. This differs from usual practice at most children’s hospitals in North America. We propose that for patients under general anesthesia, those who have failed initial radiologic reduction should have
an attempt at hydrostatic reduction under direct visualization laparoscopically. The use of laparoscopy for treatment of intussusception has been reported to be safe, effective, and associated with a length of stay reduction of over 3 days when compared with open procedures.16,25 With LAHRI, direct visualization laparoscopically allows for real-time confirmation of successful reduction by visualizing the small bowel filling with fluid. This technique gives the advantage of little or no bowel manipulation and can be accomplished via a single port. Conversion to an open procedure was required in 1 of our 7 cases due to dilated loops of small bowel resulting in poor operative visualization. Our rate of need to convert to an open laparotomy compares favorably with the conversion rate in the literature of 29% for laparoscopic reduction without intraoperative enema.16 The LAHRI technique also gives the advantage of allowing for further bowel manipulation if deemed necessary in the case of incomplete reduction with intraoperative enema. In addition, the enema can assist in confirming reduction of the edematous bowel when manual reduction is necessary. The LAHRI technique seems to be a safe treatment option as in our study no child required bowel resection, there were no complications, and no child has had any known recurrence of disease. With these initial results we conclude that laparoscopicassisted hydrostatic enema is a safe and valuable addition to the treatment of idiopathic intussusception after failed radiographic enema. The technique has the advantage of little to no bowel manipulation and has evolved into one performed via a single umbilical port. Disclosure Statement
No competing financial interests exist. References
1. Fischer TK, Bihrmann K, Perch M, et al. Intussusception in early childhood: A cohort study of 1.7 million children. Pediatrics 2004;114:782–785. 2. Jen HC, Shew SB. The impact of hospital type and experience on the operative utilization in pediatric intussusception: A nationwide study. J Pediatr Surg 2009;44: 241–246. 3. Parashar UD, Holman RC, Cummings KC, et al. Trends in intussusception-associated hospitalizations and deaths among US infants. Pediatrics 2000;106:1413–1421. 4. Stringer MD, Pablot SM, Brereton RJ. Paediatric intussusception. Br J Surg 1992;79:867–876.
4
5. Mansour AM, El Koutby M, El Barbary MM, et al. Enteric viral infections as potential risk factors for intussusception. J Infect Dev Ctries 2013;7:28–35. 6. del-Pozo G, Albillos JC, Tejedor D, et al. Intussusception in children: Current concepts in diagnosis and enema reduction. Radiographics 1999;19:299–319. 7. Verschelden P, Filiatrault D, Garel L, et al. Intussusception in children: Reliability of US in diagnosis—A prospective study. Radiology 1992;184:741–744. 8. Farr CE. The reduction of colonic intussusception by air inflation. Ann Surg 1926;84:588–590. 9. Bai YZ, Qu RB, Wang GD, et al. Ultrasound-guided hydrostatic reduction of intussusceptions by saline enema: A review of 5218 cases in 17 years. Am J Surg 2006;192:273– 275. 10. Collins DL, Pinckney LE, Miller KE, et al. Hydrostatic reduction of ileocolic intussusception: A second attempt in the operating room with general anesthesia. J Pediatr 1989; 115:204–207. 11. Fallon SC, Lopez ME, Zhang W, et al. Risk factors for surgery in pediatric intussusception in the era of pneumatic reduction. J Pediatr Surg 2013;48:1032–1036. 12. Naiditch JA, Rigsby C, Chin A. Delayed repeated enema and operative findings after unsuccessful primary enema for intussusception. Eur J Pediatr Surg 2012;22:404–408. 13. Purenne E, Franchi-Abella S, Branchereau S, Baujard C, Benhamou D, Mazoit JX. General anesthesia for intussusception reduction by enema. Paediatr Anaesth 2012;22: 1211–1215. 14. Samad L, Marven S, El Bashir H, et al. Prospective surveillance study of the management of intussusception in UK and Irish infants. Br J Surg 2012;99:411–415. 15. Somme S, To T, Langer JC. Factors determining the need for operative reduction in children with intussusception: A population-based study. J Pediatr Surg 2006;41:1014–1019. 16. Apelt N, Featherstone N, Giuliani S. Laparoscopic treatment of intussusception in children: A systematic review. J Pediatr Surg 2013;48:1789–1793. 17. Bonnard A, Demarche M, Dimitriu C, et al. Indications for laparoscopy in the management of intussusception: A mul-
GELTZEILER ET AL.
