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 Table of Contents  
ORIGINAL ARTICLE
Year : 2017  |  Volume : 15  |  Issue : 4  |  Page : 210-215

Ileopexy in open reduction of ileocolic intussusception in pediatrics: its role on recurrence


1 Pediatric Surgery, Faculty of Medicine (Damietta), Al-Azhar University, Egypt
2 Radiology Department, Faculty of Medicine (Damietta), Al-Azhar University, Egypt

Date of Submission28-Jan-2018
Date of Acceptance02-Apr-2018
Date of Web Publication19-Jul-2018

Correspondence Address:
Ibrahim Mahmoud Elsayaad
Assistant Professor of Pediatric Surgery, Pediatric Surgery, Faculty of Medicine (Damietta), Al-Azhar University, 34517
Egypt
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/AZMJ.AZMJ_5_18

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  Abstract 


Background Intussusception is the main reason of intestinal obstruction in pediatrics. Hydrostatic reduction (HR) is the cornerstone in its treatment. However, surgical treatment is indicated in case of failure of HR. Fixation of terminal ileum (ileopexy) has been used to reduce or even prevent recurrence of intussusception, but its outcome has not been well studied.
Aim The aim was to investigate the effect of fixation of terminal ileum on recurrence rate after surgical reduction of intussusception in pediatric age group.
Patients and methods A total of 80 children scheduled for surgical reduction of intussusception were included and randomly assigned to fixation of terminal ileum (group A; n=40) or no fixation (group B; n=40). All were assessed clinically, and laboratory investigations were done. Patient’s demographics and surgical outcome were documented and compared between both groups.
Results Both groups were comparable regarding demographic data, clinical presentation, duration of symptoms before admission, surgical indication, and duration of hospital stay. In addition, the recurrence rate was nonsignificantly reduced in group A when compared with group B (5.0 vs. 15.0%, respectively). In addition, HR was successful in one and failed in the other recurrent case in group A (50.0% of success) compared with only one (16.7%) of six in group B.
Conclusion Fixation of terminal ileum during surgical reduction of intussusception is safe, feasible, and simple technique. It results in reduction of the recurrence rate. However, the difference was statistically nonsignificant.

Keywords: colon, ileopexy, ileum, intussusception, laparotomy, manual reduction


How to cite this article:
Elsayaad IM, Shahin M, El-Deek AF. Ileopexy in open reduction of ileocolic intussusception in pediatrics: its role on recurrence. Al-Azhar Assiut Med J 2017;15:210-5

How to cite this URL:
Elsayaad IM, Shahin M, El-Deek AF. Ileopexy in open reduction of ileocolic intussusception in pediatrics: its role on recurrence. Al-Azhar Assiut Med J [serial online] 2017 [cited 2018 Oct 20];15:210-5. Available from: http://www.azmj.eg.net/text.asp?2017/15/4/210/237134




  Introduction Top


Intussusception is a possibly serious emergency condition, in which part of the intestine invaginates (telescoped) into an adjacent portion, leading to intestinal obstruction. The spontaneous self-reduction of small bowel intussusceptions can occur [1],[2]. However, the bulk of intussusceptions, if not treated, can advance to create an obstruction, with decreased blood supply to involved parts of intestine. Intussusception occurs usually in children, with peaking incidence at 4–6 months of age [3].

Worldwide, the estimated intussusception rate is 74 cases per 100 000 infants under the age of 1 year, ranging between nine and 328 cases per 100 000 according to geographic location [4].

The management of intussusception has been well-recognized. It includes up to 48 h of in-patient observation after succeeded hydrostatic or air reduction. The need for this observation is to search for recurrence, with estimated rate of 7–13% of recurrence after hydrostatic reduction (HR) [5],[6]. The HR in pediatric population usually succeed in approximately 69–100% even if it was after a recurrence [7],[8],[9], and each recurrence is treated as if it was the first intussusception, with surgical intervention reserved for cases with failure of HR [10].

In a trial to decrease rate of recurrence of intussusception, authors proposed resection of involved segment with fixation of the terminal ileum to the cecum or peritoneum [11]. However, literature is deficient in studies investigating the association between methods of operative intervention and the incidence of intussusception recurrence for each procedure.

Ileopexy has widely been used as a technique to minimize the recurrent intussusception, but its outcome has not been well evaluated [12]. Here, we intended to investigate the effect of fixation of terminal ileum to the ascending colon by interrupted sutures, compared with nonfixation of the terminal ileum on the incidence of recurrent intussusception in children.


