Recurrence Rates After Intussusception Enema Reduction: A Meta-analysis Matthew P. Gray, Shun-Hwa Li, Raymond G. Hoffmann and Marc H. Gorelick Pediatrics 2014;134;110; originally published online June 16, 2014; DOI: 10.1542/peds.2013-3102
The online version of this article, along with updated information and services, is located on the World Wide Web at: http://pediatrics.aappublications.org/content/134/1/110.full.html
PEDIATRICS is the official journal of the American Academy of Pediatrics. A monthly publication, it has been published continuously since 1948. PEDIATRICS is owned, published, and trademarked by the American Academy of Pediatrics, 141 Northwest Point Boulevard, Elk Grove Village, Illinois, 60007. Copyright © 2014 by the American Academy of Pediatrics. All rights reserved. Print ISSN: 0031-4005. Online ISSN: 1098-4275.
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Recurrence Rates After Intussusception Enema Reduction: A Meta-analysis abstract BACKGROUND AND OBJECTIVE: Reported rates of recurrence after enema reduction for intussusception are variable. Concerns for recurrence influence postreduction management. The objective of this study was to conduct a systematic review and meta-analysis to estimate overall, 24-hour, and 48-hour recurrence rates after enema reduction in children. METHODS: PubMed, Cochrane Database, and OVID Medline were searched from 1946 through December 2011 using the search terms: intussusception, recurrence, and enema. Sixty-nine studies of patients age 0 to 18 years with radiographically proven intussusception reduced by enema that report the number of enema reductions and the number of recurrences were included. Extraction was done by the primary author (M.P.G.) with 10% of included studies independently audited to ensure concordance. RESULTS: Overall recurrence rates were 12.7% (95% confidence interval [CI]: 11.1%–14.4%, I2 = 28.8%) for contrast enema (CE), 7.5% (95% CI: 5.7%–9.8%, I2 = 52.4%) for ultrasound-guided noncontrast enema (UGNCE), and 8.5% (95% CI: 6.9%–10.4%, I2 = 50.1%) for fluoroscopyguided air enema (FGAE). Recurrence rates within 24 hours were 3.9% (95% CI: 2.2%–6.7%, I2 = 47.0%) for CE, 3.9% (95% CI: 1.5%–10.1%, I2 = 0.0%) for UGNCE, and 2.2% (95% CI: 0.7%–6.5%, I2 = 59.8%) for FGAE. Recurrence rates within 48 hours were 5.4% (95% CI 3.7%–7.8%, I2 = 32.3%) for CE, 6.6% (95% CI: 4.0%–10.7%, I2 = 0.0%) for UGNCE, and 2.7% (95% CI: 1.2%–6.5%, I2 = 73.8%) for FGAE. Most included studies are retrospective and vary in quality of reporting. Few studies reported detailed patient characteristics including timing of recurrences. CONCLUSIONS: The risk of early (within 48 hours) recurrence after enema reduction is low, suggesting outpatient management of wellappearing patients should be considered. Pediatrics 2014;134:110– 119
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AUTHORS: Matthew P. Gray, MD,a Shun-Hwa Li, PhD,b,c Raymond G. Hoffmann, PhD,b,c and Marc H. Gorelick, MD, MSCEa,b Sections of aEmergency Medicine, and cQuantitative Health Sciences, Department of Pediatrics, Medical College of Wisconsin, Milwaukee, Wisconsin; and bChildren’s Research Institute, Children’s Hospital of Wisconsin, Milwaukee, Wisconsin KEY WORDS intussusception, recurrence, enema ABBREVIATIONS CE—contrast enema CI—confidence interval FGAE—fluoroscopy-guided air enema UGNCE—ultrasound-guided noncontrast enema Dr Gray conceptualized and designed the study, conducted data collection, and drafted the initial manuscript; Dr Gorelick conceptualized and designed the study, aided in data collection, and revised and reviewed the initial manuscript; Drs Hoffmann and Li carried out the initial analyses, and reviewed and revised the manuscript; and all authors approved the final manuscript as submitted. Please note that Dr Li is no longer employed at the Medical College of Wisconsin. She is now affiliated with United Healthcare Group. The change in affiliation occurred after analysis of the results was completed. www.pediatrics.org/cgi/doi/10.1542/peds.2013-3102 doi:10.1542/peds.2013-3102 Accepted for publication Apr 7, 2014 Address correspondence to Matthew Gray, MD, Department of Pediatrics, Medical College of Wisconsin, 999 North 92nd St, Milwaukee, WI 53226. E-mail: [email protected]. PEDIATRICS (ISSN Numbers: Print, 0031-4005; Online, 1098-4275). Copyright © 2014 by the American Academy of Pediatrics FINANCIAL DISCLOSURE: The authors have indicated they have no financial relationships relevant to this article to disclose. FUNDING: No external funding. POTENTIAL CONFLICT OF INTEREST: The authors have indicated they have no potential conflicts of interest to disclose.
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Intussusception is a common cause of abdominal pain and intestinal obstruction in the pediatric population. Since 2000, annual hospitalization rates for intussusception in the United States have remained steady at approximately 35 cases per 100 000 infants, and are as high as 62 per 100 000 infants 26 to 29 weeks of age.1 Currently, the management of intussusception remains variable; however, there has been a significant trend away from surgical reduction toward enema reduction.1,2 Despite a growing body of literature supporting outpatient management of patients with successful enema reduction, it is still common practice to hospitalize patients for 24 to 48 hours of observation.3–6 This is based on historical recommendations founded on the concerns for recurrence and postreduction complications.7 A body of evidence has emerged suggesting that the rate of significant complications, specifically perforation, post enema reduction is very low. As part of their review of intussusception management, Daneman and Navarro2 reported rates of perforation between 0% and 5.9%, with the vast majority of series reporting rates ,1%. Reported recurrence rates, however, are highly variable, are not calculated in a standardized manner, and most are based on relatively small trials. In addition, many of the reported recurrences occurred .48 to 72 hours postreduction. Consequently, management recommendations would be best based on a precise understanding of the risk of early (within 24–48 hours) recurrence for an individual patient. The aim of our study was to perform a systematic review of the existing literature to estimate overall, 24-hour, and 48-hour recurrence rates post enema reduction in children with a radiographic diagnosis of ileocolic intussusception in an effort to pose suggested recommendations for clinical practice.
METHODS Data Sources and Searches We performed electronic searches of PubMed, the Cochrane Database, and OVID Medline from 1966 to the end of December 2011. The search included the following keywords: intussusception, recurrence, and enema (Supplemental Table 5). A prevalidated filter to limit the search to children was also used.8 The search was limited to human studies and publications in English. Hand searches of the bibliographies of all articles identified in the initial online search were completed to identify further articles for final inclusion. Authors were contacted if studies quoted a recurrence rate but did not define the numerator or denominator needed to calculate this rate. Study Selection Studies were included if they met all of the following criteria: (1) included
patients age 0 to 18 years; (2) intussusception was radiographically proven and reduced by enema; and (3) the number of intussusceptions reduced by enema and the number of recurrences was provided or could be calculated. Two reviewers (M.P.G. and M.H.G.) independently evaluated titles and abstracts of articles retrieved from the initial search. A list of relevant articles was created, agreed on by both authors, and retrieved in full. Both authors (M.P.G. and M.H.G.) reviewed all full-text articles independently for final inclusion and disagreements were reconciled by consensus. Data Extraction Data were extracted onto a preformatted data sheet by the primary author (M.P.G.). The second author (M.H.G.) audited 10% of the articles included to ensure concordance. Outcome measures
FIGURE 1 Study selection for the meta-analysis.
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TABLE 1 Characteristics of Studies Included in the Meta-analysis Study (Year)
Setting
n
Quality Score
Adekunle-Ojo et al (2011)21 Beasley et al (1987)22 Bonadio (1988)23 Champoux et al (1994)24 Chung et al (1994)25 Collins et al (1989)26 Courtney et al (1981)27 Crankson et al (2003)28 Crystal et al (2002)29 Daneman et al (1998)18 Dawod and Osundwa (1992)30 Denenholz and Feher (1955)31 Eshel et al (1997)32 Fecteau et al (1996)17 Freund et al (1977)33 Goon Hong (1986)34 Hadidi and El Shal(1999)14 Hiller (1955)35 Kaushal (1972)36 Kellog et al (1961)37 Kim and Rhu (1989)38 Korttila (1952)39 Krasna et al (1990)40 Le Masne et al (1999)41 Liu et al (1986)42 MacKay et al (1987)43 Meyer et al (1993)44 Minami and Fujii (1975)45 Nordshus and Swensen (1979)46 Okuyama et al (1999)47 Packard (1955)48 Paes et al (1988)49 Palder et al (1991)50 Ravitch (1958)51 Reid et al (2001)52 Riebel et al (1993)53 Shehata et al (2000)54 Simon et al (1994)55 Skipper et al (1990)56 Tangi et al (1991)57 van den Ende et al (2005)58 Wayne et al (1973)59 West et al (1987)60 Winstanley et al (1987)61 Yang (2001)62 Bai et al (2006)63 Chan et al (1997)64 Choi et al (1994)65 Essa et al (2011)66 Gonzalez-Spinola et al (1999)67 Hadidi and El Shal(1999)14 Krishnakumar et al (2006)68 Rohrschneider and Troger (1995)69 Shehata et al (2000)54 Al-Jazaeri et al (2006)3 Daneman et al (1998)18 Eshel et al (1997)32 Fragoso et al (2007)70 Gu et al (2000)71
United States Australia United States United States China United States Ireland Saudi Arabia Israel Canada Qatar United States Israel Canada Israel Malaysia Egypt Australia England United Kingdom Korea Finland United States France Ireland Australia United States Japan Norway Japan United States United Kingdom Canada United States New Zealand Germany Egypt Australia United States Wales Netherlands United States United States United Kingdom Taiwan China China Korea Egypt Spain Egypt India Germany
149 602 88 263 333 58 56 33 83 262 67 29 58 258 49 8 50 60 87 80 385 33 56 113 66 91 27 104 108 104 89 89 100 199 34 41 50 20 157 119 113 344 83 75 89 5218 26 115 75 176 47 25 40
5 5 6 7 5 5 5 7 8 8 7 5 7 7 5 3 10 5 4 5 6 3 6 7 5 5 10 5 9 6 3 5 7 3 5 5 3 7 7 5 10 5 6 7 10 5 5 7 10 5 10 4 5
840 121 501 35 164 199
3 7 8 7 10 3
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Egypt Canada Canada Israel Portugal China
Age, mo
% Male
Enema Type
Outcomes
Overall Recurrence Rate, %
