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Intussusception is the most common cause of intestinal obstruction among children and occurs when one segment of bowel invaginates into an adjacent distal segment. If left untreated, this can lead to bowel infarction, sepsis and death. The exact aetiology of the condition remains unclear in the majority of cases with a small proportion of cases occurring secondary to anatomical abnormalities. Knowledge of the condition is important as early diagnosis may lead to successful enema reduction, lower operative reduction and resection rates and reduced morbidity.1 It is important to obtain local data of the condition to both understand the possible aetiology and clinical picture of the condition in this setting as well as evaluate radiological and surgical outcomes. There has not been a published study of intussusception in the North Island since a 1981 series of 98 cases.2 This study was initiated to obtain a comprehensive summary of intussusception including demographics, clinical presentation, management and outcome of intussusception as seen at Starship Hospital, New Zealands largest childrens hospital. Methods A retrospective case-based study of all patients with intussusception presenting to the Starship Childrens Hospital, Auckland between 1 January 1998 to 31 December 2007 was performed. The Ethical Review Committee of Auckland Hospital granted exemption from requiring ethical approval. Starship Hospital provides secondary paediatric care for the Auckland region as well as much of the northern half of the North Island for paediatric surgical conditions. It also contains the only dedicated paediatric intensive care unit in New Zealand. Many patients are referred to the hospital from regional centres for investigation and management. The hospital records of all admissions to the Starship Hospital with a primary or secondary diagnosis of intussusception (as coded by the International Classification of Disease codes (ICD 9 and 10- K56.1 and 560) discharged within this period were reviewed. Data was collected using a standard proforma. Information collected included demographic factors, presenting symptoms and signs, time and onset of symptoms, time to diagnosis, radiological features, and treatment modality (air enema reduction, surgical reduction and resection outcomes and complications). Details of the presenting history were obtained from the clinical notes of the admitting doctor and standardised definitions were used for each symptom and sign noted. Radiology reports by consultant radiologists were reviewed and findings documented. Histological reports were reviewed and pathological lead points were also noted. A univariate analysis was conducted to identify features associated with failed air enema reduction and need for surgery. Microsoft Excel (Microsoft Corporation 2003) software was used for the data storage and statistical analysis. Results There were 210 discharges with a diagnosis of intussusception over this period with 197 individual patients. There were 8 patients who accounted for 13 repeat admissions. 6 patients were incorrectly coded and excluded. 2 further patients who had prior operative resection in the Pacific Islands and who were transferred for postoperative management were excluded. This left 189 patients for analysis. DemographicsThe median age was 10 months (range 3 days to 14 years). 122 (66%) of the patients were boys giving a male to female ratio of 2:1. There was no significant seasonal variation in the incidence of cases or change in incidence rate over the period. The median length of stay was 31 hours (range 8 to 408). Ethnicity data is shown below in Figure 1. 168/189 (89%) patients were from the Auckland region leaving 20 patients transferred from peripheral New Zealand hospitals (Whangarei, New Plymouth, Gisborne, Whakatane) and one from Samoa. DiagnosisThe range and frequency of presenting symptoms and signs is shown in the table below. 86/189 (45.5%) patients presented less than 24 hours from the onset of abdominal pain. The frequency of various clinical signs and symptoms are noted in Table 1 below. Only 57/189 (30%) presented with the classic triad of abdominal pain, vomiting and rectal bleeding. Figure 1. Ethnicity of children in study (%) Table 1. Frequency of presenting signs and symptoms (%) The relative frequency of radiological sign demonstrated by plain film and ultrasound examination are shown below in Table 2. A mass on plain radiograph was present in a similar proportion of patients as that found clinically (41%). No patients had evidence of perforation on plain radiograph. Table 2. Frequency of findings on plain film and ultrasound Management150 children proceed for air enema reduction. Barium enema was not undertaken at Starship Hospital for reduction purposes. 105/150 (70%) patients had a successful air enema on the first attempt. A second attempt occurred on 37 occasions with success in 13 (35.1%) On five occasions a third attempt was undertaken but was not successful in any patients. This gave an overall air enema reduction rate of 78.7% (118/150). Perforation occurred in two cases (1.5%). 54/189 patients proceeded to theatre of whom 22 proceeded directly to theatre without attempt of air enema reduction. Surgical reduction was attempted in 51 patients and was successful in 36 (71%). This was performed laparoscopically in 17 cases and was successful in 12 (71%). 26/54 (48%) patients required surgical resection for nonviable bowel, perforation or excision of pathological lead point. There were few intraoperative or postoperative complications. Five patients developed postoperative ileus, three required total parenteral nutrition, two required further operation (perforation) and two patients required treatment in the intensive care unit. There was one case of hospital readmission for postoperative abdominal pain. There were no recurrences of intussusception in surgically managed patients or patient deaths. 19 patients were noted to have a pathological lead point. The range and frequency of pathological lead points are shown below in Table 3. Predictors of outcomeThe presence of abdominal distention on clinical examination and plain film obstruction were the strongest predictors of enema failure and need for resection at surgery. There was also a significant association between duration of symptoms and enema failure and need for resection. Maori & Pacific patients were more likely to have failed enema 35% vs 13% compared to European (p=0.005) and proceed to surgery 38% vs 23% (p=0.04) despite no difference in duration of symptoms between the groups. Table 3. Number and type of pathological leadpoint Table 4. Factors associated with enema failure and surgical resection RR: relative risk; n/s: not statistically significant. Table 4 above demonstrates the increased risk of enema failure and need for surgical resection associated with each clinical or radiographic finding. Auckland vs Rest of New ZealandPatients from outside the greater Auckland region were more likely to have failed surgical reduction and to have surgical resection than patients from the Auckland region as shown in Table 5. However the time to treatment between the two groups did not differ significantly. Six patients transferred had prior attempt at barium enema reduction. Table 5. Comparison of patients in Auckland versus the Rest of New Zealand Discussion This study aimed to characterize and evaluate the patients, presentation and management of intussusception at Starship Hospital. There have only been two prior studies of intussusception in New Zealand. The first was Raudkivis series in 1981 which examined 96 patients and found a low (barium) enema reduction rate of 19%, and a subsequently high operative rate of 88% including a resection rate of 28%2. The second study was Reids series of 81 South Island cases in 2001 which demonstrated a similarly low barium enema reduction rate of 32% with a similar air enema reduction rate to this study of 79%3. This study hence is the largest review of intussusception in New Zealand. The median age and male predominance found in patients in this study is similar to that quoted in the literature.1 The lack of a seasonal variation suggests that an infectious aetiology may be less likely in intussusception in New Zealand. The proportion of cases with the accepted symptoms and signs of intussusception are similar to other reports.4,5However certain symptoms and signs were shown to be more helpful in making the diagnosis. This study has shown that a history of pallor and the presence of an abdominal mass are both common features of intussusception and can be vital in differentiating intussusception from gastroenteritis and other causes of vomiting and abdominal pain. Plain radiography was also shown to be an important diagnostic aid in the hands of experienced radiologists with a very high proportion having an abnormal film, and a lesser but significant proportion having a mass seen on x-ray. Enema reduction rates were similar to the range quoted in the literature but not as high as that found in some other studies which have shown rates closer to 90%.4,5 The possibilities for this are numerous. One reason is that Starship Hospital receives a significant number of referrals from other regional hospitals, and some referrals were following failed enema reduction in district hospitals. Furthermore the delay in being seen and treated in another hospital as well as the delay in transfer could lead to a less likely chance of successful enema reduction. The rate of perforation following air enema reduction at 1.5% was similar to the rate in other published studies5. We have shown that certain factors are associated with failed enema; with both clinical distension and plain film evidence of obstruction predictive of failed enema and need for surgery. A similar relationship exists for duration of symptoms till enema treatment- emphasizing the importance of prompt diagnosis and treatment/transfer. The reasons for Maori and Pacific patients having higher rates of failed enema reduction than their European counterparts are unclear as times from symptoms to presentation were similar. One possibility is that there is a fundamental difference in pathophysiology of the condition in these ethnicities leading to these differences in outcome. Another possibility is that there was a delay in recognition of symptoms by parents in the Maori and Pacific group effectively leading to a delay in presentation. Surgical resection rates found in this study were similar to those quoted elsewhere in the literature.4\u20136 However a higher number of children (27%) proceeded to surgery when compared to other studies. This may be partly explained by the high numbers of patients transferred as detailed above. Laparoscopic reduction was successful in the majority (71%) of cases where attempted and at a similar rate to that quoted in the literature.. Low postoperative morbidity and zero mortality were typical of modern day management of intussusception. The rate of pathological lead point (10%) was also similar to that found in other studies7,8 (2\u201312%) with the two most common being Meckels diverticulum and duplication cyst. This study does however demonstrate a higher rate of duplication cyst (6/19) than that quoted in other studies. The exact reason for this is unclear. This studys limitations are that this was a retrospective review of case notes and thus the findings were dependant on the clinical competency of the admitting doctor and the legibility and completion of the documentation. If a particular symptom or sign was not reported in the notes (by either emergency or surgical admitting staff) then it was presumed to be absent. This may of course not be true and that the symptom or sign may not have been sought, or alternatively may have been sought but not documented. A prospective study would be better equipped to review the clinical presentation as it would ensure that each relevant symptom and sign would be sought as well as provide more information on how children were being triaged to air enema reduction or directly to surgery. The key issue in the management of intussusception in New Zealand is whether any child with intussusception seen in a peripheral hospital is transferred directly to a tertiary centre once stabilised or whether regional outcomes are of a sufficient standard to allow management in these regions. A study conducted in the United States into intussusception outcomes compared smaller and larger hospitals and showed children managed in large US childrens hospitals had decreased risk of operative care and shorter length of stay10. This was confirmed in a review conducted in the United Kingdom which suggested \u201call confirmed cases should be resuscitated then referred to tertiary centres for treatment\u201d11. In New Zealand this may be further true as there may not be sufficient case volume of intussusception in regional hospitals to maintain high standards in enema treatment which is evidenced by a recent study that showed only one case of intussusception was seen in a one year period at a district hospital in New Zealand12. In this study all patients who were transferred from peripheral hospitals only had barium enema attempts (no air enema reductions) which confirms the lower success rate of this method of reduction and suggests that early transfer to a paediatric surgical centre may be preferable if facilities for air enema reduction are not available. However further research is required into the management and outcomes of all children treated in peripheral hospitals to determine if centralising treatment of intussusception where appropriate would lead to improved outcomes. The findings of this study provide useful preliminary data given the well known difficulties of obtaining national data on intussusception in New Zealand3. Wherever children are managed, this study has shown that it is vital for clinicians to know that intussusception does not often present in classical fashion, and early diagnosis and management leads to an increased likelihood of successful air enema and reduced need for operative management. This study has also demonstrated that there are differences in outcome for children with intussusception based on ethnicity which is a finding not previously demonstrated in the literature.

