Management of intussusception in children: A systematic review.

OBJECTIVE: The goal of this systematic review by the American Pediatric Surgical Association Outcomes and Evidence-Based Practice Committee was to develop recommendations for the management of ileocolic intussusception in children. METHODS: The ClinicalTrials.gov, Embase, PubMed, and Scopus databases were queried for literature from January 1988 through December 2018. Search terms were designed to address the following topics in intussusception: prophylactic antibiotic use, repeated enema reductions, outpatient management, and use of minimally invasive techniques for children with intussusception. The Preferred Reporting Items for Systematic reviews and Meta-Analyses (PRISMA) guidelines were followed. Consensus recommendations were derived based on the best available evidence. RESULTS: A total of 83 articles were analyzed and included for review. Prophylactic antibiotic use does not decrease complications after radiologic reduction. Repeated enema reductions may be attempted when clinically appropriate. Patients can be safely observed in the emergency department following enema reduction of ileocolic intussusception, avoiding hospital admission. Laparoscopic reduction is often successful. CONCLUSIONS: Regarding intussusception in hemodynamically stable children without critical illness, pre-reduction antibiotics are unnecessary, non-operative outpatient management should be maximized, and minimally invasive techniques may be used to avoid laparotomy. LEVEL OF EVIDENCE: Level 3-5 (mainly level 3-4) TYPE OF STUDY: Systematic Review of level 1-4 studies.

Emergency department discharge following successful radiologic reduction of ileocolic intussusception in children: A protocol based prospective observational study.

PURPOSE: Pediatric intussusception's first line treatment consists of fluoroscopic guided air enema reduction. Postprocedure, these patients are usually admitted overnight for observation. The purpose of our study was to document the results of emergency department (ED) observation and discharge protocol after successful reduction of ileocolic intussusception. METHODS: A prospective observational study was conducted after implementation of an ED protocol for ileocolic intussusception from 10/2014 to 7/2017 and compared these patients to a historical cohort immediately prior to protocol initiation (10/2011-9/2014). Data collected included demographics, total time in the ED and hospital, enema reduction, recurrence, and requirement for operative intervention. Results reported as means with standard deviation and medians reported with interquartile ranges (IQR). RESULTS: 115 patients were treated with the prospective protocol and were compared to a 90 patient historical cohort. Reduction was successful in 84%-89% of cases. Median hospital time after enema was shorter in the protocol group [4.8 h (4.25, 14.97) versus 19.7 h (13.9, 33.45), p < 0.01]. Only 33% of patients were admitted following the protocol; the most common admission reason was persistent abdominal discomfort. CONCLUSION: ED observation and discharge after successful air enema reduction in children with ileocolic intussusception are safe, facilitate early discharge, and reduce hospital resource utilization. LEVEL OF EVIDENCE: III.

The Laparoscopic Versus Open Approach for Reduction of Intussusception in Infants and Children: An Updated Institutional Experience.

PURPOSE: We have previously demonstrated successful laparoscopic management after failed enema reduction of children with intussusception. The purpose of this study is to assess the effectiveness of our mature experience with laparoscopic reduction by evaluating operative success, duration of hospital stay, postoperative complications, and hospital readmission rates. MATERIALS AND METHODS: After IRB approval, a retrospective review was conducted on children (age 0-18 years) who failed enema reduction of intussusception between 2008 and 2017. Cases were classified as either open or laparoscopic. Demographic data, incidence of bowel resection, postoperative length of stay, complications, and hospital readmission rates were abstracted from patient medical records. Comparative analysis was performed in STATA with a P value <.05 determined as significant. RESULTS: A total of 81 children were included in our study with 63 patients (78%) undergoing a laparoscopic reduction and 18 patients (22%) undergoing an open operation. Laparoscopic reduction carried similar complication rates (11%) when compared with children undergoing an open reduction (11%, P = 1.00). Furthermore, both hospital readmission rates and returns to the operating room were similar between the two groups (P = .345 and P = .672, respectively). The median postoperative length of stay was shorter for patients undergoing a laparoscopic reduction (4 days, interquartile range [IQR], 2-5 days) than for patients undergoing an open reduction (5 days, IQR, 4-6 days, P = .001). Children undergoing a laparoscopic reduction had a decreased rate of bowel resection (43% versus 50%, P = .591) despite similar rate of pathological lead points (21% versus 22%, P = .884). CONCLUSION: Laparoscopic management of intussusception after failed radiographic reduction yields a reduced hospital length of stay with no increase in hospital readmission rates and reoperations.

Variation in bowel preparation among pediatric surgeons for elective colorectal surgery: A problem of equipoise or a knowledge gap of the available clinical evidence?

PURPOSE: Despite rigorous data from adult literature demonstrating that oral antibiotics (OA) reduce infectious complications and mechanical bowel preparation (MBP) alone does not, MBP alone remains the preferred approach among pediatric surgeons. We aimed to explore the nature of this discrepancy through a survey of the American Pediatric Surgical Association membership. METHODS: Surgeons were queried for their choice of bowel preparation, factors influencing their practice, and their impression of the strength and relevance of the adult literature to pediatric practice. RESULTS: Surgeons who used MBP alone (31%) cited a reduction in stool burden and infectious complications as important factors, whereas surgeons choosing not to use OA (70%) reported a lack of benefit in reducing infectious complications as the primary reason. Although 53% of surgeons reported that evidence from adult literature was the most important influence, 73% of surgeons reported there was poor evidence supporting the use of OA (±MBP), and only 25% used a preparation supported by adult randomized data. CONCLUSIONS: Wide variation exists among pediatric surgeons in the perceived utility of MBP and OA. Although the majority of pediatric surgeons cited the adult literature as the strongest influence on their practice, this is not consistent with stated perceptions or practice.

