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Journal of Pediatric Surgery 50 (2015) 647650

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Journal of Pediatric Surgery


journal homepage: www.elsevier.com/locate/jpedsurg

Surgical approach to intussusception in older children: Inuence of


lead points
Pooya Banapour , Roman M. Sydorak 1, Donald Shaul 2
Kaiser Los Angeles Medical Center, Department of Surgery, 4760 Sunset Blvd., 3rd , Los Angeles, CA 90027

a r t i c l e

i n f o

Article history:
Received 22 July 2014
Received in revised form 2 September 2014
Accepted 24 September 2014
Key words:
Ileocolic intussusception
Intussusception
Pediatric
Hydrostatic

a b s t r a c t
Background: The likelihood of a lead point as the cause of ileocolic intussusception increases as children get older.
This study looks at whether a different management strategy should be employed in older patients.
Methods: 7 year multi-institutional retrospective study of intussusception in patients aged b 12 years.
Results: Ileocolic intussusception with complete data was found in 153 patients: 109 02 years, 34 35 years, and
10 612 years, respectively. Bloody stools occurred in 42/143 of 05 years and 0/10 of 612 years, p b 0.001. Combined hydrostatic and/or surgical reduction was successful in 113/143 05 year olds vs 5/10 612 year olds,
p b 0.001. Enemas were safe but reduced only 1 patient over age 5. Resections were required in 29 patients
(15 idiopathic, 14 lead points). Lead points were found in 4/109 children under 3 years, in 5/34 aged 35 years
and 5/10 aged 612 years (p = 0.04 vs 35 years and p b 0.001 vs 05 years). Lead points consisted of 7 Meckels
diverticula and 7 others.
Conclusion: Children older than 5 years are much more likely to have a pathologic lead point and early surgical
intervention should be considered. In this study, enema reduction was safe but minimally benecial in this
age group.
2015 Elsevier Inc. All rights reserved.

Younger children (aged 02 years) with intussusception usually do


not have a pathological lead point. In these cases, resection of the involved intestinal segment is not necessary, provided that the intussusception can be completely reduced, either radiologically or surgically.
The management of intussusception in these younger children is well
established and begins with either hydrostatic or air reduction, sometimes under ultrasound guidance. Ultrasound Doppler studies are also
used to determine the presence or absence of blood ow in the
intussusceptum and guide the aggressiveness of the reduction [1,2]. In
many studies, the success rate with this approach is very high with
the majority of patients avoiding the need for laparoscopy or laparotomy to complete the reduction [13]. In the occasional patient where
the intussusception cannot be reduced, resection is required. The
usual ndings are necrosis due to prolonged vascular compression,
rather than a true pathological lead point.
Increasing age is associated with a higher likelihood of nding a
pathological lead point. In adult patients, pathological lead points are
an expected nding among patients with intussusception. The question
is: Is there an age at which the presence of a pathological lead point becomes so common that surgery is the best rst step? A classic pediatric
surgical textbook states that hydrostatic reduction should be attempted

Corresponding author. Tel.: +1 323 783 5500.


E-mail addresses: pooya.banapour@kp.org (P. Banapour), roman.m.sydorak@kp.org
(R.M. Sydorak), donald.b.shaul@kp.org (D. Shaul).
1
Tel.: +1 323 783 4857.
2
Tel.: +1 323 783 4857; fax: +1 323 783 8747.
http://dx.doi.org/10.1016/j.jpedsurg.2014.09.078
0022-3468/ 2015 Elsevier Inc. All rights reserved.

in all patients regardless of age [4]. It was standard training in the senior
authors institution to perform surgery on all pediatric patients with intussusception older than 2 years of age. Similarly, Van der Laan et al.
found that all patients older than 2 years of age with intussusception required laparotomy with the majority requiring a bowel resection [5].
This study was performed to determine the characteristics of older
children (312 years old) with ileocolic intussusception, to determine
the incidence of pathological lead points and most importantly, to determine how to best manage these patients.
1. Materials and methods
Hospital records from six regional hospitals within a single
healthcare system were searched using the diagnosis code intussusception. Electronic medical records of all patients with this diagnosis from
January 2007 to December 2013 were reviewed. Patients aged greater
than 12 years were excluded, because it was felt that they would
share the same characteristics as adult patients with respect to this diagnosis. Hospital charts were reviewed by three individuals. Only cases
with a diagnosis of ileocolic intussusception were included in the
study. The following data were extracted from electronic medical records: demographics, date of birth, age at diagnosis of intussusception,
symptoms at presentation (emesis, grossly bloody stool, fever), length
of symptoms, and date of last follow up. Fever was dened as oral or rectal temperature greater than 100.6 F. Radiology reports were reviewed
for the following information: date of contrast enema, number of contrast enema studies, presence of radiologic lead point, level of