Summary

Abstract

Aim

To review the demographics, presenting features, rates of air enema reduction success, prevalence of pathological lead points and surgical intervention rates and outcomes in patients with intussusception at Starship Childrens Hospital (Auckland, New Zealand). To use this data to guide management of children at a national level in New Zealand.

Method

Retrospective case series. Patients discharged from Starship Childrens Hospital between 1 January 1998 and 31 December 2007 with a diagnosis of intussusception were obtained from coding data.

Results

189 patients were analysed. 30% presented with the classic triad of pain, rectal bleeding and mass. 150/189 proceeded to air enema reduction which was successful in 118 (78.7%) of cases with 2 perforations. 54/189 (28.6%) proceeded for operative reduction of which 26 patients required surgical resection. Clinical and radiological evidence of bowel obstruction and duration of symptoms were associated with failed enema and surgical resection.

Conclusion

Intussusception only occasionally presents with the typical triad of abdominal pain, rectal bleeding and abdominal mass. Air enema reduction is successful at this institution with a low level of complication. M ori and Pacific patients had higher rates of failed enema reduction and need for surgery compared to European patients. Further research is needed from peripheral centres to evaluate outcomes of children treated in district hospitals to identify how and where these children are best managed.

Author Information

Hemal Kodikara, Surgical Registrar, Starship Childrens Hospital, Auckland; Amiria Lynch, Surgical Registrar, Starship Childrens Hospital, Auckland; Phillip Morreau, Paediatric Surgeon, Starship Childrens Hospital, Auckland; Sally Vogel, Paediatric Radiologist, Starship Childrens Hospital, Auckland

Acknowledgements

We thank Peter Reed (Childrens Research Centre, Starship Hospital) for assistance with statistical analysis.

Correspondence

Dr Hemal Kodikara, Surgical Registrar, Starship Childrens Hospital, Auckland, New Zealand.

Correspondence Email

hemal83@hotmail.com

Competing Interests

None.

-  Blanch A, Perel B, Acworth J. Paediatric intussusception: epidemiology and outcome. Emergency Medicine Australasia 2007;19:45-50.--  Raudkivi P. Smith L. Intussusception: analysis of 98 cases. British Journal of Surgery. 1981;68:645-648.--  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;441-443.--  Justice F, Auldist A, Bines J. Intussusception: trends in clinical presentation and management. Journal of Gastroenterology and Hepatology 2006;21:842-846.--  Kaiser A, Applegate KE, Ladd AP. Current success in the treatment of intussusception in children. Surgery. 2007;142:469-77.--  Saxena A, Hollwarth E. Factors influencing management and comparison of outcomes in paediatric intussusceptions. Acta Paediatr. 2007 Aug;96(8):1199-202. Epub 2007 Jun 21.--  Somme S, To T, Langer J. Factors determining the need for operative reduction in children with intussusception: a population-based study. Journal of Paediatric Surgery 2006;41:1014-1019.--  Buettche M, Baier G, Bonhoeffer J, et al. Three year surveillance of intussusception in children in Switzerland. Pediatrics 2007;120:473-480.--  Webby RJ, Bines JE, Barnes GL, et al. Intussusception in the Northern Territory: the incidence is low in Aboriginal and Torres Strait Islander children. Journal of Paediatrics and Child Health. 2006;42:235-239.--  Bratton. S. Intussusception: Hospital size and risk of surgery. Pediatrics 2001;107;299-303.--  Calder FR, Tan S, Kitteringham L, et al. Patterns of management of intussusception outside tertiary centres. Journal of Pediatric Surgery 2001;36:312-315.--  Peng S, Fancourt M, Gilkison W, et al. Paediatric surgery carried out by general surgeons: A rural NZ experience. A N Z Journal of Surgery. 2008;78:662-664.-