Use of mechanical bowel preparation and oral antibiotics for elective colorectal procedures in children: is current practice evidence-based?

PURPOSE: It is well established through randomized trials that oral antibiotics given with or without a mechanical bowel preparation (MBP) prior to colorectal procedures reduce complications, while MBP given alone provides no benefit. We aimed to characterize trends surrounding bowel preparation in children and determine whether contemporary practice is evidence-based. METHODS: Retrospective analysis of patients undergoing colorectal procedures at 42 children's hospitals (1/2/2007-12/31/2011) was performed. Patients were analyzed for diagnosis, pre-admission status, and inpatient bowel preparation. Bowel preparation was considered evidence-based if oral antibiotics were utilized with or without a MBP. RESULTS: 49% of all patients were pre-admitted (n=5,473), and the most common diagnoses were anorectal malformations (55%), inflammatory bowel disease (26%), and Hirschsprung's Disease (19%). The most common preparation approaches were MBP alone (54.3%), MBP+oral antibiotics (18.8%), and oral antibiotics alone (4.2%), although significant variation was found in hospital-specific rates for each approach (MBP alone: 0-96.1%, MBP+oral antibiotics: 0-83.6%, orals alone: 0-91.6%, p<0.0001). Only 22.9% of all patients received an evidence-based preparation (range by hospital: 0-92.3%, p<0.0001), and this rate decreased significantly during the five-year study period (27.6% in 2007 vs. 17.3% in 2011, p<0.0001). CONCLUSION: According to the best available clinical evidence, less than a quarter of all children pre-admitted for elective colorectal procedures receive a bowel preparation proven to reduce infectious complications.

Predictors of failed enema reduction in childhood intussusception.

BACKGROUND: Initial management of intussusception is enema reduction. Data are scarce on predicting which patients are unlikely to have a successful reduction. Therefore, we reviewed our experience to identify factors predictive of enema failure. METHODS: A retrospective review of all episodes of intussusception over the past 10 years was conducted. Demographics, presentation variables, colonic extent of intussusceptions, and hospital course were collected. Extent of intussusception was classified as right, transverse, descending, and rectosigmoid. Episodes were grouped as success or failure of enema reduction and compared using the Student t test for continuous variables and χ(2) test for dichotomous variables. Significance was P less than .05. RESULTS: We identified 405 episodes of intussusception and 371 attempts at enema reduction. There were 285 successful enema reductions. There was no difference between groups in age; sex; or the presence of emesis, fever, or abdominal mass. The failed enema group was more likely to have had symptoms over 24 hours before presentation (P = .006), bloody diarrhea (P < .001), and lethargy (P < .001). The chance of success diminished with colonic extent (right, 88%; transverse, 73%; left, 43%; colorectal, 29%; P < .001). CONCLUSION: Predictors of failed enema reduction of intussusception include presence of symptoms over 24 hours, diarrhea, lethargy, and distal extent of intussusception.

Diminishing role of contrast enema in simple meconium ileus.

PURPOSE: Contrast enema is the initial study of choice for simple meconium ileus to confirm diagnosis and to relieve obstruction. Despite favorable historically published results, our clinical impression suggests decreased effectiveness of the contrast enema resulting in more surgical interventions in contemporary practice. METHODS: A retrospective multiinstitutional review for a 12-year period was conducted for neonates diagnosed with meconium ileus by contrast enema. The neonates were divided into 2 groups-historic group (HG = before 2002) and contemporary group (CG = after 2002). T test was used for comparison of continuous variables and chi(2) for categorical data. RESULTS: Thirty-seven total patients were identified (21 females and 16 males). Obstruction was relieved in 8 neonates (22% overall success rate). Average enema attempt per patient was decreased in the CG group compared to HG (1.4 vs 1.9). The success rate in the CG group was 5.5% (1/18) compared to 39% (7/18) in HG. CONCLUSIONS: In this review, success of contrast enema for relief of meconium ileus has significantly decreased over time. These findings may be because of reluctance to repeat enemas, change in radiologist experience, or use of contrast agent. As a result, higher rates of operative intervention are now observed. In stable patients, surgeons should recommend repeat enemas before exploration.

Current significance of meconium plug syndrome.

BACKGROUND: The significance of meconium plug syndrome is dependent on the underlying diagnosis. The incidence of pathologic finding, particularly Hirschsprung's disease, contributing to the presence of these plugs, has been debated. However, there are little recent data in the literature. Therefore, we reviewed our experience with meconium plugs as a cause of abdominal distension to evaluate the associated conditions and incidence of Hirschsprung's disease. METHODS: We reviewed the records of newborns with meconium plugs found in the distal colon on contrast enema from 1994 to 2007. Demographics, radiologic findings, histologic findings, operative findings, and clinical courses were reviewed. RESULTS: During the study period, 77 patients were identified. Mean gestational age was 37.4 weeks and birth weight, 2977 g. Hirschsprung's disease was found in 10 patients (13%). One had ultrashort segment disease and another had total colonic aganglionosis. Maternal diabetes was identified in 6 patients. No patients were diagnosed with cystic fibrosis, meconium ileus, malrotation, or intestinal atresia. CONCLUSION: Meconium plugs found on contrast enema are associated with a 13% incidence of Hirschsprung's disease in our experience. Although all patients with plugs and persistent abnormal stooling patterns should prompt a rectal biopsy and genetic probe, the incidence of Hirschsprung's and cystic fibrosis may not be as high as previously reported.