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P. Banapour et al. / Journal of Pediatric Surgery 50 (2015) 647650

intussusception at start of enema, level of intussusception at end of


enema and date(s) of repeat enema(s). Operative notes were reviewed
for the following: type of operation (laparoscopic, laparoscopic converted to open, open), presence of pathological lead point, reduction of intussusception and resection. Pathology reports were reviewed for all
ndings including the location and presence of any pathology which
served as the lead point for the intussusception. We dened pathological lead point as the nding of a pathologic abnormality in the resected
specimen which served as the lead point for the intussusception. The
nding of ischemia and/or necrosis without a co-existing lead point
was not considered a pathological lead point. Cases involving small
bowel-small bowel intussusception (n = 10) and patients who had no
follow up and/or had insufcient hospital records were excluded
(n = 12). Patients were grouped into the following age categories: 0,
1, 2, 3, 4, 5, 612 years old before statistical analyses were performed.
The general radiological approach was to use the hydrostatic enema
with the bag 3 feet above the level of the rectum, infusing water soluble
contrast up to 3 min at a time or until no further reduction was evident.
In most cases the colon was drained and the infusion was repeated up to
three additional times until no further progress was made.
Analyses of length of symptoms, presence of emesis, bloody stools,
fever at diagnosis, hydrostatic enema reduction attempts, hydrostatic
enema reductions, surgical reductions, surgical resections and presence
of pathological lead points were performed based on age groups. Using
GraphPad QuickCalcs Software (2014, GraphPad Software, Inc, La Jolla,
CA), the statistical signicance of differences between age groups 05
and 612 years was calculated. Fishers exact test was used for categorical data and students t test was used for continuous data. A 5% level of
signicance was used for all cases. The study was approved by our regional institutional review board, approval number 10251.
2. Results
A total of 153 cases of ileocolic intussusception were identied
among the ages of 012 years from January, 2007 to December, 2013.
Of these patients, 55 were age b 12 months, 37 were age 1 year, 17
were age 2 years, 34 were age 35 years and 10 were age 612 years
(Table 1). Examination of the data revealed a natural break between
ages 5 and 6 years, rather than an anticipated break between ages 2
and 3 years. For this reason, comparisons were made between groups
aged 05 years and 612 years, respectively. Average length of symptoms for the different age groups was 1.9, 2.1, 2.4, 2.2 and 3.3 days, respectively. There was a signicant difference in length of symptoms
between children of age 612 (3.3 days) and 05 (2.1 days, p b 0.001).
In children aged 05 years, 56% presented with emesis whereas only
40% presented with emesis in children aged 612 years (p b 0.001).
Similarly, 29% of children aged 05 years presented with bloody stools
whereas none of the children aged 612 years presented with bloody
stools (p b 0.001). Only 9% of patients aged 05 presented with fever
whereas 30% of patients aged 612 years had a fever upon
diagnosis (p b 0.001).
In many cases, the patients initial presentation was to the emergency department. If the diagnosis of intussusception was not suspected