3–95 Undefined 2–36 1–174 1–180 3–72 1–120 0–36 2–54 Undefined 2–24 5–32 1–20 1–20 1–108 1–60 Undefined Undefined Undefined 0–96 1–72 3.5–132 Undefined 0–108 1–28 2–48 Undefined 2–22 0–147 1–83 Undefined Undefined 3–167 Undefined Undefined 3–105 Undefined 2.5–17 Undefined Undefined Undefined 0.5–216 2–264 0–36 0–180 2–216 Undefined 2–60 5–24 2–108 Undefined 4–48 3.5–52
56 64 62 62 61.6 64 61 64 58 Undefined 72 Undefined 68 Undefined 65 100 66 Undefined Undefined 56 69 64 Undefined 62 70 60 67 67 66 56 Undefined Undefined 45 Undefined Undefined 68 Undefined 60 68 Undefined 60 66 61 Undefined 74 67.4 43 71 79 59 62 64 60
CE CE CE CE CE CE CE CE CE CE CE CE CE CE CE CE CE CE CE CE CE CE CE CE CE CE CE CE CE CE CE CE CE CE CE CE CE CE CE CE CE CE CE CE CE UGNCE UGNCE UGNCE UGNCE UGNCE UGNCE UGNCE UGNCE
TotR TotR 24 h, 48 h, TotR 24 h, TotR TotR TotR 24 h, 48 h, TotR TotR 48 h, TotR 48 h, TotR TotR 24 h, 48 h, TotR 24 h, 48 h, TotR TotR TotR 24 h, 48 h, TotR 24 h, 48 h, TotR 24 h, 48 h, TotR TotR TotR 24 h, 48 h, TotR 24 h, 48 h, TotR 24 h, 48 h, TotR 24 h, 48 h, TotR 24 h, 48 h, TotR TotR 24 h, 48 h, TotR 24 h, 48 h, TotR TotR TotR TotR 24 h, 48 h, TotR TotR TotR TotR TotR TotR 24 h, 48 h, TotR TotR TotR 24 h, 48 h, TotR 48 h, TotR TotR 24 h, 48 h, TotR 24 h, 48 h, TotR TotR TotR TotR 24 h, 48 h, TotR 48 h, TotR 24 h, 48 h, TotR 24 h, 48 h, TotR TotR
12.5 8.9 2.1 13.2 11.6 10.4 5.0 31.3 14.3 11.1 9.1 0.0 14.7 12.5 5.6 0.0 0.0 8.3 17.9 14.8 9.5 28.6 0.0 13.0 8.9 17.1 11.8 9.6 25.0 7.2 10.0 17.1 13.2 5.7 9.1 12.1 9.7 0.0 20.7 10.9 11.7 6.9 29.4 7.4 14.5 5.6 9.1 6.5 10.0 10.0 0.0 4.2 16.7
Undefined 5–133 Undefined 1–20 Undefined 3.5–120
Undefined 71 Undefined 68 72 59
UGNCE FGAE FGAE FGAE FGAE FGAE
TotR TotR 48 h, TotR 24 h, 48 h, TotR TotR 24 h, 48 h, TotR
6.9 13.8 8.0 3.3 6.5 14.1
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TABLE 1 Continued Study (Year)
Hadidi and El Shal (1999)14 Herwig et al (2009)5 Katz et al (1993)72 Lehnert et al (2009)73 Lui et al (2001)74 McDermott et al (1994)75 Mensah et al (2011)76 Meyer et al (1993)44 Palder et al (1991)50 Reid et al (2001)52 Renwick et al (1992)77 Rubi et al (2002)78 Stringer and Ein (1990)19 Tamahana et al (1987)79 Tangi et al (1991)57 Tareen et al 201180 Todani et al (1990)81 Wang et al (1995)82 Yoon et al (2001)83
Setting
Egypt United States Australia Germany Taiwan Scotland Ghana United States Canada New Zealand Australia Spain Canada Japan Wales Ireland Japan China South Korea
n
Quality Score
50 124 255 98 194 54 18 25 100 42 187 21 364 222 11 256 137 224 49
10 8 10 7 7 8 9 10 7 5 10 5 5 5 5 5 5 5 9
Age, mo
% Male
Undefined 2–135 1–96 2–144 1–60 2.5–52 0–18 Undefined 2–96 Undefined Undefined 2–144 0–96 1–84 Undefined 0–144 Undefined 1.5–48 2–84
Enema Type
62 71 76 61 58 59 67 67 62 Undefined Undefined 55 Undefined 72 Undefined 70 Undefined 72 73
FGAE FGAE FGAE FGAE FGAE FGAE FGAE FGAE FGAE FGAE FGAE FGAE FGAE FGAE FGAE FGAE FGAE FGAE FGAE
Outcomes
Overall Recurrence Rate, %
24 h, 48 h, TotR 24 h, 48 h, TotR TotR 24 h, 48 h, TotR TotR TotR 24 h, 48 h, TotR 24 h, 48 h, TotR TotR TotR TotR TotR TotR TotR 24 h, 48 h, TotR TotR TotR 24 h, 48 h, TotR 24 h, 48 h, TotR
0.0 6.7 10.1 6.1 6.6 15.8 0.0 5.3 5.3 6.1 7.9 4.8 10.7 6.6 0.0 15.8 8.7 1.4 6.7
24 h, 24-hour recurrence rate; 48 h, 48-hour recurrence rate; TotR, total recurrence rate.
included the number of successful reductions and the total number of recurrences. When data were available, the number of recurrences occurring ,24 hours post reduction and ,48 hours post reduction was recorded separately. For articles reporting both enema-reduced and operatively reduced intussusceptions, only data on those reduced by enema were included. Factors that were believed to affect recurrence rates also were recorded. These included the type of enema performed (contrast enema [CE], fluoroscopy-guided air enema [FGAE], ultrasound-guided noncontrast enema [UGNCE]), year of publication, and country in which the study was conducted. Study location was stratified into “Developed” and “Developing” countries based on United Nations Children’s Fund definitions of industrialized countries, with “Developed” defined as the United States, England, Finland, France, Ireland, Israel, Germany, the Netherlands, Norway, Portugal, Scotland, Spain, the United Kingdom, Australia, Japan, and New Zealand.9
Quality Assessment It has been shown that the quality of reporting is associated with the methodological quality of clinical trials; however, there are currently no validated scales to assess the quality of observational studies.10,11 Most studies included in our meta-analysis are observational; therefore, we chose to evaluate the methodological quality of the studies included in this review and meta-analysis using a scale we developed. Studies were assigned a score of 0 to 2 for each of the following criteria (the criteria for assigning 0, 1, or 2 points are indicated respectively in parentheses): 1. Enrollment (not specified, nonconsecutive, consecutive); 2. Design (not specified, retrospective, prospective).
Studies were then assigned a score of 1 to 3 for each of the following criteria (the criteria for assigning 1, 2, or 3 points are indicated respectively in parentheses): 1. Definition of data source (not specified, specific but general mention of data source, eg, “medical records were reviewed,” specifically defined, eg, “inpatient and radiology records were reviewed”); 2. Data abstraction (not specified, specific mention of data to be extracted but not method of abstraction, specific mention of what data and how it was abstracted). We made note of follow-up (retrospective versus prospective) when possible, and found little variance. Most studies had retrospective follow-up. As such, we did not include “follow-up” in our
TABLE 2 Pooled Recurrence Rates by Enema Modality Enema Modality CE UGNCE FGAE
I2, %
Pooled Recurrence Rate, % (95% CI) Overall
48-h
24-h
Overall
48-h
24-h
12.7 (11.1–14.4) 7.5 (5.7–9.8) 8.5 (6.9–10.4)
5.4 (3.7–7.8) 6.6 (4.0–10.7) 2.7 (1.2–6.5)
3.9 (2.2–6.7) 3.9 (1.5–10.1) 2.2 (0.7–6.5)
28.8 52.4 50.1
32.3 0.0 73.8
47.0 0.0 59.8
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quality score. Total net scores could range from 2 to 10, with higher scores indicating higher quality. Both authors (M.P.G. and M.H.G.) independently assigned the quality scores for each study and differences were reconciled by mutual agreement. k for interrater agreement was calculated. Data Analysis Recurrence rates were calculated in a standardized manner for each study
by dividing the total number of patients with recurrence by the total number of patients with a successful reduction. Patients with .1 recurrence were counted only once. Heterogeneity between studies was identified by using a x 2 test and quantified with the I2 statistic.12 Meta-analysis was performed by using a random effects model based on the method of DerSimonian and Laird.13 To account for the number of zero proportions in this study, the
log-transformed proportion was used to calculate confidence intervals that would be non-negative. The analysis was stratified based on enema type. Meta-regression was performed to identify potential sources of heterogeneity. We planned a priori to assess for sources of heterogeneity, including quality score, the year of study completion, and study location. In post hoc analysis, estimated median age was included in the meta-regression. The vast majority of studies reported only an age range. As such, median age was estimated by the midpoint and squareroot transformation of the midpoint. Both variables were tested in the regression analysis. For the primary outcome, recurrence rates by enema modalities, a P value of .05 was used. For the secondary analyses comparing different time frames and covariates, a P , .01 was used to account for multiple testing of the secondary outcomes. R 2.13 (R Foundation for Statistical Computing, Vienna, Austria) and Stata 11.2 (Stata Corp, College Station, TX) were used for this analysis.
RESULTS Description of Articles The described search strategies identified 325 articles and abstracts (Fig 1). Of these, 154 were excluded based on their title or abstract, and 167 were retrieved in full. Sixty-nine articles met full inclusion criteria and were included in the meta-analysis (Table 1). Ninety-eight articles were excluded arter review of the full text (Supplemental Table 4).
FIGURE 2 Overall recurrence rates by enema modality.
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The studies included were drawn from a wide body of literature including general pediatric, emergency medicine, and radiology journals. The quality scores for the 69 included studies were widely variable and ranged from 2 to 10; however, interrater reliability for quality scores was excellent (k = 0.93). Fifty-five of these articles were retrospective
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studies and 49 of them had consecutive enrollment. One study was a randomized controlled study.14 The studies included were conducted in 28 different countries, with 13 studies conducted in the United States. The ages of study participants ranged from ,1 month to 22 years. Recurrence Rates When estimating pooled recurrence rates across all studies, independent of enema modality, we found that the results were highly heterogeneous signifying that effect sizes varied between studies and enema modality. The overall results were heavily biased toward contrast enema reduction, largely due to the substantial difference in the number of studies included for each enema modality (46 CE, 9 UGNCE, 24 FGAE). Although to some extent the number of subjects adjusts for this (5362 subjects with CE vs 10 013 subjects with FGAE or UGNCE), it is not enough to fully account for the bias. Because the results for individual enema modalities are not subject to this bias, subsequent analyses were stratified by modality. Recurrence rates are reported by modality in Table 2. Overall recurrence rates were 12.7% (95% confidence interval [CI] 11.1%–14.4%, I2 = 28.8%) for CE, 7.5% (95% CI 5.7%–9.8%, I2 = 52.4%) for UGNCE, and 8.5% (95% CI 6.9%– 10.4%, I2 = 50.1%) for FGAE (Fig 2). The recurrence rates at 24 hours and 48 hours were low. Recurrence rates within 24 hours post reduction were 3.9% (95% CI 2.2%–6.7%, I2 = 47.0%) for CE, 3.9% (95% CI 1.5%–10.1%, I2 = 0.0%) for UGNCE, and 2.2% (95% CI 0.7%– 6.5%, I2 = 59.8%) for FGAE (Fig 3). Recurrence rates within 48 hours post reduction were 5.4% (95% CI 3.7%– 7.8%, I2 = 32.3%) for CE, 6.6% (95% CI 4.0%–10.7%, I2 = 0.0%) for UGNCE, and 2.7% (95% CI 1.2%–6.5%, I2 = 73.8%) for FGAE (Fig 4).