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contact nzmj@nzma.org.nz

View Article PDF

Intussusception is the most common cause of intestinal obstruction among children and occurs when one segment of bowel invaginates into an adjacent distal segment. If left untreated, this can lead to bowel infarction, sepsis and death. The exact aetiology of the condition remains unclear in the majority of cases with a small proportion of cases occurring secondary to anatomical abnormalities. Knowledge of the condition is important as early diagnosis may lead to successful enema reduction, lower operative reduction and resection rates and reduced morbidity.1 It is important to obtain local data of the condition to both understand the possible aetiology and clinical picture of the condition in this setting as well as evaluate radiological and surgical outcomes. There has not been a published study of intussusception in the North Island since a 1981 series of 98 cases.2 This study was initiated to obtain a comprehensive summary of intussusception including demographics, clinical presentation, management and outcome of intussusception as seen at Starship Hospital, New Zealands largest childrens hospital. Methods A retrospective case-based study of all patients with intussusception presenting to the Starship Childrens Hospital, Auckland between 1 January 1998 to 31 December 2007 was performed. The Ethical Review Committee of Auckland Hospital granted exemption from requiring ethical approval. Starship Hospital provides secondary paediatric care for the Auckland region as well as much of the northern half of the North Island for paediatric surgical conditions. It also contains the only dedicated paediatric intensive care unit in New Zealand. Many patients are referred to the hospital from regional centres for investigation and management. The hospital records of all admissions to the Starship Hospital with a primary or secondary diagnosis of intussusception (as coded by the International Classification of Disease codes (ICD 9 and 10- K56.1 and 560) discharged within this period were reviewed. Data was collected using a standard proforma. Information collected included demographic factors, presenting symptoms and signs, time and onset of symptoms, time to diagnosis, radiological features, and treatment modality (air enema reduction, surgical reduction and resection outcomes and complications). Details of the presenting history were obtained from the clinical notes of the admitting doctor and standardised definitions were used for each symptom and sign noted. Radiology reports by consultant radiologists were reviewed and findings documented. Histological reports were reviewed and pathological lead points were also noted. A univariate analysis was conducted to identify features associated with failed air enema reduction and need for surgery. Microsoft Excel (Microsoft Corporation 2003) software was used for the data storage and statistical analysis. Results There were 210 discharges with a diagnosis of intussusception over this period with 197 individual patients. There were 8 patients who accounted for 13 repeat admissions. 6 patients were incorrectly coded and excluded. 2 further patients who had prior operative resection in the Pacific Islands and who were transferred for postoperative management were excluded. This left 189 patients for analysis. DemographicsThe median age was 10 months (range 3 days to 14 years). 122 (66%) of the patients were boys giving a male to female ratio of 2:1. There was no significant seasonal variation in the incidence of cases or change in incidence rate over the period. The median length of stay was 31 hours (range 8 to 408). Ethnicity data is shown below in Figure 1. 168/189 (89%) patients were from the Auckland region leaving 20 patients transferred from peripheral New Zealand hospitals (Whangarei, New Plymouth, Gisborne, Whakatane) and one from Samoa. DiagnosisThe range and frequency of presenting symptoms and signs is shown in the table below. 86/189 (45.5%) patients presented less than 24 hours from the onset of abdominal pain. The frequency of various clinical signs and symptoms are noted in Table 1 below. Only 57/189 (30%) presented with the classic triad of abdominal pain, vomiting and rectal bleeding. Figure 1. Ethnicity of children in study (%) Table 1. Frequency of presenting signs and symptoms (%) The relative frequency of radiological sign demonstrated by plain film and ultrasound examination are shown below in Table 2. A mass on plain radiograph was present in a similar proportion of patients as that found clinically (41%). No patients had evidence of perforation on plain radiograph. Table 2. Frequency of findings on plain film and ultrasound Management150 children proceed for air enema reduction. Barium enema was not undertaken at Starship Hospital for reduction purposes. 105/150 (70%) patients had a successful air enema on the first attempt. A second attempt occurred on 37 occasions with success in 13 (35.1%) On five occasions a third attempt was undertaken but was not successful in any patients. This gave an overall air enema reduction rate of 78.7% (118/150). Perforation occurred in two cases (1.5%). 54/189 patients proceeded to theatre of whom 22 proceeded directly to theatre without attempt of air enema reduction. Surgical reduction was attempted in 51 patients and was successful in 36 (71%). This was performed laparoscopically in 17 cases and was successful in 12 (71%). 26/54 (48%) patients required surgical resection for nonviable bowel, perforation or excision of pathological lead point. There were few intraoperative or postoperative complications. Five patients developed postoperative ileus, three required total parenteral nutrition, two required further operation (perforation) and two patients required treatment in the intensive care unit. There was one case of hospital readmission for postoperative abdominal pain. There were no recurrences of intussusception in surgically managed patients or patient deaths. 19 patients were noted to have a pathological lead point. The range and frequency of pathological lead points are shown below in Table 3. Predictors of outcomeThe presence of abdominal distention on clinical examination and plain film obstruction were the strongest predictors of enema failure and need for resection at surgery. There was also a significant association between duration of symptoms and enema failure and need for resection. Maori & Pacific patients were more likely to have failed enema 35% vs 13% compared to European (p=0.005) and proceed to surgery 38% vs 23% (p=0.04) despite no difference in duration of symptoms between the groups. Table 3. Number and type of pathological leadpoint Table 4. Factors associated with enema failure and surgical resection RR: relative risk; n/s: not statistically significant. Table 4 above demonstrates the increased risk of enema failure and need for surgical resection associated with each clinical or radiographic finding. Auckland vs Rest of New ZealandPatients from outside the greater Auckland region were more likely to have failed surgical reduction and to have surgical resection than patients from the Auckland region as shown in Table 