18. 19. 20. 21. 22. 23.
24.
25.
ticenter retrospective study conducted by the French Study Group for Pediatric Laparoscopy (GECI). J Pediatr Surg 2008;43:1249–1253. Fraser JD, Aguayo P, Ho B, et al. Laparoscopic management of intussusception in pediatric patients. J Laparoendosc Adv Surg Tech A 2009;19:563–565. Kia KF, Mony VK, Drongowski RA, et al. Laparoscopic vs open surgical approach for intussusception requiring operative intervention. J Pediatr Surg 2005;40:281–284. Ein SH, Palder SB, Alton DJ, Daneman A. Intussusception: Toward less surgery? J Pediatr Surg 1994;29:433–435. Applegate KE. Intussusception in children: Evidence-based diagnosis and treatment. Pediatr Radiol 2009;39(Suppl 2):S140–S143. Niramis R, Watanatittan S, Kruatrachue A, et al. Management of recurrent intussusception: Nonoperative or operative reduction? J Pediatr Surg 2010;45:2175–2180. Digant SM, Rucha S, Eke D. Ultrasound guided reduction of an ileocolic intussusception by a hydrostatic method by using normal saline enema in paediatric patients: A study of 30 cases. J Clin Diagn Res 2012;6: 1722–1725. Chandrasekharam VV, Gazula S, Gorthi RP. Laparoscopyassisted hydrostatic in situ reduction of intussusception: A reasonable alternative? J Indian Assoc Pediatr Surg 2011; 16:8–10. Wei CH, Fu YW, Wang NL, Du YC, Sheu JC. Laparoscopy versus open surgery for idiopathic intussusception in children. Surg Endosc 2015;29:668–672.
Address correspondence to: Cristina B. Geltzeiler, MD Department of Surgery Oregon Health and Science University Mail Code L223A 3181 S.W. Sam Jackson Park Road Portland, OR 97239 E-mail: [email protected]
2014 IPEG Paper
LAHRI: Laparoscopic-Assisted Hydrostatic Reduction of Intussusception Cristina B. Geltzeiler, MD,1 Thomas L. Sims, MD,2 and Andrew F. Zigman, MD1,3
Abstract
Background/Purpose: Intussusception is the most common cause of bowel obstruction in children from 3 months to 3 years of age. In the absence of peritonitis, initial treatment is either hydrostatic or pneumatic reduction. If these measures fail, operative intervention is required. In nonreducible cases, we propose the use of intraoperative hydrostatic enema to achieve or confirm reduction. In this study we describe a cohort of patients who have undergone laparoscopic-assisted hydrostatic reduction of intussusception (LAHRI). Materials and Methods: This is a retrospective cohort study of all patients undergoing LAHRI from the years 2011 to 2013. We performed LAHRI in seven children 4 months to 2 years of age. All patients had ileocolic intussusception that failed initial reduction by radiographic enema. With the patient under general anesthesia, saline enema reduction was facilitated by direct laparoscopic visualization. Results: In 2 of the 7 cases, intussusception reduction was visually confirmed in real time, and only a laparoscopic camera port was required. In 1 patient, the bowel was extensively dilated, requiring mini-laparotomy for visualization. The enema, however, reduced the intussusception without any need for manual reduction. In the remaining 4 cases, minimal laparoscopic manipulation was required after the enema failed to completely reduce the intussusceptum, but enema was used to confirm reduction. No child required bowel resection. Conclusions: In cases of failed reduction by contrast enema, we have demonstrated LAHRI to be a successful treatment modality. The technique has the advantage of little to no bowel manipulation and has evolved into one performed via a single umbilical port.
enema is performed within 12 hours after the onset of symptoms.13 If enema reduction measures are not successful, operative intervention is required.6,15 Approximately 25% of patients with intussusception will ultimately require an operation, and of those, approximately 27% will require a bowel resection.15 Recently, attempts at laparoscopic management have been determined to be safe and effective with an approximately 10%–30% conversion rate to an open procedure.16–19 Laparoscopic management reduces the length of hospital stay and hospital costs without a change in postoperative complications.15,16,19 We propose the use of laparoscopic-assisted hydrostatic reduction of intussusception (LAHRI) to achieve and confirm reduction of intussusception in cases that are nonreducible by radiologic enema.