FIGURE 3 The 24-hour recurrence rates by enema modality.
Sensitivity Analyses Heterogeneity was found when combining studies by enema modality (Table 2). A study by Higgins et al15 suggests that I2 values from 0% to 50% represent a low to moderate amount of heterogeneity. Meta-regression was conducted to identify potential sources of heterogeneity. Enema modality was a significant source of heterogeneity (P = .002 FGAE, P = .028 UGNCE, P = .151 CE) for overall recurrence rates. Enema modality, however, was not a significant source of heterogeneity for 48-hour
(P = .461 CE, P = .706 UGNCE, P = .515 FGAE) or 24-hour recurrence rates (P = .471 CE, P = .702 UGNCE, P = .661 FGAE). Study quality, year of study publication, and country of origin were not found to be significant sources of heterogeneity for overall, 48-hour, or 24-hour recurrence rates. In post hoc regression analysis, estimated median age was not found to be significant for overall, 24-hour, or 48-hour recurrence rates. Because the study by Bai et al63 accounted for nearly one-third of the
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Bai et al63 had minimal effect on the pooled estimate. Learning effect was assessed by examining results by year. A significant trend was identified for quality score. Quality scores showed a significant trend (even using the multiple testing adjustment) with year (Spearman r = 0.504, P = .0004) for CE only. If studies are restricted to 1980 and later, there is no correlation between quality scores and year of publication (Supplemental Table 6). Of note, all studies of noncontrast reductions were published after 1980. The Begg test for publication bias was used and did not demonstrate bias for any of the outcome variables.
DISCUSSION This meta-analysis of published studies demonstrates that an individual’s risk of having an early (within 24 to 48 hours) recurrent intussusception after a successful enema reduction is low. In addition, the risk of recurrence is independent of enema type, study location, year of study completion, and study quality. The risk of recurrence in the first 24 hours post reduction is 2.2% to 3.9% and 2.7% to 6.6% in the first 48 hours. Assuming a 24-hour recurrence risk of 3.9%, it would require hospitalizing 26 patients for 24 hours to identify a single recurrence.
FIGURE 4 The 48-hour recurrence rates by enema modality.
patients included in the overall recurrence rate data for UGNCE, we conducted a weighted meta-regression to estimate the effect of each method.
Pooled estimates including the study by Bai et al63 were compared with pooled estimates excluding this study (Table 3). Inclusion of the study by
TABLE 3 Effect of Study Size on Overall Recurrence Rate
All studies, n = 16 178 CE FGAE UGNCE Excluding Bai et al,63 n = 11 050 CE FGAE UGNCE
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Recurrence Rate, % (95% CI)
P Value (Compared With CE)
10.455 (9.00–11.91) 6.984 (4.51–9.45) 7.038 (5.49–8.58)
.018 .002
10.467 (9.1–11.93) 7.466 (4.57–10.56) 7.049 (5.48–8.61)
.069 .002
This suggests that the vast majority of recurrences will not be identified by overnight hospitalization. In addition, recurrent intussusceptions can be safely and successfully reduced via repeat enema, and significant complications associated with enema reduction are rare. Multiple studies supporting outpatient management after successful enema reduction have demonstrated high rates of success with repeat enema reduction without delayed complications.16–20 In their series of 1340 patients, Niramis et al20 reported success rates as high as 96% with barium enema and 92% with air enema.
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There are several limitations to our study. First, because of the relative infrequency with which intussusception occurs, most of the studies included in this meta-analysis are retrospective studies. Many are small, and they vary widely in quality. As such, we attempted to measure and control for the quality of reporting for each study. Second, the studies differ in both known features, such as enema reduction technique or setting, and possibly unknown features that we were unable to measure. As these differences were expected, we used random effects modeling in our analyses, adjusting for the suspected
confounders and providing more conservative estimates of confidence limits. Finally, the number of studies reporting the specific timing of recurrences was limited. Despite these limitations, our study improves the understanding of the risk of early (within 24 to 48 hours) recurrence for an individual patient, and strongly suggests that that risk is low. In combination with the knowledge that serious postreduction complications are rare and that recurrences can be safely and successfully managed nonoperatively, it is reasonable to suggest that outpatient management in an
appropriately selected population of well-appearing patients would be appropriate. In addition to the risk of recurrence, providers need to consider clinical factors, such as ease of reduction, number of reduction attempts, and a patient’s hemodynamic status pre- and postreduction when making disposition decisions. Consistent with other recently published studies, our results support the development of multidisciplinary guidelines for the appropriate outpatient management of those asymptomatic patients who have had successful enema reduction.
view search strategies in finding child health systematic reviews in MEDLINE. Arch Pediatr Adolesc Med. 2008;162(2):111–116 UNICEF. State of the World’s Children 2012: Children in an Urban World. New York, NY: 2012 Schulz KF, Chalmers I, Hayes RJ, Altman DG. Empirical evidence of bias. Dimensions of methodological quality associated with estimates of treatment effects in controlled trials. JAMA. 1995;273(5):408–412 Moher D, Pham B, Jones A, et al. Does quality of reports of randomised trials affect estimates of intervention efficacy reported in meta-analyses? Lancet. 1998; 352(9128):609–613 Huedo-Medina TB, Sánchez-Meca J, MarínMartínez F, Botella J. Assessing heterogeneity in meta-analysis: Q statistic or I2 index? Psychol Methods. 2006;11(2):193–206 DerSimonian R, Laird N. Meta-analysis in clinical trials. Control Clin Trials. 1986;7(3):177–188 Hadidi AT, El Shal N. Childhood intussusception: a comparative study of nonsurgical management. J Pediatr Surg. 1999;34(2):304– 307 Higgins JP, Thompson SG, Deeks JJ, Altman DG. Measuring inconsistency in meta-analyses. BMJ. 2003;327(7414):557–560 Ein SH. Recurrent intussusception in children. J Pediatr Surg. 1975;10(5):751–755 Fecteau A, Flageole H, Nguyen LT, Laberge JM, Shaw KS, Guttman FM. Recurrent intussusception: safe use of hydrostatic enema. J Pediatr Surg. 1996;31(6):859–861
18. Daneman A, Alton DJ, Lobo E, Gravett J, Kim P, Ein SH. Patterns of recurrence of intussusception in children: a 17-year review. Pediatr Radiol. 1998;28(12):913–919 19. Stringer DA, Ein SH. Pneumatic reduction: advantages, risks and indications. Pediatr Radiol. 1990;20(6):475–477 20. Niramis R, Watanatittan S, Kruatrachue A, et al. Management of recurrent intussusception: nonoperative or operative reduction? J Pediatr Surg. 2010;45(11):2175–2180 21. Adekunle-Ojo AO, Craig AM, Ma L, Caviness AC. Intussusception: postreduction fasting is not necessary to prevent complications and recurrences in the emergency department observation unit. Pediatr Emerg Care. 2011;27(10):897–899 22. Beasley SW, Auldist AW, Stokes KB. Recurrent intussusception: barium or surgery? Aust N Z J Surg. 1987;57(1):11–14 23. Bonadio WA. Intussuception Reduced by Barium Enema. Clinical Pediatrics. 1988;27 (12):601–604 24. Champoux AN, Del Beccaro MA, NazarStewart V. Recurrent intussusception. Risks and features. Arch Pediatr Adolesc Med. 1994;148(5):474–478 25. Chung JL, Kong MS, Lin JN, Wang KL, Lou CC, Wong HF. Intussusception in infants and children: risk factors leading to surgical reduction. J Formos Med Assoc. 1994;93(6): 481–485 26. Collins DL, Pinckney LE, Miller KE, et al. Hydrostatic reduction of ileocolic intussusception: a second attempt in the operating
REFERENCES 1. Tate JE, Simonsen L, Viboud C, et al. Trends in intussusception hospitalizations among US infants, 1993-2004: implications for monitoring the safety of the new rotavirus vaccination program. Pediatrics. 2008;121(5). Available at: www.pediatrics.org/cgi/content/ full/121/5/e1125 2. Daneman A, Navarro O. Intussusception. Part 2: an update on the evolution of management. Pediatr Radiol. 2004;34(2):97–108, quiz 187 3. Al-Jazaeri A, Yazbeck S, Filiatrault D, Beaudin M, Emran M, Bütter A. Utility of hospital admission after successful enema reduction of ileocolic intussusception. J Pediatr Surg. 2006;41(5):1010–1013 4. Bajaj L, Roback MG. Postreduction management of intussusception in a children’s hospital emergency department. Pediatrics. 2003;112(6 pt 1):1302–1307 5. Herwig K, Brenkert T, Losek JD. Enemareduced intussusception management: is hospitalization necessary? Pediatr Emerg Care. 2009;25(2):74–77 6. Whitehouse JS, Gourlay DM, Winthrop AL, Cassidy LD, Arca MJ. Is it safe to discharge intussusception patients after successful hydrostatic reduction? J Pediatr Surg. 2010;45(6):1182–1186 7. Eklöf O, Reiter S. Recurrent intussusception. Analysis of a series treated with hydrostatic reduction. Acta Radiol Diagn (Stockh). 1978; 19(1B):250–258 8. Boluyt N, Tjosvold L, Lefebvre C, Klassen TP, Offringa M. Usefulness of systematic re-
9.
10.
11.
12.
13. 14.
15.
16. 17.
PEDIATRICS Volume 134, Number 1, July 2014
Downloaded from pediatrics.aappublications.org at Queen Mary, University of London on July 15, 2014
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27.
28.
29.
30.
31.
32.
33.
34.
35.
36.
37.
38.
39.
40.
41.
42.