clinically, the emergency department physician may have ordered an


abdominal CT scan. In other cases, where the diagnosis of intussusception was suspected, an ultrasound or a contrast enema was obtained
as the initial study. When intussusception was diagnosed by CT scan,
the attending surgeon made a decision on whether to proceed with an
attempt at hydrostatic reduction or proceed with surgical intervention.
If this study suggested a small bowel to small bowel intussusception the
patient may have been taken to surgery without an attempt at enema
reduction. In some cases, primarily early in the study period, the lack
of an experienced radiologist may have prompted the surgeon to proceed directly to the operating room, rather than attempt a hydrostatic
reduction. This was more likely to be true in older patients. Of the 153
patients with intussusception, contrast enema reduction was attempted
168 times in 130 patients and successfully reduced the intussusception
in 67 patients (Table 2).There were 6 patients in whom a CT scan
showed ileocolic intussusception but the intussusception was spontaneously reduced by the time the patient underwent a contrast enema
or surgical exploration. These cases were counted as spontaneous reductions. There were also 10 patients in whom the CT scan showed
small bowel to small bowel intussusception (6 reduced spontaneously,
3 underwent open or laparoscopic reduction, and one patient with
PeutzJeghers syndrome underwent resection of a polyp that had
served as the lead point). These patients were excluded from the overall
analysis. The number of delayed repeated enemas ranged from 0 to 2
times per patient. A total of 80 patients underwent laparoscopic or
open surgical intervention. Of the surgical cases, 51 were reduced intraoperatively whereas 29 intestinal resections were performed. Changes
consistent with ischemia and necrosis were seen in 15 patients, none
of which had a pathological lead point, and all of whom were less
than three years of age. 14 patients had a pathological lead point. Specifically among the patients aged 6 and above, 10 patients were diagnosed
with ileocolic intussusception. Hydrostatic reduction was attempted in
four patients and was successful in one. The other 3 went to the operating room, one was reduced and the other two underwent resection of a
pathological lead point. It was the surgeons choice to take the other 6
patients directly to the operating room, without attempting hydrostatic
reduction. Of these 6 patients who went to the operating room, one had
reduced spontaneously, two were reduced surgically without discovering a pathological lead point and the remaining 3 had lead points removed. Pathological lead points were found in 9/143 (6%) of
children aged 5 and younger and in 5/10 (50%) of children aged
612 years (p b 0.001).
The pathologic ndings in the patients with lead points are shown in
Table 3. Of the patients aged 612 years, the lead points included 2 patients with Meckels diverticulum, 1 patient with a metastasis from a
Ewings sarcoma primary, 1 patient with appendiceal mass and cystic brosis and 1 patient with a hyperplastic mesenteric lymph node, which
served as the lead point. In patients aged 35 years, 11 patients were
taken to the operating room. Lead points were present in 5 patients
and 5 patients were reduced intraoperatively. The remaining intussusception reduced spontaneously. Of the 8 patients aged 2 years who
were taken to the operating room, one had a pathologic lead point. All
3 of the resected specimens had pathologic ndings consistent with

Table 1
Patient characteristics.
Emesis

Bloody stools

Fever

Age (years)

Average days of Symptoms (mean SD)

Number

Percent

Number

Percent

Number

Percent

0
1
2
35
Total 05
612
Total

55
37
17
34
143
10
153

1.9
2.1
2.4
2.2
2.1
3.3
2.1

45
24
11
20
80
4
180

82
65
65
59
56
40

29
12
1
6
42
0
90

53
32
6
18
29
0

6
6
1
7
13
3
33

11
16
6
21
9
30

p b 0.001 for 612 vs 05.

1.1
1.5
1.5
1.5
0.2
2.2
1.2

P. Banapour et al. / Journal of Pediatric Surgery 50 (2015) 647650

649

Table 2
Therapeutic intervention.
Hydrostatic Enema

Operations

Age (years)

Number of patients (%)

Number reduced (%)

Number of patients (%)

Number reduced (%)

Resected (%)

Lead Point (% of N)

0
1
2
35
Total 05
612
Total

55
37
17
34
143
10
153

45 (82)
34 (92)
15 (88)
32 (94)
126 (88)
4 (40)
130 (85)

17 (38)
20 (59)
10 (67)
19 (59)
66 (52)
1 (25)
67 (52)

39 (71)
13 (35)
8 (47)
11 (32)
71 (50)
9 (90)
80 (52)

25 (64)
11 (85)
5 (63)
6 (55)
47 (69)
4 (44)
51 (51)

14 (36)
2 (15)
3 (38)
5 (45)
24 (34)
5 (56)
29 (36)

1 (1.8)
2 (5.4)
1 (5.9)
5 (14.7)
9 (6.3)
5 (50)
14 (18)

p b 0.001 for 612 vs 05.