5. However the time to treatment between the two groups did not differ significantly. Six patients transferred had prior attempt at barium enema reduction. Table 5. Comparison of patients in Auckland versus the Rest of New Zealand Discussion This study aimed to characterize and evaluate the patients, presentation and management of intussusception at Starship Hospital. There have only been two prior studies of intussusception in New Zealand. The first was Raudkivis series in 1981 which examined 96 patients and found a low (barium) enema reduction rate of 19%, and a subsequently high operative rate of 88% including a resection rate of 28%2. The second study was Reids series of 81 South Island cases in 2001 which demonstrated a similarly low barium enema reduction rate of 32% with a similar air enema reduction rate to this study of 79%3. This study hence is the largest review of intussusception in New Zealand. The median age and male predominance found in patients in this study is similar to that quoted in the literature.1 The lack of a seasonal variation suggests that an infectious aetiology may be less likely in intussusception in New Zealand. The proportion of cases with the accepted symptoms and signs of intussusception are similar to other reports.4,5However certain symptoms and signs were shown to be more helpful in making the diagnosis. This study has shown that a history of pallor and the presence of an abdominal mass are both common features of intussusception and can be vital in differentiating intussusception from gastroenteritis and other causes of vomiting and abdominal pain. Plain radiography was also shown to be an important diagnostic aid in the hands of experienced radiologists with a very high proportion having an abnormal film, and a lesser but significant proportion having a mass seen on x-ray. Enema reduction rates were similar to the range quoted in the literature but not as high as that found in some other studies which have shown rates closer to 90%.4,5 The possibilities for this are numerous. One reason is that Starship Hospital receives a significant number of referrals from other regional hospitals, and some referrals were following failed enema reduction in district hospitals. Furthermore the delay in being seen and treated in another hospital as well as the delay in transfer could lead to a less likely chance of successful enema reduction. The rate of perforation following air enema reduction at 1.5% was similar to the rate in other published studies5. We have shown that certain factors are associated with failed enema; with both clinical distension and plain film evidence of obstruction predictive of failed enema and need for surgery. A similar relationship exists for duration of symptoms till enema treatment- emphasizing the importance of prompt diagnosis and treatment/transfer. The reasons for Maori and Pacific patients having higher rates of failed enema reduction than their European counterparts are unclear as times from symptoms to presentation were similar. One possibility is that there is a fundamental difference in pathophysiology of the condition in these ethnicities leading to these differences in outcome. Another possibility is that there was a delay in recognition of symptoms by parents in the Maori and Pacific group effectively leading to a delay in presentation. Surgical resection rates found in this study were similar to those quoted elsewhere in the literature.4\u20136 However a higher number of children (27%) proceeded to surgery when compared to other studies. This may be partly explained by the high numbers of patients transferred as detailed above. Laparoscopic reduction was successful in the majority (71%) of cases where attempted and at a similar rate to that quoted in the literature.. Low postoperative morbidity and zero mortality were typical of modern day management of intussusception. The rate of pathological lead point (10%) was also similar to that found in other studies7,8 (2\u201312%) with the two most common being Meckels diverticulum and duplication cyst. This study does however demonstrate a higher rate of duplication cyst (6/19) than that quoted in other studies. The exact reason for this is unclear. This studys limitations are that this was a retrospective review of case notes and thus the findings were dependant on the clinical competency of the admitting doctor and the legibility and completion of the documentation. If a particular symptom or sign was not reported in the notes (by either emergency or surgical admitting staff) then it was presumed to be absent. This may of course not be true and that the symptom or sign may not have been sought, or alternatively may have been sought but not documented. A prospective study would be better equipped to review the clinical presentation as it would ensure that each relevant symptom and sign would be sought as well as provide more information on how children were being triaged to air enema reduction or directly to surgery. The key issue in the management of intussusception in New Zealand is whether any child with intussusception seen in a peripheral hospital is transferred directly to a tertiary centre once stabilised or whether regional outcomes are of a sufficient standard to allow management in these regions. A study conducted in the United States into intussusception outcomes compared smaller and larger hospitals and showed children managed in large US childrens hospitals had decreased risk of operative care and shorter length of stay10. This was confirmed in a review conducted in the United Kingdom which suggested \u201call confirmed cases should be resuscitated then referred to tertiary centres for treatment\u201d11. In New Zealand this may be further true as there may not be sufficient case volume of intussusception in regional hospitals to maintain high standards in enema treatment which is evidenced by a recent study that showed only one case of intussusception was seen in a one year period at a district hospital in New Zealand12. In this study all patients who were transferred from peripheral hospitals only had barium enema attempts (no air enema reductions) which confirms the lower success rate of this method of reduction and suggests that early transfer to a paediatric surgical centre may be preferable if facilities for air enema reduction are not available. However further research is required into the management and outcomes of all children treated in peripheral hospitals to determine if centralising treatment of intussusception where appropriate would lead to improved outcomes. The findings of this study provide useful preliminary data given the well known difficulties of obtaining national data on intussusception in New Zealand3. Wherever children are managed, this study has shown that it is vital for clinicians to know that intussusception does not often present in classical fashion, and early diagnosis and management leads to an increased likelihood of successful air enema and reduced need for operative management. This study has also demonstrated that there are differences in outcome for children with intussusception based on ethnicity which is a finding not previously demonstrated in the literature.