118
room with general anesthesia. J Pediatr. 1989;115(2):204–207 Courtney DF, Kelleher J, O’Donnell B. Intussusception—a change in policy where management has been satisfactory. Ir J Med Sci. 1981;150(3):69–72 Crankson SJ, Al-Rabeeah AA, Fischer JD, Al-Jadaan SA, Namshan MA. Idiopathic intussusception in infancy and childhood. Saudi Med J. 2003;24(suppl):S18–S20 Crystal P, Hertzanu Y, Farber B, Shabshin N, Barki Y. Sonographically guided hydrostatic reduction of intussusception in children. J Clin Ultrasound. 2002;30(6):343–348 Dawod ST, Osundwa VM. Intussusception in children under 2 years of age in the State of Qatar: analysis of 67 cases. Ann Trop Paediatr. 1992;12(1):121–126 Denenholz EJ, Feher GS. Barium reduction of intussusception in infancy. Calif Med. 1955;82(1):8–12 Eshel G, Barr J, Heyman E, et al. Intussusception: a 9-year survey (1986-1995). J Pediatr Gastroenterol Nutr. 1997;24(3): 253–256 Freund H, Hurvitz H, Schiller M. Etiologic and therapeutic aspects of intussusception in childhood. Am J Surg. 1977;134(2):272–274 Goon Hong K. Barium enema reduction of intussusception in children. Med J Malaysia. 1986;41(2):166–169 Hiller HG. Barium enema reduction of intussusception in infancy. Med J Aust. 1955; 42(5):157 Kaushal V. Role of barium enema in acute intussusception. Indian Pediatr. 1972;9(3): 152–154 Kellogg HB Jr, Bill AH Jr. The treatment of intussusception. An evaluation of surgical and of barium enema reduction in a series of eighty cases. Am J Surg. 1961;101:626– 632 Kim YS, Rhu JH. Intussusception in infancy and childhood. Analysis of 385 cases. Int Surg. 1989;74(2):114–118 Korttila K. On the treatment of intussusception in children. Acta Chir Scand. 1952;104(1):45–55 Krasna IH, Benjamin BG, Zitsman JL, Rosenfeld D. Intussusception in childhood. N J Med. 1990;87(9):715–720 Le Masne A, Lortat-Jacob S, Sayegh N, Sannier N, Brunelle F, Cheron G. Intussusception in infants and children: feasibility of ambulatory management. Eur J Pediatr. 1999;158(9):707–710 Liu KW, MacCarthy J, Guiney EJ, Fitzgerald RJ. Intussusception—current trends in management. Arch Dis Child. 1986;61(1): 75–77
43. Mackay AJ, MacKellar A, Sprague P. Intussusception in children: a review of 91 cases. Aust N Z J Surg. 1987;57(1):15–17 44. 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(2):507–511 45. Minami A, Fujii K. Intussusception in children: hydrostatic reduction. Am J Dis Child. 1975;129(3):346–348 46. Nordshus T, Swensen T. Barium enema in pediatric intussusception; a review of 108 cases. Rofo. 1979;131(1):42–46 47. Okuyama H, Nakai H, Okada A. Is barium enema reduction safe and effective in patients with a long duration of intussusception? [see comment] Pediatr Surg Int. 1999;15(2):105–107 48. Packard GB. The treatment of intussusception in infancy and childhood. Pediatrics. 1955; 15(3):291–297 49. Paes RA, Hyde I, Griffiths DM. The management of intussusception. Br J Radiol. 1988; 61(723):187–189 50. Palder SB, Ein SH, Stringer DA, Alton D. Intussusception: barium or air? [see comment] J Pediatr Surg. 1991;26(3):271–274, discussion 274–275 51. Ravitch MM. Intussusception in infancy and childhood; an analysis of seventy-seven cases treated by barium enema. N Engl J Med. 1958;259(22):1058–1064 52. Reid R, Kulkarni M, Beasley S. The potential for improvement in outcome of children with intussusception in the South Island. N Z Med J. 2001;114(1141):441–443 53. Riebel TW, Nasir R, Weber K. US-guided hydrostatic reduction of intussusception in children. Radiology. 1993;188(2):513–516 54. Shehata S, El Kholi N, Sultan A, El Sahwi E. Hydrostatic reduction of intussusception: barium, air, or saline? Pediatr Surg Int. 2000;16(5-6):380–382 55. Simon RA, Hugh TJ, Curtin AM. Childhood intussusception in a regional hospital. Aust N Z J Surg. 1994;64(10):699–702 56. Skipper RP, Boeckman CR, Klein RL. Childhood intussusception. Surg Gynecol Obstet. 1990;171(2):151–153 57. Tangi VT, Bear JW, Reid IS, Wright JE. Intussusception in Newcastle in a 25 year period. Aust N Z J Surg. 1991;61(8):608–613 58. van den Ende ED, Allema JH, Hazebroek FW, Breslau PJ. Success with hydrostatic reduction of intussusception in relation to duration of symptoms. Arch Dis Child. 2005; 90(10):1071–1072 59. Wayne ER, Campbell JB, Burrington JD, Davis WS. Management of 344 children
60.
61.
62.
63.
64.
65.
66.
67.
68.
69.
70.
71.
72.
with intussusception. Radiology. 1973;107(3): 597–601 West KW, Stephens B, Vane DW, Grosfeld JL. Intussusception: current management in infants and children. Surgery. 1987;102(4): 704–710 Winstanley JH, Doig CM, Brydon H. Intussusception: the case for barium reduction. J R Coll Surg Edinb. 1987;32(5):285–287 Yang CM, Hsu HY, Tsao PN, Chang MH, Lin FY. Recurrence of intussusception in childhood. Acta Paediatr Taiwan. 2001;42(3): 158–161 Bai YZ, Qu RB, Wang GD, et al. Ultrasoundguided hydrostatic reduction of intussusceptions by saline enema: a review of 5218 cases in 17 years. Am J Surg. 2006;192(3): 273–275 Chan KL, Saing H, Peh WC, et al. Childhood intussusception: ultrasound-guided Hartmann’s solution hydrostatic reduction or barium enema reduction? J Pediatr Surg. 1997;32 (1):3–6 Choi SO, Park WH, Woo SK. Ultrasoundguided water enema: an alternative method of nonoperative treatment for childhood intussusception. J Pediatr Surg. 1994;29(4): 498–500 Essa AE, Eltayeb AA, Mansour E. Evaluation of the role of dexamethasone in decreasing early recurrence of intussusception: Using ultrasound-guided saline enema for reduction. Surgical Practice. 2011;15(4):114– 119 González-Spínola J, Del Pozo G, Tejedor D, Blanco A. Intussusception: the accuracy of ultrasound-guided saline enema and the usefulness of a delayed attempt at reduction. J Pediatr Surg. 1999;34(6):1016– 1020 Krishnakumar HS, Hameed S, Umamaheshwari . Ultrasound guided hydrostatic reduction in the management of intussusception. Indian J Pediatr. 2006;73(3):217–220 Rohrschneider WK, Tröger J. Hydrostatic reduction of intussusception under US guidance. Pediatr Radiol. 1995;25(7):530– 534 Fragoso AC, Campos M, Tavares C, CostaPereira A, Estevão-Costa J. Pneumatic reduction of childhood intussusception. Is prediction of failure important? J Pediatr Surg. 2007;42(9):1504–1508 Gu L, Zhu H, Wang S, Han Y, Wu X, Miao H. Sonographic guidance of air enema for intussusception reduction in children. Pediatr Radiol. 2000;30(5):339–342 Katz M, Phelan E, Carlin JB, Beasley SW. Gas enema for the reduction of intussusception: relationship between clinical signs
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and symptoms and outcome. AJR Am J Roentgenol. 1993;160(2):363–366 73. Lehnert T, Sorge I, Till H, Rolle U. Intussusception in children—clinical presentation, diagnosis and management. Int J Colorectal Dis. 2009;24(10):1187–1192 74. Lui KW, Wong HF, Cheung YC, et al. Air enema for diagnosis and reduction of intussusception in children: clinical experience and fluoroscopy time correlation. J Pediatr Surg. 2001;36(3):479–481 75. McDermott VG, Taylor T, Mackenzie S, Hendry GM. Pneumatic reduction of intussusception: clinical experience and factors affecting outcome. Clin Radiol. 1994;49(1): 30–34
76. Mensah YB, Glover-Addy H, Etwire V, et al. Pneumatic reduction of intussusception in children at Korle Bu Teaching Hospital: an initial experience. Afr J Paediatr Surg. 2011;8(2):176–181 77. Renwick A, Beasley S, Phelan E. Intussusception: recurrence following gas (oxygen) enema reduction. Pediatr Surg Int. 1992;7(5):361– 363 78. Rubí I, Vera R, Rubí SC, et al. Air reduction of intussusception. Eur J Pediatr Surg. 2002;12(6):387–390 79. Tamanaha K, Wimbish K, Talwalkar YB, Ashimine K. Air reduction of intussusception in infants and children. J Pediatr. 1987;111(5):733–736
80. Tareen F, Ryan S, Avanzini S, Pena V, Mc Laughlin D, Puri P. Does the length of the history influence the outcome of pneumatic reduction of intussusception in children? Pediatr Surg Int. 2011;27(6):587–589 81. Todani T, Sato Y, Watanabe Y, Toki A, Uemura S, Urushihara N. Air reduction for intussusception in infancy and childhood: ultrasonographic diagnosis and management without x-ray exposure. Z Kinderchir. 1990;45(4):222–226 82. Wang G, Liu XG, Zitsman JL. Nonfluoroscopic reduction of intussusception by air enema. World J Surg. 1995;19(3):435–438 83. Yoon CH, Kim HJ, Goo HW. Intussusception in children: US-guided pneumatic reduction— initial experience. Radiology. 2001;218(1):85–88
THE NEW LIBRARY: A few weeks ago, my wife and I went downtown to the Public Library to hear a talk. Amazingly, the place was packed. I have been in libraries of various sizes over the past year: the small Charlotte, VT library, the huge New York City Library, and the medium sized Burlington Library. All were humming with activity. A few years ago, many predicted the demise of the public library citing the rise of the internet, e-readers, and social media. However, libraries have been busy re-inventing themselves and not only have staved off extinction but are thriving. As reported in The New York Times (U.S.: March 7, 2014), physical visits to libraries are off the charts. For example, the Boston Public Library had an almost 50% increase in the number of visitors in 2012 to more than 1.7 million. My son can borrow movies, physical books, and electronic books from the Burlington Library. Some libraries offer access to 3-D printers, laser cutters, and milling machines, while others lend out musical instruments or plots of land on which to practice organic farming. Many are trying to lure visitors with wide open spaces, lobbies, and even food courts. I see people eating in libraries all the time – which when I was a child would have led to automatic dismissal and revocation of my library card. Librarians too have different jobs. Rather than answering single questions, they may act as information navigators to help customers sift through many, many answers. While some libraries have gone completely digital – meaning that no books are present at all – all-digital libraries have not been entirely successful and have often brought back books. The reason is that while almost a third of Americans read e-books, in 2012 less than 5% read e-books only. I for one am thrilled with the change. I like the fact there are still large tables and comfy chairs, but now there are food courts, computers, internet access, and all kinds of activities that appeal to not only my parents and I, but my children as well. Noted by WVR, MD
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Recurrence Rates After Intussusception Enema Reduction: A Meta-analysis Matthew P. Gray, Shun-Hwa Li, Raymond G. Hoffmann and Marc H. Gorelick Pediatrics 2014;134;110; originally published online June 16, 2014; DOI: 10.1542/peds.2013-3102 Updated Information & Services
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PEDIATRICS is the official journal of the American Academy of Pediatrics. A monthly publication, it has been published continuously since 1948. PEDIATRICS is owned, published, and trademarked by the American Academy of Pediatrics, 141 Northwest Point Boulevard, Elk Grove Village, Illinois, 60007. Copyright © 2014 by the American Academy of Pediatrics. All rights reserved. Print ISSN: 0031-4005. Online ISSN: 1098-4275.