  Patients and methods Top


The present study was conducted at Al-Azhar University Hospital, Damietta (Tertiary Healthcare Center). The protocol was explained and accepted by the Ethical Research Committee of Al-Azhar University. According to diagnosis, the pathology, planned treatment, and possible complications were explained, and an informed consent was obtained from parents or guardians.

The study included 116 patients who were presented with intussusception: 65 at the first 24 h and 51 after that. HR was attempted on 65 children presented in the first 24 h and succeeded in 36 cases, whereas HR failed in 29 cases. Failed HR was defined as failure of the passage of dye into the small intestine 1 h after the gastrografin enema (by ultrasound or plain radiography). Cases with failure of HR and cases presented after 48 h were subjected to surgical intervention. Thus, the final surgical intervention was done for 80 children.

Patients scheduled for surgical intervention were randomized into two equal groups (40 patients): group A received manual reduction with fixation of ileum to ascending colon and group B received manual reduction only without fixation of the ileum to ascending colon. Randomization was done by a closed envelope that was opened at the surgical theater by a nurse not included in the study. The study was conducted during the period from June 2013 to June 2017 (the end of follow-up for the last patient). Patient characteristics, main clinical presentation(s), duration of symptoms, complications, and duration of hospital stay were documented. Diagnosis of intussusception was confirmed radiologically by plain radiography, gastrografin enema, and abdominal ultrasound ([Figure 1],[Figure 2],[Figure 3],[Figure 4],[Figure 5]). Patients with ileo-ileal, jejuno-jejunal, or colo-colonic intussusceptions and cases that underwent resection anastomosis were excluded.
Figure 1 Abdominal ultrasound with axial cross section of the affected bowel shows pseudokindy sign with thickened hypoechoic layer representing the oedematous outer bowel & hyperechoic center secondary to the compressed loop of bowel.

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Figure 2 Gasterographin enema shows a classical claw sign with intra-luminal filling defect (the intussusceptum) in the proximal and middle part of transverse colon with no flow of dye proximally.

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Figure 3 Preoperative plain x-ray of an infant with intussucception showing multiple fluid levels.

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Figure 4 A: Ileo-colic intussusception before reduction, B: After reduction with marked edema of terminal ileum.

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Figure 5 Ileopxy with multiple interrupted sutures.

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The method of nonsurgical reduction was radiography-guided or ultrasound-guided HR. It was done as the following: broad-spectrum antibiotics to cover colonic flora were given before HR attempts. The child was then retained in the prone position; the enema tip was positioned within the child’s rectum and firmly taped in place. An assistant squeezed the child’s buttocks in position to prevent water-soluble contrast (gastrografin) leak. The enema bag was located ∼100 cm above the level of the rectum. Gastrografin was diluted in normal saline (1 : 5), and continuous drip was permitted for approximately 30–45 min. Reduction was confirmed by free flow of contrast into the small bowel. Other signs of reduction success included symptom resolution, disappearance of the abdominal mass if initially present, and disappearance of the target sign if present on initial ultrasound. All HRs were done under sedation by intravenous midazolam at a dose of 0.1–0.2 mg/kg.

Surgical technique

The bowel was typically explored by a transverse incision in the right lower quadrant. After examination for signs of perforation, the intussusception is recognized and brought into the wound. First, a try was done at manual reduction by backward milking of the intussusceptum, with gentle pulling until complete reduction of intussusception. An incidental appendectomy is often done (32 in group A and 28 in group B). Then in group A, ileopexy was done by multiple polygalactine (3/0) or polyester (2/0) interrupted sutures, starting from the ileocecal valve upwards, with 3 cm apart.

Data analysis

The collected data were organized, tabulated, and statistically analyzed by statistical package for the social sciences (SPSS) version 16 (SPSS Inc., Chicago, Illinois, USA). Numerical variables are presented as mean and SD; whereas qualitative data were presented as number and percentage distribution. Comparison between groups was done by student samples (t) test and χ2 or Mann–Whitney for quantitative and qualitative data, respectively. P value of less than 0.05 was considered significant.