Summary

Abstract

Aim

To review the demographics, presenting features, rates of air enema reduction success, prevalence of pathological lead points and surgical intervention rates and outcomes in patients with intussusception at Starship Childrens Hospital (Auckland, New Zealand). To use this data to guide management of children at a national level in New Zealand.

Method

Retrospective case series. Patients discharged from Starship Childrens Hospital between 1 January 1998 and 31 December 2007 with a diagnosis of intussusception were obtained from coding data.

Results

189 patients were analysed. 30% presented with the classic triad of pain, rectal bleeding and mass. 150/189 proceeded to air enema reduction which was successful in 118 (78.7%) of cases with 2 perforations. 54/189 (28.6%) proceeded for operative reduction of which 26 patients required surgical resection. Clinical and radiological evidence of bowel obstruction and duration of symptoms were associated with failed enema and surgical resection.

Conclusion

Intussusception only occasionally presents with the typical triad of abdominal pain, rectal bleeding and abdominal mass. Air enema reduction is successful at this institution with a low level of complication. M ori and Pacific patients had higher rates of failed enema reduction and need for surgery compared to European patients. Further research is needed from peripheral centres to evaluate outcomes of children treated in district hospitals to identify how and where these children are best managed.

Author Information

Hemal Kodikara, Surgical Registrar, Starship Childrens Hospital, Auckland; Amiria Lynch, Surgical Registrar, Starship Childrens Hospital, Auckland; Phillip Morreau, Paediatric Surgeon, Starship Childrens Hospital, Auckland; Sally Vogel, Paediatric Radiologist, Starship Childrens Hospital, Auckland

Acknowledgements

We thank Peter Reed (Childrens Research Centre, Starship Hospital) for assistance with statistical analysis.

Correspondence

Dr Hemal Kodikara, Surgical Registrar, Starship Childrens Hospital, Auckland, New Zealand.

Correspondence Email

hemal83@hotmail.com

Competing Interests

None.

-  Blanch A, Perel B, Acworth J. Paediatric intussusception: epidemiology and outcome. Emergency Medicine Australasia 2007;19:45-50.--  Raudkivi P. Smith L. Intussusception: analysis of 98 cases. British Journal of Surgery. 1981;68:645-648.--  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;441-443.--  Justice F, Auldist A, Bines J. Intussusception: trends in clinical presentation and management. Journal of Gastroenterology and Hepatology 2006;21:842-846.--  Kaiser A, Applegate KE, Ladd AP. Current success in the treatment of intussusception in children. Surgery. 2007;142:469-77.--  Saxena A, Hollwarth E. Factors influencing management and comparison of outcomes in paediatric intussusceptions. Acta Paediatr. 2007 Aug;96(8):1199-202. Epub 2007 Jun 21.--  Somme S, To T, Langer J. Factors determining the need for operative reduction in children with intussusception: a population-based study. Journal of Paediatric Surgery 2006;41:1014-1019.--  Buettche M, Baier G, Bonhoeffer J, et al. Three year surveillance of intussusception in children in Switzerland. Pediatrics 2007;120:473-480.--  Webby RJ, Bines JE, Barnes GL, et al. Intussusception in the Northern Territory: the incidence is low in Aboriginal and Torres Strait Islander children. Journal of Paediatrics and Child Health. 2006;42:235-239.--  Bratton. S. Intussusception: Hospital size and risk of surgery. Pediatrics 2001;107;299-303.--  Calder FR, Tan S, Kitteringham L, et al. Patterns of management of intussusception outside tertiary centres. Journal of Pediatric Surgery 2001;36:312-315.--  Peng S, Fancourt M, Gilkison W, et al. Paediatric surgery carried out by general surgeons: A rural NZ experience. A N Z Journal of Surgery. 2008;78:662-664.-