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PEDIATRICS is the official journal of the American Academy of Pediatrics. A monthly publication, it has been published continuously since 1948. PEDIATRICS is owned, published, and trademarked by the American Academy of Pediatrics, 141 Northwest Point Boulevard, Elk Grove Village, Illinois, 60007. Copyright © 2014 by the American Academy of Pediatrics. All rights reserved. Print ISSN: 0031-4005. Online ISSN: 1098-4275.
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Recurrence Rates After Intussusception Enema Reduction: A Meta-analysis abstract BACKGROUND AND OBJECTIVE: Reported rates of recurrence after enema reduction for intussusception are variable. Concerns for recurrence influence postreduction management. The objective of this study was to conduct a systematic review and meta-analysis to estimate overall, 24-hour, and 48-hour recurrence rates after enema reduction in children. METHODS: PubMed, Cochrane Database, and OVID Medline were searched from 1946 through December 2011 using the search terms: intussusception, recurrence, and enema. Sixty-nine studies of patients age 0 to 18 years with radiographically proven intussusception reduced by enema that report the number of enema reductions and the number of recurrences were included. Extraction was done by the primary author (M.P.G.) with 10% of included studies independently audited to ensure concordance. RESULTS: Overall recurrence rates were 12.7% (95% confidence interval [CI]: 11.1%–14.4%, I2 = 28.8%) for contrast enema (CE), 7.5% (95% CI: 5.7%–9.8%, I2 = 52.4%) for ultrasound-guided noncontrast enema (UGNCE), and 8.5% (95% CI: 6.9%–10.4%, I2 = 50.1%) for fluoroscopyguided air enema (FGAE). Recurrence rates within 24 hours were 3.9% (95% CI: 2.2%–6.7%, I2 = 47.0%) for CE, 3.9% (95% CI: 1.5%–10.1%, I2 = 0.0%) for UGNCE, and 2.2% (95% CI: 0.7%–6.5%, I2 = 59.8%) for FGAE. Recurrence rates within 48 hours were 5.4% (95% CI 3.7%–7.8%, I2 = 32.3%) for CE, 6.6% (95% CI: 4.0%–10.7%, I2 = 0.0%) for UGNCE, and 2.7% (95% CI: 1.2%–6.5%, I2 = 73.8%) for FGAE. Most included studies are retrospective and vary in quality of reporting. Few studies reported detailed patient characteristics including timing of recurrences. CONCLUSIONS: The risk of early (within 48 hours) recurrence after enema reduction is low, suggesting outpatient management of wellappearing patients should be considered. Pediatrics 2014;134:110– 119
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AUTHORS: Matthew P. Gray, MD,a Shun-Hwa Li, PhD,b,c Raymond G. Hoffmann, PhD,b,c and Marc H. Gorelick, MD, MSCEa,b Sections of aEmergency Medicine, and cQuantitative Health Sciences, Department of Pediatrics, Medical College of Wisconsin, Milwaukee, Wisconsin; and bChildren’s Research Institute, Children’s Hospital of Wisconsin, Milwaukee, Wisconsin KEY WORDS intussusception, recurrence, enema ABBREVIATIONS CE—contrast enema CI—confidence interval FGAE—fluoroscopy-guided air enema UGNCE—ultrasound-guided noncontrast enema Dr Gray conceptualized and designed the study, conducted data collection, and drafted the initial manuscript; Dr Gorelick conceptualized and designed the study, aided in data collection, and revised and reviewed the initial manuscript; Drs Hoffmann and Li carried out the initial analyses, and reviewed and revised the manuscript; and all authors approved the final manuscript as submitted. Please note that Dr Li is no longer employed at the Medical College of Wisconsin. She is now affiliated with United Healthcare Group. The change in affiliation occurred after analysis of the results was completed. www.pediatrics.org/cgi/doi/10.1542/peds.2013-3102 doi:10.1542/peds.2013-3102 Accepted for publication Apr 7, 2014 Address correspondence to Matthew Gray, MD, Department of Pediatrics, Medical College of Wisconsin, 999 North 92nd St, Milwaukee, WI 53226. E-mail: [email protected]. PEDIATRICS (ISSN Numbers: Print, 0031-4005; Online, 1098-4275). Copyright © 2014 by the American Academy of Pediatrics FINANCIAL DISCLOSURE: The authors have indicated they have no financial relationships relevant to this article to disclose. FUNDING: No external funding. POTENTIAL CONFLICT OF INTEREST: The authors have indicated they have no potential conflicts of interest to disclose.
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Intussusception is a common cause of abdominal pain and intestinal obstruction in the pediatric population. Since 2000, annual hospitalization rates for intussusception in the United States have remained steady at approximately 35 cases per 100 000 infants, and are as high as 62 per 100 000 infants 26 to 29 weeks of age.1 Currently, the management of intussusception remains variable; however, there has been a significant trend away from surgical reduction toward enema reduction.1,2 Despite a growing body of literature supporting outpatient management of patients with successful enema reduction, it is still common practice to hospitalize patients for 24 to 48 hours of observation.3–6 This is based on historical recommendations founded on the concerns for recurrence and postreduction complications.7 A body of evidence has emerged suggesting that the rate of significant complications, specifically perforation, post enema reduction is very low. As part of their review of intussusception management, Daneman and Navarro2 reported rates of perforation between 0% and 5.9%, with the vast majority of series reporting rates ,1%. Reported recurrence rates, however, are highly variable, are not calculated in a standardized manner, and most are based on relatively small trials. In addition, many of the reported recurrences occurred .48 to 72 hours postreduction. Consequently, management recommendations would be best based on a precise understanding of the risk of early (within 24–48 hours) recurrence for an individual patient. The aim of our study was to perform a systematic review of the existing literature to estimate overall, 24-hour, and 48-hour recurrence rates post enema reduction in children with a radiographic diagnosis of ileocolic intussusception in an effort to pose suggested recommendations for clinical practice.
METHODS Data Sources and Searches We performed electronic searches of PubMed, the Cochrane Database, and OVID Medline from 1966 to the end of December 2011. The search included the following keywords: intussusception, recurrence, and enema (Supplemental Table 5). A prevalidated filter to limit the search to children was also used.8 The search was limited to human studies and publications in English. Hand searches of the bibliographies of all articles identified in the initial online search were completed to identify further articles for final inclusion. Authors were contacted if studies quoted a recurrence rate but did not define the numerator or denominator needed to calculate this rate. Study Selection Studies were included if they met all of the following criteria: (1) included
patients age 0 to 18 years; (2) intussusception was radiographically proven and reduced by enema; and (3) the number of intussusceptions reduced by enema and the number of recurrences was provided or could be calculated. Two reviewers (M.P.G. and M.H.G.) independently evaluated titles and abstracts of articles retrieved from the initial search. A list of relevant articles was created, agreed on by both authors, and retrieved in full. Both authors (M.P.G. and M.H.G.) reviewed all full-text articles independently for final inclusion and disagreements were reconciled by consensus. Data Extraction Data were extracted onto a preformatted data sheet by the primary author (M.P.G.). The second author (M.H.G.) audited 10% of the articles included to ensure concordance. Outcome measures
FIGURE 1 Study selection for the meta-analysis.
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TABLE 1 Characteristics of Studies Included in the Meta-analysis Study (Year)
Setting
n
Quality Score
Adekunle-Ojo et al (2011)21 Beasley et al (1987)22 Bonadio (1988)23 Champoux et al (1994)24 Chung et al (1994)25 Collins et al (1989)26 Courtney et al (1981)27 Crankson et al (2003)28 Crystal et al (2002)29 Daneman et al (1998)18 Dawod and Osundwa (1992)30 Denenholz and Feher (1955)31 Eshel et al (1997)32 Fecteau et al (1996)17 Freund et al (1977)33 Goon Hong (1986)34 Hadidi and El Shal(1999)14 Hiller (1955)35 Kaushal (1972)36 Kellog et al (1961)37 Kim and Rhu (1989)38 Korttila (1952)39 Krasna et al (1990)40 Le Masne et al (1999)41 Liu et al (1986)42 MacKay et al (1987)43 Meyer et al (1993)44 Minami and Fujii (1975)45 Nordshus and Swensen (1979)46 Okuyama et al (1999)47 Packard (1955)48 Paes et al (1988)49 Palder et al (1991)50 Ravitch (1958)51 Reid et al (2001)52 Riebel et al (1993)53 Shehata et al (2000)54 Simon et al (1994)55 Skipper et al (1990)56 Tangi et al (1991)57 van den Ende et al (2005)58 Wayne et al (1973)59 West et al (1987)60 Winstanley et al (1987)61 Yang (2001)62 Bai et al (2006)63 Chan et al (1997)64 Choi et al (1994)65 Essa et al (2011)66 Gonzalez-Spinola et al (1999)67 Hadidi and El Shal(1999)14 Krishnakumar et al (2006)68 Rohrschneider and Troger (1995)69 Shehata et al (2000)54 Al-Jazaeri et al (2006)3 Daneman et al (1998)18 Eshel et al (1997)32 Fragoso et al (2007)70 Gu et al (2000)71
United States Australia United States United States China United States Ireland Saudi Arabia Israel Canada Qatar United States Israel Canada Israel Malaysia Egypt Australia England United Kingdom Korea Finland United States France Ireland Australia United States Japan Norway Japan United States United Kingdom Canada United States New Zealand Germany Egypt Australia United States Wales Netherlands United States United States United Kingdom Taiwan China China Korea Egypt Spain Egypt India Germany
149 602 88 263 333 58 56 33 83 262 67 29 58 258 49 8 50 60 87 80 385 33 56 113 66 91 27 104 108 104 89 89 100 199 34 41 50 20 157 119 113 344 83 75 89 5218 26 115 75 176 47 25 40
5 5 6 7 5 5 5 7 8 8 7 5 7 7 5 3 10 5 4 5 6 3 6 7 5 5 10 5 9 6 3 5 7 3 5 5 3 7 7 5 10 5 6 7 10 5 5 7 10 5 10 4 5
840 121 501 35 164 199
3 7 8 7 10 3
112
Egypt Canada Canada Israel Portugal China
Age, mo
% Male
Enema Type
Outcomes
Overall Recurrence Rate, %
3–95 Undefined 2–36 1–174 1–180 3–72 1–120 0–36 2–54 Undefined 2–24 5–32 1–20 1–20 1–108 1–60 Undefined Undefined Undefined 0–96 1–72 3.5–132 Undefined 0–108 1–28 2–48 Undefined 2–22 0–147 1–83 Undefined Undefined 3–167 Undefined Undefined 3–105 Undefined 2.5–17 Undefined Undefined Undefined 0.5–216 2–264 0–36 0–180 2–216 Undefined 2–60 5–24 2–108 Undefined 4–48 3.5–52