ischemia and necrosis while the remaining 5 intussusceptions were reduced intraoperatively. There were 2 lead points seen in the 14 patients
aged 1 year who were taken to the operating room and 12 patients who
had their intussusception reduced intraoperatively. Although there
were a total of 39 patients aged 012 months who were taken to the operating room, only 1 patient had a pathologic lead point (Meckels diverticulum). In total the pathologist identied 4 patients with follicular
hyperplasia or lymphoid hyperplasia large enough to serve as the lead
point for the intussusception. There may not be substantial differences
between this diagnosis and an enlarged Peyers patch, which is felt to
represent a potential lead point in younger children with intussusception. However, the focus population in this study is the 612 year old
age group, and lymphoid hyperplasia was only diagnosed in one of
these patients.
The prevalence of pathological lead points in various age groups is
shown in Fig. 1. The overall prevalence of lead points in the different
age groups 0, 1, 2, 35 and 612 was 1.8%, 5.4%, 5.9%, 14.7% and 50%, respectively. To determine if any clinical parameters (other than age)
could predict the presence of a pathological lead point, additional analyses were performed. For example, emesis was present in 50% of patients with a pathological lead point and in 70% of patients without a
pathological lead point. Similarly, bloody stools were present in only
21% of patients with a pathological lead point and in 33% of patients
without a pathological lead point, all non-signicant. Total follow-up
for this study ranged from 1 to 199 months with a mean of 78 months.
months. Patient charts were reviewed to determine the length of follow
up while looking for recurrent intussusception. If present, this would
have suggested that intussusception caused by a pathological lead
point may have been reduced. In this specic patient population
(reduced intussusception), follow-up ranged from 1 to 130 months,
mean 74 months. Within this time frame, 9 patients were encountered
who came back with a recurrent intussusception, however, none were
found to have a surgically proven pathological lead point.

was not helpful, or even harmful. This question has not been specically
addressed in other reports in the literature. This is a hard question to answer given the relatively low prevalence of intussusception within this
older age group. This study utilizes a patient database with access to
over 4 million patients within a single healthcare system spread out
over a seven year interval. Some of the providers were adult radiologists
and adult general surgeons, especially for the older patients. Other providers were pediatric radiologists and pediatric surgeons. As such, the
success rate for hydrostatic reduction was lower than is generally quoted in the pediatric radiology literature. This fact no doubt inuenced a
surgeons decision to either attempt a hydrostatic reduction or proceed
directly to surgery. It is retrospective and there was no specic protocol
utilized by the various facilities. In view of these important limitations,
no rm conclusions can be reached about whether contrast enemas
should be obtained in older patients. Hydrostatic reduction was only
attempted in four patients aged 612 years. One of these was successfully reduced. Five of the ten patients in this age group were unable to
have their intussusceptions surgically reduced and underwent surgical
resection of a pathological lead point. If hydrostatic reduction had
been attempted in all 10 patients, it is unlikely that these 5 patients
would have been reduced, giving at most a 50% success rate. Therefore,
only a 50% success rate should be expected, due to the higher incidence
of pathological lead points in this age group. This study does suggest
that attempted hydrostatic reduction appears safe in older patients, as
no perforations were observed. It also showed that a pathological lead
point is unlikely to be reduced using standard surgical or radiological
techniques. Based upon these data it is recommended that a therapeutic
enema reduction be attempted in all patients with suspected or proven
intussusception aged 5 years and below, who do not have a contraindication to the enema. This study can not say that hydrostatic reduction
should not be performed in older patients, only that it is less likely to
be successful in this older age group. The decision to attempt a contrast
enema must be made by the surgeon based upon the patients presentation and the skill level of their radiology department.

3. Discussion
The objective of this study was to determine if there is an age at
which attempted hydrostatic reduction of an ileocolic intussusception

50

Table 3
Pathologic ndings in patients with lead points.
Age (years)
0
1
2
35
612
Total
+

60

40

Patients w/lead
points

Meckels
diverticulum

Lymphoid
Hyperplasia+

Other

1
2
1
5
5
14

1
1
0
3
2
7

0
1
1
1
1
4

0
0
0
1
2
3

includes patients with follicular hyperplasia.


Pathologic ndings included raised vascular lesion (35 age group), 2 cm small
bowel metastasis from primary Ewings sarcoma and inspissated appendiceal mass
(612 age group).

30

number of patients
without lead point

20

number of patients with


lead point

10
0
0 yr

1 yr

2 yrs 3 yrs 4 yrs 5 yrs 6-12


yrs
Fig. 1. Pathologic lead points by age group.