For the PDF of this article,
contact nzmj@nzma.org.nz

View Article PDF

Intussusception is the most common cause of intestinal obstruction among children and occurs when one segment of bowel invaginates into an adjacent distal segment. If left untreated, this can lead to bowel infarction, sepsis and death. The exact aetiology of the condition remains unclear in the majority of cases with a small proportion of cases occurring secondary to anatomical abnormalities. Knowledge of the condition is important as early diagnosis may lead to successful enema reduction, lower operative reduction and resection rates and reduced morbidity.1 It is important to obtain local data of the condition to both understand the possible aetiology and clinical picture of the condition in this setting as well as evaluate radiological and surgical outcomes. There has not been a published study of intussusception in the North Island since a 1981 series of 98 cases.2 This study was initiated to obtain a comprehensive summary of intussusception including demographics, clinical presentation, management and outcome of intussusception as seen at Starship Hospital, New Zealands largest childrens hospital. Methods A retrospective case-based study of all patients with intussusception presenting to the Starship Childrens Hospital, Auckland between 1 January 1998 to 31 December 2007 was performed. The Ethical Review Committee of Auckland Hospital granted exemption from requiring ethical approval. Starship Hospital provides secondary paediatric care for the Auckland region as well as much of the northern half of the North Island for paediatric surgical conditions. It also contains the only dedicated paediatric intensive care unit in New Zealand. Many patients are referred to the hospital from regional centres for investigation and management. The hospital records of all admissions to the Starship Hospital with a primary or secondary diagnosis of intussusception (as coded by the International Classification of Disease codes (ICD 9 and 10- K56.1 and 560) discharged within this period were reviewed. Data was collected using a standard proforma. Information collected included demographic factors, presenting symptoms and signs, time and onset of symptoms, time to diagnosis, radiological features, and treatment modality (air enema reduction, surgical reduction and resection outcomes and complications). Details of the presenting history were obtained from the clinical notes of the admitting doctor and standardised definitions were used for each symptom and sign noted. Radiology reports by consultant radiologists were reviewed and findings documented. Histological reports were reviewed and pathological lead points were also noted. A univariate analysis was conducted to identify features associated with failed air enema reduction and need for surgery. Microsoft Excel (Microsoft Corporation 2003) software was used for the data storage and statistical analysis. Results There were 210 discharges with a diagnosis of intussusception over this period with 197 individual patients. There were 8 patients who accounted for 13 repeat admissions. 6 patients were incorrectly coded and excluded. 2 further patients who had prior operative resection in the Pacific Islands and who were transferred for postoperative management were excluded. This left 189 patients for analysis. DemographicsThe median age was 10 months (range 3 days to 14 years). 122 (66%) of the patients were boys giving a male to female ratio of 2:1. There was no significant seasonal variation in the incidence of cases or change in incidence rate over the period. The median length of stay was 31 hours (range 8 to 408). Ethnicity data is shown below in Figure 1. 168/189 (89%) patients were from the Auckland region leaving 20 patients transferred from peripheral New Zealand hospitals (Whangarei, New Plymouth, Gisborne, Whakatane) and one from Samoa. DiagnosisThe range and frequency of presenting symptoms and signs is shown in the table below. 86/189 (45.5%) patients presented less than 24 hours from the onset of abdominal pain. The frequency of various clinical signs and symptoms are noted in Table 1 below. Only 57/189 (30%) presented with the classic triad of abdominal pain, vomiting and rectal bleeding. Figure 1. Ethnicity of children in study (%) Table 1. Frequency of presenting signs and symptoms (%) The relative frequency of radiological sign demonstrated by plain film and ultrasound examination are shown below in Table 2. A mass on plain radiograph was present in a similar proportion of patients as that found clinically (41%). No patients had evidence of perforation on plain radiograph. Table 2. Frequency of findings on plain film and ultrasound Management150 children proceed for air enema reduction. Barium enema was not undertaken at Starship Hospital for reduction purposes. 105/150 (70%) patients had a successful air enema on the first attempt. A second attempt occurred on 37 occasions with success in 13 (35.1%) On five occasions a third attempt was undertaken but was not successful in any patients. This gave an overall air enema reduction rate of 78.7% (118/150). Perforation occurred in two cases (1.5%). 54/189 patients proceeded to theatre of whom 22 proceeded directly to theatre without attempt of air enema reduction. Surgical reduction was attempted in 51 patients and was successful in 36 (71%). This was performed laparoscopically in 17 cases and was successful in 12 (71%). 26/54 (48%) patients required surgical resection for nonviable bowel, perforation or excision of pathological lead point. There were few intraoperative or postoperative complications. Five patients developed postoperative ileus, three required total parenteral nutrition, two required further operation (perforation) and two patients required treatment in the intensive care unit. There was one case of hospital readmission for postoperative abdominal pain. There were no recurrences of intussusception in surgically managed patients or patient deaths. 19 patients were noted to have a pathological lead point. The range and frequency of pathological lead points are shown below in Table 3. Predictors of outcomeThe presence of abdominal distention on clinical examination and plain film obstruction were the strongest predictors of enema failure and need for resection at surgery. There was also a significant association between duration of symptoms and enema failure and need for resection. Maori & Pacific patients were more likely to have failed enema 35% vs 13% compared to European (p=0.005) and proceed to surgery 38% vs 23% (p=0.04) despite no difference in duration of symptoms between the groups. Table 3. Number and type of pathological leadpoint Table 4. Factors associated with enema failure and surgical resection RR: relative risk; n/s: not statistically significant. Table 4 above demonstrates the increased risk of enema failure and need for surgical resection associated with each clinical or radiographic finding. Auckland vs Rest of New ZealandPatients from outside the greater Auckland region were more likely to have failed surgical reduction and to have surgical resection than patients from the Auckland region as shown in Table 5. However