56 64 62 62 61.6 64 61 64 58 Undefined 72 Undefined 68 Undefined 65 100 66 Undefined Undefined 56 69 64 Undefined 62 70 60 67 67 66 56 Undefined Undefined 45 Undefined Undefined 68 Undefined 60 68 Undefined 60 66 61 Undefined 74 67.4 43 71 79 59 62 64 60
CE CE CE CE CE CE CE CE CE CE CE CE CE CE CE CE CE CE CE CE CE CE CE CE CE CE CE CE CE CE CE CE CE CE CE CE CE CE CE CE CE CE CE CE CE UGNCE UGNCE UGNCE UGNCE UGNCE UGNCE UGNCE UGNCE
TotR TotR 24 h, 48 h, TotR 24 h, TotR TotR TotR 24 h, 48 h, TotR TotR 48 h, TotR 48 h, TotR TotR 24 h, 48 h, TotR 24 h, 48 h, TotR TotR TotR 24 h, 48 h, TotR 24 h, 48 h, TotR 24 h, 48 h, TotR TotR TotR 24 h, 48 h, TotR 24 h, 48 h, TotR 24 h, 48 h, TotR 24 h, 48 h, TotR 24 h, 48 h, TotR TotR 24 h, 48 h, TotR 24 h, 48 h, TotR TotR TotR TotR 24 h, 48 h, TotR TotR TotR TotR TotR TotR 24 h, 48 h, TotR TotR TotR 24 h, 48 h, TotR 48 h, TotR TotR 24 h, 48 h, TotR 24 h, 48 h, TotR TotR TotR TotR 24 h, 48 h, TotR 48 h, TotR 24 h, 48 h, TotR 24 h, 48 h, TotR TotR
12.5 8.9 2.1 13.2 11.6 10.4 5.0 31.3 14.3 11.1 9.1 0.0 14.7 12.5 5.6 0.0 0.0 8.3 17.9 14.8 9.5 28.6 0.0 13.0 8.9 17.1 11.8 9.6 25.0 7.2 10.0 17.1 13.2 5.7 9.1 12.1 9.7 0.0 20.7 10.9 11.7 6.9 29.4 7.4 14.5 5.6 9.1 6.5 10.0 10.0 0.0 4.2 16.7
Undefined 5–133 Undefined 1–20 Undefined 3.5–120
Undefined 71 Undefined 68 72 59
UGNCE FGAE FGAE FGAE FGAE FGAE
TotR TotR 48 h, TotR 24 h, 48 h, TotR TotR 24 h, 48 h, TotR
6.9 13.8 8.0 3.3 6.5 14.1
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TABLE 1 Continued Study (Year)
Hadidi and El Shal (1999)14 Herwig et al (2009)5 Katz et al (1993)72 Lehnert et al (2009)73 Lui et al (2001)74 McDermott et al (1994)75 Mensah et al (2011)76 Meyer et al (1993)44 Palder et al (1991)50 Reid et al (2001)52 Renwick et al (1992)77 Rubi et al (2002)78 Stringer and Ein (1990)19 Tamahana et al (1987)79 Tangi et al (1991)57 Tareen et al 201180 Todani et al (1990)81 Wang et al (1995)82 Yoon et al (2001)83
Setting
Egypt United States Australia Germany Taiwan Scotland Ghana United States Canada New Zealand Australia Spain Canada Japan Wales Ireland Japan China South Korea
n
Quality Score
50 124 255 98 194 54 18 25 100 42 187 21 364 222 11 256 137 224 49
10 8 10 7 7 8 9 10 7 5 10 5 5 5 5 5 5 5 9
Age, mo
% Male
Undefined 2–135 1–96 2–144 1–60 2.5–52 0–18 Undefined 2–96 Undefined Undefined 2–144 0–96 1–84 Undefined 0–144 Undefined 1.5–48 2–84
Enema Type
62 71 76 61 58 59 67 67 62 Undefined Undefined 55 Undefined 72 Undefined 70 Undefined 72 73
FGAE FGAE FGAE FGAE FGAE FGAE FGAE FGAE FGAE FGAE FGAE FGAE FGAE FGAE FGAE FGAE FGAE FGAE FGAE
Outcomes
Overall Recurrence Rate, %
24 h, 48 h, TotR 24 h, 48 h, TotR TotR 24 h, 48 h, TotR TotR TotR 24 h, 48 h, TotR 24 h, 48 h, TotR TotR TotR TotR TotR TotR TotR 24 h, 48 h, TotR TotR TotR 24 h, 48 h, TotR 24 h, 48 h, TotR
0.0 6.7 10.1 6.1 6.6 15.8 0.0 5.3 5.3 6.1 7.9 4.8 10.7 6.6 0.0 15.8 8.7 1.4 6.7
24 h, 24-hour recurrence rate; 48 h, 48-hour recurrence rate; TotR, total recurrence rate.
included the number of successful reductions and the total number of recurrences. When data were available, the number of recurrences occurring ,24 hours post reduction and ,48 hours post reduction was recorded separately. For articles reporting both enema-reduced and operatively reduced intussusceptions, only data on those reduced by enema were included. Factors that were believed to affect recurrence rates also were recorded. These included the type of enema performed (contrast enema [CE], fluoroscopy-guided air enema [FGAE], ultrasound-guided noncontrast enema [UGNCE]), year of publication, and country in which the study was conducted. Study location was stratified into “Developed” and “Developing” countries based on United Nations Children’s Fund definitions of industrialized countries, with “Developed” defined as the United States, England, Finland, France, Ireland, Israel, Germany, the Netherlands, Norway, Portugal, Scotland, Spain, the United Kingdom, Australia, Japan, and New Zealand.9
Quality Assessment It has been shown that the quality of reporting is associated with the methodological quality of clinical trials; however, there are currently no validated scales to assess the quality of observational studies.10,11 Most studies included in our meta-analysis are observational; therefore, we chose to evaluate the methodological quality of the studies included in this review and meta-analysis using a scale we developed. Studies were assigned a score of 0 to 2 for each of the following criteria (the criteria for assigning 0, 1, or 2 points are indicated respectively in parentheses): 1. Enrollment (not specified, nonconsecutive, consecutive); 2. Design (not specified, retrospective, prospective).
Studies were then assigned a score of 1 to 3 for each of the following criteria (the criteria for assigning 1, 2, or 3 points are indicated respectively in parentheses): 1. Definition of data source (not specified, specific but general mention of data source, eg, “medical records were reviewed,” specifically defined, eg, “inpatient and radiology records were reviewed”); 2. Data abstraction (not specified, specific mention of data to be extracted but not method of abstraction, specific mention of what data and how it was abstracted). We made note of follow-up (retrospective versus prospective) when possible, and found little variance. Most studies had retrospective follow-up. As such, we did not include “follow-up” in our
TABLE 2 Pooled Recurrence Rates by Enema Modality Enema Modality CE UGNCE FGAE
I2, %
Pooled Recurrence Rate, % (95% CI) Overall
48-h
24-h
Overall
48-h
24-h
12.7 (11.1–14.4) 7.5 (5.7–9.8) 8.5 (6.9–10.4)
5.4 (3.7–7.8) 6.6 (4.0–10.7) 2.7 (1.2–6.5)
3.9 (2.2–6.7) 3.9 (1.5–10.1) 2.2 (0.7–6.5)
28.8 52.4 50.1
32.3 0.0 73.8
47.0 0.0 59.8
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quality score. Total net scores could range from 2 to 10, with higher scores indicating higher quality. Both authors (M.P.G. and M.H.G.) independently assigned the quality scores for each study and differences were reconciled by mutual agreement. k for interrater agreement was calculated. Data Analysis Recurrence rates were calculated in a standardized manner for each study
by dividing the total number of patients with recurrence by the total number of patients with a successful reduction. Patients with .1 recurrence were counted only once. Heterogeneity between studies was identified by using a x 2 test and quantified with the I2 statistic.12 Meta-analysis was performed by using a random effects model based on the method of DerSimonian and Laird.13 To account for the number of zero proportions in this study, the
log-transformed proportion was used to calculate confidence intervals that would be non-negative. The analysis was stratified based on enema type. Meta-regression was performed to identify potential sources of heterogeneity. We planned a priori to assess for sources of heterogeneity, including quality score, the year of study completion, and study location. In post hoc analysis, estimated median age was included in the meta-regression. The vast majority of studies reported only an age range. As such, median age was estimated by the midpoint and squareroot transformation of the midpoint. Both variables were tested in the regression analysis. For the primary outcome, recurrence rates by enema modalities, a P value of .05 was used. For the secondary analyses comparing different time frames and covariates, a P , .01 was used to account for multiple testing of the secondary outcomes. R 2.13 (R Foundation for Statistical Computing, Vienna, Austria) and Stata 11.2 (Stata Corp, College Station, TX) were used for this analysis.
RESULTS Description of Articles The described search strategies identified 325 articles and abstracts (Fig 1). Of these, 154 were excluded based on their title or abstract, and 167 were retrieved in full. Sixty-nine articles met full inclusion criteria and were included in the meta-analysis (Table 1). Ninety-eight articles were excluded arter review of the full text (Supplemental Table 4).
FIGURE 2 Overall recurrence rates by enema modality.
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The studies included were drawn from a wide body of literature including general pediatric, emergency medicine, and radiology journals. The quality scores for the 69 included studies were widely variable and ranged from 2 to 10; however, interrater reliability for quality scores was excellent (k = 0.93). Fifty-five of these articles were retrospective
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studies and 49 of them had consecutive enrollment. One study was a randomized controlled study.14 The studies included were conducted in 28 different countries, with 13 studies conducted in the United States. The ages of study participants ranged from ,1 month to 22 years. Recurrence Rates When estimating pooled recurrence rates across all studies, independent of enema modality, we found that the results were highly heterogeneous signifying that effect sizes varied between studies and enema modality. The overall results were heavily biased toward contrast enema reduction, largely due to the substantial difference in the number of studies included for each enema modality (46 CE, 9 UGNCE, 24 FGAE). Although to some extent the number of subjects adjusts for this (5362 subjects with CE vs 10 013 subjects with FGAE or UGNCE), it is not enough to fully account for the bias. Because the results for individual enema modalities are not subject to this bias, subsequent analyses were stratified by modality. Recurrence rates are reported by modality in Table 2. Overall recurrence rates were 12.7% (95% confidence interval [CI] 11.1%–14.4%, I2 = 28.8%) for CE, 7.5% (95% CI 5.7%–9.8%, I2 = 52.4%) for UGNCE, and 8.5% (95% CI 6.9%– 10.4%, I2 = 50.1%) for FGAE (Fig 2). The recurrence rates at 24 hours and 48 hours were low. Recurrence rates within 24 hours post reduction were 3.9% (95% CI 2.2%–6.7%, I2 = 47.0%) for CE, 3.9% (95% CI 1.5%–10.1%, I2 = 0.0%) for UGNCE, and 2.2% (95% CI 0.7%– 6.5%, I2 = 59.8%) for FGAE (Fig 3). Recurrence rates within 48 hours post reduction were 5.4% (95% CI 3.7%– 7.8%, I2 = 32.3%) for CE, 6.6% (95% CI 4.0%–10.7%, I2 = 0.0%) for UGNCE, and 2.7% (95% CI 1.2%–6.5%, I2 = 73.8%) for FGAE (Fig 4).
