Intestinal intussusception remains a challenging problem and constant interest of pediatric surgeons. Many questions regarding clinical features, diagnosis and treatment have been elaborated and widely elucidated in numerous relevant publications. Nowadays non-surgical reduction of intussusception is the priority method in treatment of acute intestinal intussusception in pediatric patients, and according to S. Ya. Doletskiy “…being temporary by its nature, this condition requires predominantly conservative treatment. Therefore, it would be better to avoid surgeries, and reduction of intestinal intussusception would better to be carried out by the safest and a well-elaborated non-surgical technique - strictly controlled intestinal insufflation” . However, there are some doubts about the reliability of the methods allowing surgeons to control the process of the reduction of intussusception that according to the authors can negate the advantages of non-surgical treatment [8, 11]. The possibility of non-surgical reduction of intussusception in children with disease duration of more than 24 hours as well as in pediatric patients over 1 year of age and children with recurrent intussusception remains to be disputable [1, 4]. At the same time, a number of researchers point out that with the accumulation of experience neither the duration of the condition nor the child’s age and the presence of the recurrence will be the dominant criteria when choosing an appropriate treatment tactic [1, 10].
The objective of the research was to analyze own 30-year experience in treatment of intestinal intussusception in children to determine the changes in diagnosis and treatment tactics.
249 pediatric patients (172 boys and 77 girls) with intestinal intussusception at the age of 2 months -13 years were treated at the surgical department of the Poltava Municipal Clinical Pediatric Hospital during 1986-2016. The experience of treating 265 children with intestinal intussusception including 16 cases of the recurrence in 11 children was analyzed. Conservative treatment was performed in 178 (71.5%) children, 71 (28.5%) children were operated on. To make the analysis children were divided into 3 groups according to three ten-year periods: Group I involved cases from 1986 to 1995; Group II included cases from 1996 to 2005; Group III included cases from 2006 to 2016.
The analysis of statistical data demonstrated the decrease in the number of patients over the past two decades (110 children during the first period, 71 children during the second period, and 68 children during the third period) that is confirmed by other researchers as well . The decrease in the number of patients was primarily due to the decrease in the number of boys (82/45/45), while the number of girls remained relatively stable (28/26/23). Gender ratio for the 1st period was 3:1; for the 2nd period it was 1.7:1; for the 3rd period it was 2:1. At the same time, in the last decade a tendency to increase in the number of patients over 1 year of age (21 (19%) patients – the 1st period; 13 (18%) patients - the 2nd period; 26 (41%) patients - the 3rd period) has been observed. Having analyzed the terms of hospitalization there was found that 89 (81%) children of Group I were hospitalized within the first 24 hours after illness onset, 21 (19%) children were hospitalized 24 hours after the onset of symptoms. In Group II there were 49 (69%) children hospitalized within the first 24 hours after illness onset and 22 (31%) children hospitalized later 24 hours after the onset of symptoms. In Group III there were 49 (72%) and 19 (28%) children, respectively.
During 1986-1995, 110 children were hospitalized with intestinal intussusception. This period was characterized by the development and experimental substantiation of flow-through pneumatic insufflation, its clinical testing and implementation. This method of flow-through pneumatic insufflation was first proposed by M. I. Grytsenko in 1986. Being modified and improved it became widely used in pediatric surgery [6, 9]. The methods of objectification of the criteria for non-surgical reduction of intussusception using flow-through pneumatic insufflation were developed experimentally.
To confirm disinvagination in case of non-surgical reduction of intussusception in children the pressure in the rectum and stomach was recorded with a manometer. In gas injection, the pressure in the rectum prior to disinvagination may rise up to 120 mm Hg, at the same time the pressure in the stomach is significantly different equating to zero. After disinvagination and release of gas through a gastric tube the pressure in the rectum and stomach became equal being reliable and objective evidence of disinvagination (Ukrainian Patent 7015 U).
The following method designed to evaluate the success of non-surgical reduction of intussusception was based on using medically pure oxygen to assess its content in the gas mixture obtained from the stomach (Ukrainian Patent 7014 U). The volume fraction of oxygen was assessed using a gas analyzer AK-M1. According to J. M. Dederer (1971,) intestinal gas consists of 70% of nitrogen (N2), 10 - 12% of oxygen (O2), 6-9% of carbon dioxide (CO2), 1.5% of hydrogen sulfide and 0.5-5% of other gases. In the air, the amount of oxygen is about 21%. Thus, pumping oxygen into the gastrointestinal tract through the rectum and obtaining oxygen content above 21% in the gas mixture released from the stomach through a tube, the success of the reduction was indicated objectively and reliably. Immediately after the start of gas release from gastric tube we assessed the volume of gas pumped through the gastrointestinal tract retrogradely using a volumeter, and the release of more than 1 L of gas was considered as the evidence of successful disinvagination (Ukrainian Patent 7013 U).
These methods allowed us to confirm the effectiveness of flow-through pneumatic insufflation as well as to avoid serious problems in non-surgical treatment, namely the lack or insufficient reliability of the methods of objective control over the process of reduction of intestinal intussusception [8, 11].