the time to treatment between the two groups did not differ significantly. Six patients transferred had prior attempt at barium enema reduction. Table 5. Comparison of patients in Auckland versus the Rest of New Zealand Discussion This study aimed to characterize and evaluate the patients, presentation and management of intussusception at Starship Hospital. There have only been two prior studies of intussusception in New Zealand. The first was Raudkivis series in 1981 which examined 96 patients and found a low (barium) enema reduction rate of 19%, and a subsequently high operative rate of 88% including a resection rate of 28%2. The second study was Reids series of 81 South Island cases in 2001 which demonstrated a similarly low barium enema reduction rate of 32% with a similar air enema reduction rate to this study of 79%3. This study hence is the largest review of intussusception in New Zealand. The median age and male predominance found in patients in this study is similar to that quoted in the literature.1 The lack of a seasonal variation suggests that an infectious aetiology may be less likely in intussusception in New Zealand. The proportion of cases with the accepted symptoms and signs of intussusception are similar to other reports.4,5However certain symptoms and signs were shown to be more helpful in making the diagnosis. This study has shown that a history of pallor and the presence of an abdominal mass are both common features of intussusception and can be vital in differentiating intussusception from gastroenteritis and other causes of vomiting and abdominal pain. Plain radiography was also shown to be an important diagnostic aid in the hands of experienced radiologists with a very high proportion having an abnormal film, and a lesser but significant proportion having a mass seen on x-ray. Enema reduction rates were similar to the range quoted in the literature but not as high as that found in some other studies which have shown rates closer to 90%.4,5 The possibilities for this are numerous. One reason is that Starship Hospital receives a significant number of referrals from other regional hospitals, and some referrals were following failed enema reduction in district hospitals. Furthermore the delay in being seen and treated in another hospital as well as the delay in transfer could lead to a less likely chance of successful enema reduction. The rate of perforation following air enema reduction at 1.5% was similar to the rate in other published studies5. We have shown that certain factors are associated with failed enema; with both clinical distension and plain film evidence of obstruction predictive of failed enema and need for surgery. A similar relationship exists for duration of symptoms till enema treatment- emphasizing the importance of prompt diagnosis and treatment/transfer. The reasons for Maori and Pacific patients having higher rates of failed enema reduction than their European counterparts are unclear as times from symptoms to presentation were similar. One possibility is that there is a fundamental difference in pathophysiology of the condition in these ethnicities leading to these differences in outcome. Another possibility is that there was a delay in recognition of symptoms by parents in the Maori and Pacific group effectively leading to a delay in presentation. Surgical resection rates found in this study were similar to those quoted elsewhere in the literature.4\u20136 However a higher number of children (27%) proceeded to surgery when compared to other studies. This may be partly explained by the high numbers of patients transferred as detailed above. Laparoscopic reduction was successful in the majority (71%) of cases where attempted and at a similar rate to that quoted in the literature.. Low postoperative morbidity and zero mortality were typical of modern day management of intussusception. The rate of pathological lead point (10%) was also similar to that found in other studies7,8 (2\u201312%) with the two most common being Meckels diverticulum and duplication cyst. This study does however demonstrate a higher rate of duplication cyst (6/19) than that quoted in other studies. The exact reason for this is unclear. This studys limitations are that this was a retrospective review of case notes and thus the findings were dependant on the clinical competency of the admitting doctor and the legibility and completion of the documentation. If a particular symptom or sign was not reported in the notes (by either emergency or surgical admitting staff) then it was presumed to be absent. This may of course not be true and that the symptom or sign may not have been sought, or alternatively may have been sought but not documented. A prospective study would be better equipped to review the clinical presentation as it would ensure that each relevant symptom and sign would be sought as well as provide more information on how children were being triaged to air enema reduction or directly to surgery. The key issue in the management of intussusception in New Zealand is whether any child with intussusception seen in a peripheral hospital is transferred directly to a tertiary centre once stabilised or whether regional outcomes are of a sufficient standard to allow management in these regions. A study conducted in the United States into intussusception outcomes compared smaller and larger hospitals and showed children managed in large US childrens hospitals had decreased risk of operative care and shorter length of stay10. This was confirmed in a review conducted in the United Kingdom which suggested \u201call confirmed cases should be resuscitated then referred to tertiary centres for treatment\u201d11. In New Zealand this may be further true as there may not be sufficient case volume of intussusception in regional hospitals to maintain high standards in enema treatment which is evidenced by a recent study that showed only one case of intussusception was seen in a one year period at a district hospital in New Zealand12. In this study all patients who were transferred from peripheral hospitals only had barium enema attempts (no air enema reductions) which confirms the lower success rate of this method of reduction and suggests that early transfer to a paediatric surgical centre may be preferable if facilities for air enema reduction are not available. However further research is required into the management and outcomes of all children treated in peripheral hospitals to determine if centralising treatment of intussusception where appropriate would lead to improved outcomes. The findings of this study provide useful preliminary data given the well known difficulties of obtaining national data on intussusception in New Zealand3. Wherever children are managed, this study has shown that it is vital for clinicians to know that intussusception does not often present in classical fashion, and early diagnosis and management leads to an increased likelihood of successful air enema and reduced need for operative management. This study has also demonstrated that there are differences in outcome for children with intussusception based on ethnicity which is a finding not previously demonstrated in the literature.