Introduction
I
ntussusception is the most common cause of bowel obstruction in children 3 months to 3 years of age.1–4 It is a common disease process faced by pediatric surgeons. The most common etiology of intussusception in this age group is idiopathic.1,3,5 In the absence of a lead point such as Meckel’s diverticulum, preceding viral infection with prominent lymphoid follicles is proposed as the most likely inciting illness.1,5 Diagnosis of intussusception is usually confirmed by ultrasound, which has a high sensitivity and specificity.6,7 In the absence of peritonitis or a known lead point, initial treatment is either hydrostatic or pneumatic reduction under radiographic guidance.2 This initial treatment has been well established for decades.8 Enema reduction is successful 61%–90% of the time.9–15 The success rate of the procedure is improved if a diagnosis of intussusception is prompt and 1 2 3
Materials and Methods
We propose a unique technique for reduction of pediatric ileocolic intussusception that has failed radiographic reduction.
Department of Surgery, Oregon Health and Science University, Portland, Oregon. Department of Surgery, Nemours Children’s Clinic Jacksonville, Jacksonville, Florida. Division of Pediatric Surgery, Northwest Permanente, Portland, Oregon.
1
2
GELTZEILER ET AL.
FIG. 1. (Left) Ileocolic intussusception visualized laparoscopically with ileum (intussusceptum) into cecum (intussuscipiens). (Right) Reduction of intussusception confirmed by ileum distended with hydrostatic enema fluid (arrow). A single staff pediatric surgeon at two separate children’s hospitals in Portland, OR performed all of the operations. We report a case series of seven children who ranged in age from 4 months to 2 years who underwent the procedure over a 25-month period, from the years 2011 to 2013. All 7 patients had a history and examination consistent with idiopathic intussusception. Patients presenting with a suspected pathologic lead point were not candidates for the LAHRI procedure. The diagnosis of intussusception was confirmed by ultrasound in all children. The pediatric surgery team evaluated all patients on presentation. With the exception of the youngest child, all children had symptoms of abdominal discomfort lasting for more than 48 hours prior to consultation with a surgeon. The youngest child was reported to have had noticeable abdominal discomfort for approximately 14 hours. In addition to abdominal pain, all children were reported to have episodes of emesis. Three of the seven children were reported to have bloody stools. The first attempt at reduction of intussusception was by radiologic enema, as per standard of care in this age group. The contrast material of choice for the radiologic enema was at the discretion of the attending radiologist. One child underwent barium enema, three children underwent watersoluble contrast enemas, and the remaining three underwent air enema. All intussusceptums on radiographic enema were visualized to extend distally to the hepatic flexure or midtransverse colon. All preoperative enemas were at least partially successful in reducing the intussusceptum, either to the ascending colon (2 of 7 cases) or to the ileocecal valve but without reflux into the small bowel (5 of 7 cases). Three of the seven children underwent two radiographic enemas prior to surgical intervention. One child had already undergone attempted reduction enema at a referring facility prior to radiographic enema performed at our institution. One child had incomplete reduction of intussusceptum at our facility. A decision in collaboration with the pediatric surgery team and the attending radiologist was made to repeat radiographic enema, which in this case failed again. The third child had what appeared to be a complete reduction at completion of the radiographic enema, but symptoms recurred a few hours later, at which time a second enema was unsuccessful. Following final failed radiographic enema reduction, all children went to the operating room urgently. All patients had general anesthesia. After induction of anesthesia, a large-bore (16–24 French) Foley catheter was placed into the anus and advanced a few centimeters to ensure positioning above the