FIGURE 3 The 24-hour recurrence rates by enema modality.
Sensitivity Analyses Heterogeneity was found when combining studies by enema modality (Table 2). A study by Higgins et al15 suggests that I2 values from 0% to 50% represent a low to moderate amount of heterogeneity. Meta-regression was conducted to identify potential sources of heterogeneity. Enema modality was a significant source of heterogeneity (P = .002 FGAE, P = .028 UGNCE, P = .151 CE) for overall recurrence rates. Enema modality, however, was not a significant source of heterogeneity for 48-hour
(P = .461 CE, P = .706 UGNCE, P = .515 FGAE) or 24-hour recurrence rates (P = .471 CE, P = .702 UGNCE, P = .661 FGAE). Study quality, year of study publication, and country of origin were not found to be significant sources of heterogeneity for overall, 48-hour, or 24-hour recurrence rates. In post hoc regression analysis, estimated median age was not found to be significant for overall, 24-hour, or 48-hour recurrence rates. Because the study by Bai et al63 accounted for nearly one-third of the
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Bai et al63 had minimal effect on the pooled estimate. Learning effect was assessed by examining results by year. A significant trend was identified for quality score. Quality scores showed a significant trend (even using the multiple testing adjustment) with year (Spearman r = 0.504, P = .0004) for CE only. If studies are restricted to 1980 and later, there is no correlation between quality scores and year of publication (Supplemental Table 6). Of note, all studies of noncontrast reductions were published after 1980. The Begg test for publication bias was used and did not demonstrate bias for any of the outcome variables.
DISCUSSION This meta-analysis of published studies demonstrates that an individual’s risk of having an early (within 24 to 48 hours) recurrent intussusception after a successful enema reduction is low. In addition, the risk of recurrence is independent of enema type, study location, year of study completion, and study quality. The risk of recurrence in the first 24 hours post reduction is 2.2% to 3.9% and 2.7% to 6.6% in the first 48 hours. Assuming a 24-hour recurrence risk of 3.9%, it would require hospitalizing 26 patients for 24 hours to identify a single recurrence.
FIGURE 4 The 48-hour recurrence rates by enema modality.
patients included in the overall recurrence rate data for UGNCE, we conducted a weighted meta-regression to estimate the effect of each method.
Pooled estimates including the study by Bai et al63 were compared with pooled estimates excluding this study (Table 3). Inclusion of the study by
TABLE 3 Effect of Study Size on Overall Recurrence Rate
All studies, n = 16 178 CE FGAE UGNCE Excluding Bai et al,63 n = 11 050 CE FGAE UGNCE
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Recurrence Rate, % (95% CI)
P Value (Compared With CE)
10.455 (9.00–11.91) 6.984 (4.51–9.45) 7.038 (5.49–8.58)
.018 .002
10.467 (9.1–11.93) 7.466 (4.57–10.56) 7.049 (5.48–8.61)
.069 .002
This suggests that the vast majority of recurrences will not be identified by overnight hospitalization. In addition, recurrent intussusceptions can be safely and successfully reduced via repeat enema, and significant complications associated with enema reduction are rare. Multiple studies supporting outpatient management after successful enema reduction have demonstrated high rates of success with repeat enema reduction without delayed complications.16–20 In their series of 1340 patients, Niramis et al20 reported success rates as high as 96% with barium enema and 92% with air enema.
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There are several limitations to our study. First, because of the relative infrequency with which intussusception occurs, most of the studies included in this meta-analysis are retrospective studies. Many are small, and they vary widely in quality. As such, we attempted to measure and control for the quality of reporting for each study. Second, the studies differ in both known features, such as enema reduction technique or setting, and possibly unknown features that we were unable to measure. As these differences were expected, we used random effects modeling in our analyses, adjusting for the suspected
confounders and providing more conservative estimates of confidence limits. Finally, the number of studies reporting the specific timing of recurrences was limited. Despite these limitations, our study improves the understanding of the risk of early (within 24 to 48 hours) recurrence for an individual patient, and strongly suggests that that risk is low. In combination with the knowledge that serious postreduction complications are rare and that recurrences can be safely and successfully managed nonoperatively, it is reasonable to suggest that outpatient management in an
appropriately selected population of well-appearing patients would be appropriate. In addition to the risk of recurrence, providers need to consider clinical factors, such as ease of reduction, number of reduction attempts, and a patient’s hemodynamic status pre- and postreduction when making disposition decisions. Consistent with other recently published studies, our results support the development of multidisciplinary guidelines for the appropriate outpatient management of those asymptomatic patients who have had successful enema reduction.
view search strategies in finding child health systematic reviews in MEDLINE. Arch Pediatr Adolesc Med. 2008;162(2):111–116 UNICEF. State of the World’s Children 2012: Children in an Urban World. New York, NY: 2012 Schulz KF, Chalmers I, Hayes RJ, Altman DG. Empirical evidence of bias. Dimensions of methodological quality associated with estimates of treatment effects in controlled trials. JAMA. 1995;273(5):408–412 Moher D, Pham B, Jones A, et al. Does quality of reports of randomised trials affect estimates of intervention efficacy reported in meta-analyses? Lancet. 1998; 352(9128):609–613 Huedo-Medina TB, Sánchez-Meca J, MarínMartínez F, Botella J. Assessing heterogeneity in meta-analysis: Q statistic or I2 index? Psychol Methods. 2006;11(2):193–206 DerSimonian R, Laird N. Meta-analysis in clinical trials. Control Clin Trials. 1986;7(3):177–188 Hadidi AT, El Shal N. Childhood intussusception: a comparative study of nonsurgical management. J Pediatr Surg. 1999;34(2):304– 307 Higgins JP, Thompson SG, Deeks JJ, Altman DG. Measuring inconsistency in meta-analyses. BMJ. 2003;327(7414):557–560 Ein SH. Recurrent intussusception in children. J Pediatr Surg. 1975;10(5):751–755 Fecteau A, Flageole H, Nguyen LT, Laberge JM, Shaw KS, Guttman FM. Recurrent intussusception: safe use of hydrostatic enema. J Pediatr Surg. 1996;31(6):859–861
18. Daneman A, Alton DJ, Lobo E, Gravett J, Kim P, Ein SH. Patterns of recurrence of intussusception in children: a 17-year review. Pediatr Radiol. 1998;28(12):913–919 19. Stringer DA, Ein SH. Pneumatic reduction: advantages, risks and indications. Pediatr Radiol. 1990;20(6):475–477 20. Niramis R, Watanatittan S, Kruatrachue A, et al. Management of recurrent intussusception: nonoperative or operative reduction? J Pediatr Surg. 2010;45(11):2175–2180 21. Adekunle-Ojo AO, Craig AM, Ma L, Caviness AC. Intussusception: postreduction fasting is not necessary to prevent complications and recurrences in the emergency department observation unit. Pediatr Emerg Care. 2011;27(10):897–899 22. Beasley SW, Auldist AW, Stokes KB. Recurrent intussusception: barium or surgery? Aust N Z J Surg. 1987;57(1):11–14 23. Bonadio WA. Intussuception Reduced by Barium Enema. Clinical Pediatrics. 1988;27 (12):601–604 24. Champoux AN, Del Beccaro MA, NazarStewart V. Recurrent intussusception. Risks and features. Arch Pediatr Adolesc Med. 1994;148(5):474–478 25. Chung JL, Kong MS, Lin JN, Wang KL, Lou CC, Wong HF. Intussusception in infants and children: risk factors leading to surgical reduction. J Formos Med Assoc. 1994;93(6): 481–485 26. Collins DL, Pinckney LE, Miller KE, et al. Hydrostatic reduction of ileocolic intussusception: a second attempt in the operating
REFERENCES 1. Tate JE, Simonsen L, Viboud C, et al. Trends in intussusception hospitalizations among US infants, 1993-2004: implications for monitoring the safety of the new rotavirus vaccination program. Pediatrics. 2008;121(5). Available at: www.pediatrics.org/cgi/content/ full/121/5/e1125 2. Daneman A, Navarro O. Intussusception. Part 2: an update on the evolution of management. Pediatr Radiol. 2004;34(2):97–108, quiz 187 3. Al-Jazaeri A, Yazbeck S, Filiatrault D, Beaudin M, Emran M, Bütter A. Utility of hospital admission after successful enema reduction of ileocolic intussusception. J Pediatr Surg. 2006;41(5):1010–1013 4. Bajaj L, Roback MG. Postreduction management of intussusception in a children’s hospital emergency department. Pediatrics. 2003;112(6 pt 1):1302–1307 5. Herwig K, Brenkert T, Losek JD. Enemareduced intussusception management: is hospitalization necessary? Pediatr Emerg Care. 2009;25(2):74–77 6. Whitehouse JS, Gourlay DM, Winthrop AL, Cassidy LD, Arca MJ. Is it safe to discharge intussusception patients after successful hydrostatic reduction? J Pediatr Surg. 2010;45(6):1182–1186 7. Eklöf O, Reiter S. Recurrent intussusception. Analysis of a series treated with hydrostatic reduction. Acta Radiol Diagn (Stockh). 1978; 19(1B):250–258 8. Boluyt N, Tjosvold L, Lefebvre C, Klassen TP, Offringa M. Usefulness of systematic re-
9.
10.
11.
12.
13. 14.
15.
16. 17.
PEDIATRICS Volume 134, Number 1, July 2014
Downloaded from pediatrics.aappublications.org at Queen Mary, University of London on July 15, 2014
117
27.
28.
29.
30.
31.
32.
33.
34.
35.
36.
37.
38.
39.
40.
41.
42.