28 (25.5%) children out of 110 patients with intestinal intussusception hospitalized during the 2nd decade were operated on. In most cases, surgical treatment was limited to disinvagination (14 cases), and in 2 cases we stated reduction of intussusception. Disinvagination in combination with the removal of the Meckel’s diverticulum was performed in 5 cases, and resection due to intestinal necrosis was performed in 4 cases, and 3 children underwent intestinal resection due to tumors or tumor-like masses.
Tactics for children with disease duration of more than 24 hours and children over 1 year of age remained conventional and included surgery, although there were some attempts of non-surgical treatment of such patients with positive results.
During 1996-2005, 71 children with intestinal intussusception were treated at our department. In the 2nd decade the algorithm for treatment of intestinal intussusception was developed (Fig. 1). In 68 cases non-surgical disinvagination was used being successful in 58 cases, and the success rate of non-surgical reduction of intussusception was 85.2%. 28 (39.4%) children were operated on. Surgeries included disinvagination in 17 cases (1 case of cecal ligation); disinvagination was stated in 2 cases; disinvagination in combination with the removal of the Meckel’s diverticulum was performed in 4 cases; resection due to intestinal necrosis was performed in 3 cases, and 1 child underwent intestinal resection due to tumors or tumor-like masses. The “second-look” tactic allows avoiding inaccurate assessment of intestinal viability being the main cause of unsatisfactory outcomes in the early postoperative period .
During the 2nd decade there were hospitalized 22 children with disease duration of more than 24 hours. 17 (77.3%) children were operated on; 4 children underwent surgery after ineffective non-surgical disinvagination; 5 (22.7%) children underwent non-surgical disinvagination.
There were 13 children over 1 year of age: 7 (53.8%) children were operated on and 6 (46.2%) children underwent non-surgical disinvagination. Anatomical causes of intestinal intussusception during surgery were detected in 3 children, namely the Meckel’s diverticulum (2) and enterocyst (1).
During 2006 -2016, 68 children with intestinal intussusception were treated.
In 75 cases (including 7 cases of relapse) non-surgical disinvagination was used resulted in successful outcomes in 67 cases; the success rate of non-surgical reduction of intussusception was 89.3%.15 (22%) children were operated on, and only 7 children without previous non-surgical treatment underwent surgery. The reasons for refusal of non-surgical treatment were signs of peritonitis in 4 cases, the absence of clinical presentation of intestinal intussusception with predominance of common signs of acute intestinal obstruction in 2 cases, and recurrent intussusception in 1 case. During surgery disinvagination was used in 9 cases; disinvagination in combination with the removal of the Meckel’s diverticulum was performed in 4 cases; enterocyst was removed in 1 case; disinvagination was established in 2 cases. In 1 case there were doubts about the viability of some area of the small intestine after reduction of intussusception, however, “second-look” surgery performed 48 hours after the procedure showed that area of the intestine was viable.
During this decade there were hospitalized 19 children with disease duration of more than 24 hours. 8 (42.1%) children were operated on, 2 children underwent surgery after ineffective non-surgical disinvagination; 11 (57.9%) children underwent non-surgical disinvagination. There were 27 children were over 1 year of age: 7 (25.9%) children were operated on and 20 (74.1%) children underwent non-surgical disinvagination. Anatomical cause of intestinal intussusception during surgery, namely the Meckel’s diverticulum was detected in 1 case. In general, among 14 children over 1 year of age being operated on for the last 20 years anatomical causes were detected in 4 (28.5%) patients only, that is not consistent with the data on a significant number of anatomical causes of intussusception within this group .
For two decades, we have got experience in treating 11 children with 16 recurrences of intestinal intussusception. The recurrences occurred from 2 days to2 years after the first intussusception. In 7 cases non-surgical reduction was used, 4 children were operated on. The case of treating the child who underwent the first non-surgical reduction of intussusception at the age of 4 months is demonstrational; at the age of 9 months the recurrence occurred that also reduced non-surgically as well; 2 days later the recurrence was observed again. The infant was operated on; surgical disinvagination was used; anatomical causes of intestinal intussusception were not found. 2 months after surgery the child developed recurrent intussusception that was reduced non-surgically. The case of treating the child who underwent non-surgical reduction of intussusception 5 times (at the age of 4, 6, 8, 10 and 16 months) is interesting as well. No recurrences of intussusception were registered in the follow-up period. In these both cases during surgery there were observed no anatomical causes or predispositions to intussusception.
In addition, 2 children with relapses developed after non-surgical treatment of intestinal intussusception at district hospital were sent to our department. It is difficult to determine whether these cases actually occurred as recurrences or intussusception was not completely reduced at the first attempt. Therefore, we consider non-surgical disinvagination to be performed only by experienced surgeons in specialized hospitals or departments.
Lethal outcomes were not registered.
Flow-through pneumatic insufflation is an effective and objective technique of non-surgical reduction of intestinal intussusception in infants.
Non-surgical reduction of intestinal intussusception can be performed in the majority of patients without the signs of peritonitis.
The duration of the condition, age of patients and the presence of recurrence should not be considered as absolute criteria in choosing treatment tactics in intestinal intussusception.