anal sphincters, well within the rectum. The Foley catheter balloon was then inflated with 10 mL of sterile water. The catheter was pulled back gently against the anorectal junction to maintain a seal and taped in place, secured to the buttocks. A 3-L bag of normal saline was connected to cystoscopy tubing. The tubing was then connected to the Foley catheter that was in the child’s rectum. At this time, the tubing was clamped, and the bag of saline was hung 3 feet above the bed of the patient. The abdomen was prepared and draped. An umbilical incision was made. When this technique was first developed, a 5-mm incision was made, and a laparoscope was placed into the abdominal cavity. As the technique evolved, a single 12-mm port was placed at the umbilicus in order to use a coaxial operating scope (27-cm · 10-mm operating endoscope with a 6-mm working channel; Karl Storz Endoscopy Inc., El Segundo, CA). Diagnostic laparoscopy was used to identify the origin of the intussusceptum. Intraoperative hydrostatic enema was then performed. The bowel was visualized distending with saline, and the intussusception reduction was watched in real time. Small bowel distention with saline assisted in identifying a successful reduction (Fig. 1). If the hydrostatic enema fails to immediately reduce the intussusception, gentle manipulation with an atraumatic grasper pulling the intussusceptum out of the intussuscipiens is performed. There may be a need for the placement of one or two more ports in order to accomplish this. If bowel manipulation is successful, the reduction can then be confirmed using repeat saline hydrostatic enema. If laparoscopic reduction is not successful, then an open reduction or resection can be performed. All patients are admitted following reduction for observation. Patients are observed for a minimum of 24 hours postoperatively. Prior to discharge, patients must be able to tolerate a regular diet, and pain must be well controlled with oral medication. To assess for re-admission and or recurrence, charts were reviewed for all encounters at the two major pediatric hospitals in the Portland area, with a median follow-up time of 15 months (range, 9–36 months). The institutional review boards at both hospitals in which the patients were treated approved this study. Results
A summary of patient results is listed in Table 1. In 2 of the 7 cases, intussusception reduction was visually confirmed in
LAPAROSCOPIC ENEMA TREATMENT FOR INTUSSUSCEPTION
3
Table 1. Summary of Patients with Enema Reduction of Intussusception
Patient 1 2 3 4 5 6 7
Age/gender
Number of ports
Conversion to open
Enema alone achieved reduction
Bowel manipulation necessary to reduce
Postoperative discharge day
8 months/M 9 months/F 2 years/M 9 months/F 4 months/F 2 years/F 10 months/M
1 3 1 3 3 1 1
No Yes No No No No No
Yes Yes Yes No No No No
No No No Yes Yes Yes Yes
2 2 2 2 2 1 1
F, female; M, male.
real time without need for any bowel manipulation. In these 2 cases only a laparoscopic camera port was required. In 1 case, the bowel was extensively dilated, requiring mini-laparotomy for visualization. However, the enema reduced the intussusception without any need for manual reduction. In the remaining 4 cases, minimal laparoscopic manipulation was required after enema failed to completely reduce the intussusceptum, but enema was used not only to assist with the reduction, but also to confirm the reduction. No child required bowel resection. Patients 2 and 3 did present again to the emergency department postdischarge (20 and 17 days postoperatively, respectively) with recurrent abdominal discomfort. Both children had repeat ultrasounds, both without evidence of recurrence. Both children were observed uneventfully for 24 hours. No child has had any known recurrence of disease. Discussion
In our small case series, we have demonstrated that in cases of idiopathic intussusception that fail radiographic enema reduction, LAHRI is a safe and valuable addition to laparoscopic reduction of intussusception. We advocate that in the absence of a pathologic lead point or peritonitis, nonoperative, radiologic enema reduction should always be attempted first as standard of care where such expertise is available.4,12,20 Radiologic reduction is successful 75%–90% of the time and is confirmed by reflux of air and/or contrast into the small bowel.11,15,21,22 If these measures fail, we propose LAHRI. In the cases in which intraoperative reduction was successful after failed standard reduction, it seems likely that the general anesthetic played a role. Performance of reduction enema with the patient under general anesthesia is not a new concept. It has been advocated by certain authors with the theoretical benefit of relaxing the abdominal wall to allow for ease of reduction.10,13,23 Collins et al.10 advocated a repeated attempt at radiologic enema within the operating room when a patient was under general anesthesia; however, they did not use direct visualization to confirm this reduction. Chandrasekharam et al.24 proposed LAHRI as a safe and feasible option, yet these patients did not receive an initial attempt at radiologic reduction prior to going to the operating room. This differs from usual practice at most children’s hospitals in North America. We propose that for patients under general anesthesia, those who have failed initial radiologic reduction should have