118
room with general anesthesia. J Pediatr. 1989;115(2):204–207 Courtney DF, Kelleher J, O’Donnell B. Intussusception—a change in policy where management has been satisfactory. Ir J Med Sci. 1981;150(3):69–72 Crankson SJ, Al-Rabeeah AA, Fischer JD, Al-Jadaan SA, Namshan MA. Idiopathic intussusception in infancy and childhood. Saudi Med J. 2003;24(suppl):S18–S20 Crystal P, Hertzanu Y, Farber B, Shabshin N, Barki Y. Sonographically guided hydrostatic reduction of intussusception in children. J Clin Ultrasound. 2002;30(6):343–348 Dawod ST, Osundwa VM. Intussusception in children under 2 years of age in the State of Qatar: analysis of 67 cases. Ann Trop Paediatr. 1992;12(1):121–126 Denenholz EJ, Feher GS. Barium reduction of intussusception in infancy. Calif Med. 1955;82(1):8–12 Eshel G, Barr J, Heyman E, et al. Intussusception: a 9-year survey (1986-1995). J Pediatr Gastroenterol Nutr. 1997;24(3): 253–256 Freund H, Hurvitz H, Schiller M. Etiologic and therapeutic aspects of intussusception in childhood. Am J Surg. 1977;134(2):272–274 Goon Hong K. Barium enema reduction of intussusception in children. Med J Malaysia. 1986;41(2):166–169 Hiller HG. Barium enema reduction of intussusception in infancy. Med J Aust. 1955; 42(5):157 Kaushal V. Role of barium enema in acute intussusception. Indian Pediatr. 1972;9(3): 152–154 Kellogg HB Jr, Bill AH Jr. The treatment of intussusception. An evaluation of surgical and of barium enema reduction in a series of eighty cases. Am J Surg. 1961;101:626– 632 Kim YS, Rhu JH. Intussusception in infancy and childhood. Analysis of 385 cases. Int Surg. 1989;74(2):114–118 Korttila K. On the treatment of intussusception in children. Acta Chir Scand. 1952;104(1):45–55 Krasna IH, Benjamin BG, Zitsman JL, Rosenfeld D. Intussusception in childhood. N J Med. 1990;87(9):715–720 Le Masne A, Lortat-Jacob S, Sayegh N, Sannier N, Brunelle F, Cheron G. Intussusception in infants and children: feasibility of ambulatory management. Eur J Pediatr. 1999;158(9):707–710 Liu KW, MacCarthy J, Guiney EJ, Fitzgerald RJ. Intussusception—current trends in management. Arch Dis Child. 1986;61(1): 75–77
43. Mackay AJ, MacKellar A, Sprague P. Intussusception in children: a review of 91 cases. Aust N Z J Surg. 1987;57(1):15–17 44. 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(2):507–511 45. Minami A, Fujii K. Intussusception in children: hydrostatic reduction. Am J Dis Child. 1975;129(3):346–348 46. Nordshus T, Swensen T. Barium enema in pediatric intussusception; a review of 108 cases. Rofo. 1979;131(1):42–46 47. Okuyama H, Nakai H, Okada A. Is barium enema reduction safe and effective in patients with a long duration of intussusception? [see comment] Pediatr Surg Int. 1999;15(2):105–107 48. Packard GB. The treatment of intussusception in infancy and childhood. Pediatrics. 1955; 15(3):291–297 49. Paes RA, Hyde I, Griffiths DM. The management of intussusception. Br J Radiol. 1988; 61(723):187–189 50. Palder SB, Ein SH, Stringer DA, Alton D. Intussusception: barium or air? [see comment] J Pediatr Surg. 1991;26(3):271–274, discussion 274–275 51. Ravitch MM. Intussusception in infancy and childhood; an analysis of seventy-seven cases treated by barium enema. N Engl J Med. 1958;259(22):1058–1064 52. Reid R, Kulkarni M, Beasley S. The potential for improvement in outcome of children with intussusception in the South Island. N Z Med J. 2001;114(1141):441–443 53. Riebel TW, Nasir R, Weber K. US-guided hydrostatic reduction of intussusception in children. Radiology. 1993;188(2):513–516 54. Shehata S, El Kholi N, Sultan A, El Sahwi E. Hydrostatic reduction of intussusception: barium, air, or saline? Pediatr Surg Int. 2000;16(5-6):380–382 55. Simon RA, Hugh TJ, Curtin AM. Childhood intussusception in a regional hospital. Aust N Z J Surg. 1994;64(10):699–702 56. Skipper RP, Boeckman CR, Klein RL. Childhood intussusception. Surg Gynecol Obstet. 1990;171(2):151–153 57. Tangi VT, Bear JW, Reid IS, Wright JE. Intussusception in Newcastle in a 25 year period. Aust N Z J Surg. 1991;61(8):608–613 58. van den Ende ED, Allema JH, Hazebroek FW, Breslau PJ. Success with hydrostatic reduction of intussusception in relation to duration of symptoms. Arch Dis Child. 2005; 90(10):1071–1072 59. Wayne ER, Campbell JB, Burrington JD, Davis WS. Management of 344 children
60.
61.
62.
63.
64.
65.
66.
67.
68.
69.
70.
71.
72.
with intussusception. Radiology. 1973;107(3): 597–601 West KW, Stephens B, Vane DW, Grosfeld JL. Intussusception: current management in infants and children. Surgery. 1987;102(4): 704–710 Winstanley JH, Doig CM, Brydon H. Intussusception: the case for barium reduction. J R Coll Surg Edinb. 1987;32(5):285–287 Yang CM, Hsu HY, Tsao PN, Chang MH, Lin FY. Recurrence of intussusception in childhood. Acta Paediatr Taiwan. 2001;42(3): 158–161 Bai YZ, Qu RB, Wang GD, et al. Ultrasoundguided hydrostatic reduction of intussusceptions by saline enema: a review of 5218 cases in 17 years. Am J Surg. 2006;192(3): 273–275 Chan KL, Saing H, Peh WC, et al. Childhood intussusception: ultrasound-guided Hartmann’s solution hydrostatic reduction or barium enema reduction? J Pediatr Surg. 1997;32 (1):3–6 Choi SO, Park WH, Woo SK. Ultrasoundguided water enema: an alternative method of nonoperative treatment for childhood intussusception. J Pediatr Surg. 1994;29(4): 498–500 Essa AE, Eltayeb AA, Mansour E. Evaluation of the role of dexamethasone in decreasing early recurrence of intussusception: Using ultrasound-guided saline enema for reduction. Surgical Practice. 2011;15(4):114– 119 González-Spínola J, Del Pozo G, Tejedor D, Blanco A. Intussusception: the accuracy of ultrasound-guided saline enema and the usefulness of a delayed attempt at reduction. J Pediatr Surg. 1999;34(6):1016– 1020 Krishnakumar HS, Hameed S, Umamaheshwari . Ultrasound guided hydrostatic reduction in the management of intussusception. Indian J Pediatr. 2006;73(3):217–220 Rohrschneider WK, Tröger J. Hydrostatic reduction of intussusception under US guidance. Pediatr Radiol. 1995;25(7):530– 534 Fragoso AC, Campos M, Tavares C, CostaPereira A, Estevão-Costa J. Pneumatic reduction of childhood intussusception. Is prediction of failure important? J Pediatr Surg. 2007;42(9):1504–1508 Gu L, Zhu H, Wang S, Han Y, Wu X, Miao H. Sonographic guidance of air enema for intussusception reduction in children. Pediatr Radiol. 2000;30(5):339–342 Katz M, Phelan E, Carlin JB, Beasley SW. Gas enema for the reduction of intussusception: relationship between clinical signs
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and symptoms and outcome. AJR Am J Roentgenol. 1993;160(2):363–366 73. Lehnert T, Sorge I, Till H, Rolle U. Intussusception in children—clinical presentation, diagnosis and management. Int J Colorectal Dis. 2009;24(10):1187–1192 74. Lui KW, Wong HF, Cheung YC, et al. Air enema for diagnosis and reduction of intussusception in children: clinical experience and fluoroscopy time correlation. J Pediatr Surg. 2001;36(3):479–481 75. McDermott VG, Taylor T, Mackenzie S, Hendry GM. Pneumatic reduction of intussusception: clinical experience and factors affecting outcome. Clin Radiol. 1994;49(1): 30–34
76. Mensah YB, Glover-Addy H, Etwire V, et al. Pneumatic reduction of intussusception in children at Korle Bu Teaching Hospital: an initial experience. Afr J Paediatr Surg. 2011;8(2):176–181 77. Renwick A, Beasley S, Phelan E. Intussusception: recurrence following gas (oxygen) enema reduction. Pediatr Surg Int. 1992;7(5):361– 363 78. Rubí I, Vera R, Rubí SC, et al. Air reduction of intussusception. Eur J Pediatr Surg. 2002;12(6):387–390 79. Tamanaha K, Wimbish K, Talwalkar YB, Ashimine K. Air reduction of intussusception in infants and children. J Pediatr. 1987;111(5):733–736
80. Tareen F, Ryan S, Avanzini S, Pena V, Mc Laughlin D, Puri P. Does the length of the history influence the outcome of pneumatic reduction of intussusception in children? Pediatr Surg Int. 2011;27(6):587–589 81. Todani T, Sato Y, Watanabe Y, Toki A, Uemura S, Urushihara N. Air reduction for intussusception in infancy and childhood: ultrasonographic diagnosis and management without x-ray exposure. Z Kinderchir. 1990;45(4):222–226 82. Wang G, Liu XG, Zitsman JL. Nonfluoroscopic reduction of intussusception by air enema. World J Surg. 1995;19(3):435–438 83. Yoon CH, Kim HJ, Goo HW. Intussusception in children: US-guided pneumatic reduction— initial experience. Radiology. 2001;218(1):85–88
THE NEW LIBRARY: A few weeks ago, my wife and I went downtown to the Public Library to hear a talk. Amazingly, the place was packed. I have been in libraries of various sizes over the past year: the small Charlotte, VT library, the huge New York City Library, and the medium sized Burlington Library. All were humming with activity. A few years ago, many predicted the demise of the public library citing the rise of the internet, e-readers, and social media. However, libraries have been busy re-inventing themselves and not only have staved off extinction but are thriving. As reported in The New York Times (U.S.: March 7, 2014), physical visits to libraries are off the charts. For example, the Boston Public Library had an almost 50% increase in the number of visitors in 2012 to more than 1.7 million. My son can borrow movies, physical books, and electronic books from the Burlington Library. Some libraries offer access to 3-D printers, laser cutters, and milling machines, while others lend out musical instruments or plots of land on which to practice organic farming. Many are trying to lure visitors with wide open spaces, lobbies, and even food courts. I see people eating in libraries all the time – which when I was a child would have led to automatic dismissal and revocation of my library card. Librarians too have different jobs. Rather than answering single questions, they may act as information navigators to help customers sift through many, many answers. While some libraries have gone completely digital – meaning that no books are present at all – all-digital libraries have not been entirely successful and have often brought back books. The reason is that while almost a third of Americans read e-books, in 2012 less than 5% read e-books only. I for one am thrilled with the change. I like the fact there are still large tables and comfy chairs, but now there are food courts, computers, internet access, and all kinds of activities that appeal to not only my parents and I, but my children as well. Noted by WVR, MD
PEDIATRICS Volume 134, Number 1, July 2014
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Recurrence Rates After Intussusception Enema Reduction: A Meta-analysis Matthew P. Gray, Shun-Hwa Li, Raymond G. Hoffmann and Marc H. Gorelick Pediatrics 2014;134;110; originally published online June 16, 2014; DOI: 10.1542/peds.2013-3102 Updated Information & Services
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PEDIATRICS is the official journal of the American Academy of Pediatrics. A monthly publication, it has been published continuously since 1948. PEDIATRICS is owned, published, and trademarked by the American Academy of Pediatrics, 141 Northwest Point Boulevard, Elk Grove Village, Illinois, 60007. Copyright © 2014 by the American Academy of Pediatrics. All rights reserved. Print ISSN: 0031-4005. Online ISSN: 1098-4275.
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