Summary

Abstract

Aim

To review the demographics, presenting features, rates of air enema reduction success, prevalence of pathological lead points and surgical intervention rates and outcomes in patients with intussusception at Starship Childrens Hospital (Auckland, New Zealand). To use this data to guide management of children at a national level in New Zealand.

Method

Retrospective case series. Patients discharged from Starship Childrens Hospital between 1 January 1998 and 31 December 2007 with a diagnosis of intussusception were obtained from coding data.

Results

189 patients were analysed. 30% presented with the classic triad of pain, rectal bleeding and mass. 150/189 proceeded to air enema reduction which was successful in 118 (78.7%) of cases with 2 perforations. 54/189 (28.6%) proceeded for operative reduction of which 26 patients required surgical resection. Clinical and radiological evidence of bowel obstruction and duration of symptoms were associated with failed enema and surgical resection.

Conclusion

Intussusception only occasionally presents with the typical triad of abdominal pain, rectal bleeding and abdominal mass. Air enema reduction is successful at this institution with a low level of complication. M ori and Pacific patients had higher rates of failed enema reduction and need for surgery compared to European patients. Further research is needed from peripheral centres to evaluate outcomes of children treated in district hospitals to identify how and where these children are best managed.

Author Information

Hemal Kodikara, Surgical Registrar, Starship Childrens Hospital, Auckland; Amiria Lynch, Surgical Registrar, Starship Childrens Hospital, Auckland; Phillip Morreau, Paediatric Surgeon, Starship Childrens Hospital, Auckland; Sally Vogel, Paediatric Radiologist, Starship Childrens Hospital, Auckland

Acknowledgements

We thank Peter Reed (Childrens Research Centre, Starship Hospital) for assistance with statistical analysis.

Correspondence

Dr Hemal Kodikara, Surgical Registrar, Starship Childrens Hospital, Auckland, New Zealand.

Correspondence Email

hemal83@hotmail.com

Competing Interests

None.

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