an attempt at hydrostatic reduction under direct visualization laparoscopically. The use of laparoscopy for treatment of intussusception has been reported to be safe, effective, and associated with a length of stay reduction of over 3 days when compared with open procedures.16,25 With LAHRI, direct visualization laparoscopically allows for real-time confirmation of successful reduction by visualizing the small bowel filling with fluid. This technique gives the advantage of little or no bowel manipulation and can be accomplished via a single port. Conversion to an open procedure was required in 1 of our 7 cases due to dilated loops of small bowel resulting in poor operative visualization. Our rate of need to convert to an open laparotomy compares favorably with the conversion rate in the literature of 29% for laparoscopic reduction without intraoperative enema.16 The LAHRI technique also gives the advantage of allowing for further bowel manipulation if deemed necessary in the case of incomplete reduction with intraoperative enema. In addition, the enema can assist in confirming reduction of the edematous bowel when manual reduction is necessary. The LAHRI technique seems to be a safe treatment option as in our study no child required bowel resection, there were no complications, and no child has had any known recurrence of disease. With these initial results we conclude that laparoscopicassisted hydrostatic enema is a safe and valuable addition to the treatment of idiopathic intussusception after failed radiographic enema. The technique has the advantage of little to no bowel manipulation and has evolved into one performed via a single umbilical port. Disclosure Statement
No competing financial interests exist. References
1. Fischer TK, Bihrmann K, Perch M, et al. Intussusception in early childhood: A cohort study of 1.7 million children. Pediatrics 2004;114:782–785. 2. Jen HC, Shew SB. The impact of hospital type and experience on the operative utilization in pediatric intussusception: A nationwide study. J Pediatr Surg 2009;44: 241–246. 3. Parashar UD, Holman RC, Cummings KC, et al. Trends in intussusception-associated hospitalizations and deaths among US infants. Pediatrics 2000;106:1413–1421. 4. Stringer MD, Pablot SM, Brereton RJ. Paediatric intussusception. Br J Surg 1992;79:867–876.
4
5. Mansour AM, El Koutby M, El Barbary MM, et al. Enteric viral infections as potential risk factors for intussusception. J Infect Dev Ctries 2013;7:28–35. 6. del-Pozo G, Albillos JC, Tejedor D, et al. Intussusception in children: Current concepts in diagnosis and enema reduction. Radiographics 1999;19:299–319. 7. Verschelden P, Filiatrault D, Garel L, et al. Intussusception in children: Reliability of US in diagnosis—A prospective study. Radiology 1992;184:741–744. 8. Farr CE. The reduction of colonic intussusception by air inflation. Ann Surg 1926;84:588–590. 9. Bai YZ, Qu RB, Wang GD, et al. Ultrasound-guided hydrostatic reduction of intussusceptions by saline enema: A review of 5218 cases in 17 years. Am J Surg 2006;192:273– 275. 10. Collins DL, Pinckney LE, Miller KE, et al. Hydrostatic reduction of ileocolic intussusception: A second attempt in the operating room with general anesthesia. J Pediatr 1989; 115:204–207. 11. Fallon SC, Lopez ME, Zhang W, et al. Risk factors for surgery in pediatric intussusception in the era of pneumatic reduction. J Pediatr Surg 2013;48:1032–1036. 12. Naiditch JA, Rigsby C, Chin A. Delayed repeated enema and operative findings after unsuccessful primary enema for intussusception. Eur J Pediatr Surg 2012;22:404–408. 13. Purenne E, Franchi-Abella S, Branchereau S, Baujard C, Benhamou D, Mazoit JX. General anesthesia for intussusception reduction by enema. Paediatr Anaesth 2012;22: 1211–1215. 14. Samad L, Marven S, El Bashir H, et al. Prospective surveillance study of the management of intussusception in UK and Irish infants. Br J Surg 2012;99:411–415. 15. Somme S, To T, Langer JC. Factors determining the need for operative reduction in children with intussusception: A population-based study. J Pediatr Surg 2006;41:1014–1019. 16. Apelt N, Featherstone N, Giuliani S. Laparoscopic treatment of intussusception in children: A systematic review. J Pediatr Surg 2013;48:1789–1793. 17. Bonnard A, Demarche M, Dimitriu C, et al. Indications for laparoscopy in the management of intussusception: A mul-
GELTZEILER ET AL.
18. 19. 20. 21. 22. 23.
24.
25.
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Address correspondence to: Cristina B. Geltzeiler, MD Department of Surgery Oregon Health and Science University Mail Code L223A 3181 S.W. Sam Jackson Park Road Portland, OR 97239 E-mail: [email protected]