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P. Banapour et al. / Journal of Pediatric Surgery 50 (2015) 647650

What this study does clearly show is that pathological lead points are
more likely at increasing ages, with a cutoff noted at age 6 years and
above. It was also unable to identify any clinical parameters (other
than age) that indicated the high likelihood that a pathologic lead
point is present. The exact reason why older patients (612 years) had
less emesis and bloody stools than their younger counterparts is not
clear. They did tend to present later than the younger patients. Perhaps
this is because many parents are more anxious about younger children
and infants who are not able to talk and bring them to the doctor sooner.
The higher incidence of fever in the older children may be due to the
higher likelihood of compromised intestine and/or a later presentation.
The overall incidence of pathological lead points in children with intussusception has been reported to be 1.5%12% [6]. In this study, pathological lead points were found to be more prevalent in older patients.
Pathological lead points occurred in 50% of patients aged 612 years,
but in only 4% of 02 year olds and in 15% of 35 year olds. Other studies
of intussusception had similar results. In a study of 1340 children aged
3 months to 12 years with recurrent intussusceptions, 3 of 7 patients
with pathological lead points were aged greater than 6 years and 1 patient was 4 years old [7]. Saxena and colleagues found 2 pathological
lead points in a study of over 100 children with intussusception aged
up to 16 years; both lead points were in children greater than 6 years
old [8]. Many other studies have shown an increased frequency of pathological lead points in children greater than 6 years old [911]. A radiologic study of patients aged 014 years with intussusception found an
equal distribution of radiological lead points among age groups [12].
However, these were lead points seen on imaging, not proven at surgery. In this study, every child with a pathological lead point eventually
underwent resection of the pathological lead point due to failed reduction. It is possible for a patient with a minor pathological lead point to
have their intussusception reduced. However, in this study, no patient
whose intussusception was initially reduced was subsequently found
to have a pathological lead point. One of the strengths of this study is
the long-term follow-up of patients who remain within our system. It
is unlikely that a lead point was missed given this length of follow up.

Early in the study period, patients with a possible diagnosis of intussusception were evaluated in a variety of ways, and sometimes without
the involvement of a pediatric surgeon until after the diagnosis was made.
In many cases, CT scans were done, in spite of the potential radiation exposure. Beginning in 2012 a regional protocol was established to expedite
the evaluation and treatment of children with suspected intussusception.
It begins with a plain abdominal X-ray and an abdominal ultrasound, as
this has been shown to be highly sensitive in diagnosing intussusception
[12]. It discourages the use of CT scans. Once imaging suggesting that an
intussusception is found the patients are transferred to facilities with
on-site pediatric surgeons and radiologists for denitive management.
References
[1] Digant SM, Rucha S, Eke D. Ultrasound guided reduction of an ileocolic intussusception by a hydrostatic method by using normal saline enema in pediatric patients: a
study of 30 cases. J Clin Diagn Res 2012;10:17225.
[2] Gonzlez-Spinola J, Pozo GD, Tejedor D, et al. Intussusception: the accuracy of
ultrasound-guided saline enema and the usefulness of a delayed attempt at reduction. J Pediatr Surg 1999;34:101620.
[3] Lee JH, Choi SH, Jeong YK, et al. Intermittent sonographic guidance in air enemas for
reduction of childhood intussusception. J Ultrasound Med 2006;25:112530.
[4] Welch KJ, Randolph JG, Ravitch MM. Intussusception. In: Welch KJ, Randolph JG,
Ravitch MM, editors. Pediatric surgery. New York, NY: Medical Publishers Inc.;
1986. p. 86882.
[5] Van der Laan M, Bax NM, Van der Zee DC, et al. The role of laparoscopy in the management of childhood intussusception. Surg Endosc 2001;4:3736.
[6] Blakelock RT, Beasley SW. The clinical implications of non-idiopathic intussusception. Pediatr Surg Int 1998;14:1637.
[7] Niramis R, Watanatittan S, Kruatrachue A, et al. Management of recurrent intussusception: nonoperative or operative reduction? J Pediatr Surg 2010;11:217580.
[8] Saxena AK, Hollwarth ME. Factors inuencing management and comparison of outcomes in pediatric intussusceptions. Acta Paediatr 2007;96:1199202.
[9] Daneman A, Alton DJ, Lobo E, et al. Patterns of recurrence of intussusception in children: a 17-year review. Pediatr Radiol 1998;28:9139.
[10] Eklof DA, Johanson L, Lohr G. Childhood intussusception: hydrostatic reducibility
and incidence of leading points in different age groups. Pediatr Radiol 1980;10:836.
[11] Schuh S, Wesson DE. Intussusception in children 2 years of age or older. Can Med
Assoc J 1987;136:26972.
[12] Navarro O, Dugougeat F, Kornecki A, et al. The impact of imaging in the management
of intussusception owing to pathologic lead points in children: a review of 43 cases.
Pediatr Radiol 2000;30:594603.