  Results Top


Patient characteristics and main presenting symptoms are presented in [Table 1]. Patient age ranged from 4 to 40 months, and the mean age was 11.23±7.86 months; there was no significant difference between groups A and B (10.07±6.88 vs. 12.40±8.66, respectively). The median age in group A was 7.5 months compared with 10 months in group B. In addition, 60.0% (48 children) of all studied children were males and 40.0% were females, with no significant difference between both the groups. The presenting symptom was abdominal pain in 80.0%, bleeding per rectum in 53.8%, vomiting in 33.8%, abdominal mass in 38.8%, and constipation in 13.8%; the mean duration of symptoms ranged from 10 to 80 h, and the mean values was 30.77±12.86 h; there was no significant difference between both groups. The mean duration in group A was 30.97±12.84 compared with 30.57±13.04 in group B.
Table 1 Patient characteristics and main presenting symptom in studied populations

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The indications of surgical intervention in studied groups were as follows: failure of HR in 35.0%, hemodynamic instability in 33.8%, and delayed presentation in 56.3%. There was no significant difference between both groups regarding indication of surgical intervention. The duration of hospital stay ranged from 2 to 6 days; the mean duration was 3.50±1.01 days, and there was no significant difference between groups A and B (3.42±1.03 vs. 3.57±1.01 days, respectively; [Table 2]). The recurrence was reported in eight (10.0%) cases (three patients occurred at the fourth postoperative day, one patient at the end of the second month, two patients at the eighth month, and the last two patients at 15th month postoperatively), and there was nonsignificant decrease of recurrence in group A when compared with group B (two cases; 5.0% vs. six cases; 15.0%, respectively). In group A, recurrence was reported in two children at the fourth postintervention day: one responded to HR, and the other needed second surgical intervention. However, in group B, the recurrence was reported in six children: only one of them was reduced by HR, whereas the others five children needed second surgical intervention. The total follow-up period ranged from 12 to 36 months (mean±SD: 28.91±4.83) with no difference between group A and group B (28.37±5.11 vs. 29.45±4.53 months, respectively; [Table 2]).
Table 2 Surgical indication and outcome in studied populations

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  Discussion Top


Intussusception is defined as telescoping of one segment into an immediately adjacent segment of the bowel. Generally, intussusception in children is idiopathic, and the cause can be discovered in only 10% of cases. Most cases classically take place within the ileocolic region but can take place in any segment of the intestine. Intussusception is typically treated with nonoperative reduction through pneumatic and/or hydrostatic enemas [13].

In most cases of intussusception, the cause is not identifiable, and delayed diagnosis may lead to bowel perforation [14].

Surgical reduction is ascertained for cases in whom HR failed, those who are hemodynamically unstable, and those with known pathological lead point [15].

However, there is a recent study on the role of colonoscopy for the treatment of intussusception. Tafner et al. [16] stated that the overall treatment with colonoscopy was successful in reversing invagination in 66.7% of the patients.

Fixation of ileum to the ascending colon is not a routine maneuver after manual surgical reduction, although, theoretically it seems to reduce the recurrence rate. Here, we reported our experience with fixation of the terminal ileum after manual reduction of intussusception. Our study included 80 children fulfilling the indications for surgical intervention. All patients were subjected to surgical reduction with fixation of the ileum in group A and no fixation of the ileum in group B to compare the effect of fixation of the ileum on the recurrence of intussusception.

The results revealed that the recurrence rate was nonsignificantly higher in group B when compared with group A, and the need for surgical reintervention is higher in recurrent cases. Thus, we can say that fixation of terminal ileum to ascending colon potentially had a benefit of reducing recurrence rate, although the difference was statistically nonsignificant.

The recurrence rate in the present work was 10% regardless of the technique, and this is lower than that reported by Esmaeili-Dooki et al. [17] from Iran who reported a recurrence rate of 16% (38/237). Other studies reported that the overall incidence of recurrence of intussusception ranged from 8 to 15% [18],[19]. Ksia et al. [20] reported a total rate of 2–20%. The difference of recurrence rate could be owing to the method of determination, because in some reports, the recurrence rate was estimated as a percentage of the recurrent cases [19],[21],[22] or the percentage of the recurrence episodes from the total participants [23]. The recurrence rate of intussusception was 10–15% after nonoperative reduction [18],[24] and 0–4% after operative reduction [25].It is possible that adhesions created in intestines to surrounding tissues with operative reduction reduced recurrence of intussusception [21],[23]. Thus, the fixation of terminal ileum to the ascending colon seems to be more suitable method for reduction of recurrence rate. However, the present study did not confirm this assumption.

On the contrary, Han and Lian [26] compared the recurrence rate after manual reduction without fixation, after fixation once or after fixation twice and reported that there were five (5.9%) episodes of recurrence in patients who had simple manual reduction, four (6.0%) episodes in patients who had underwent ileopexy one, and five (6.2%) episodes after ileopexy two. They added that there was no significant difference in recurrence rate among the three groups and concluded that ileopexy is not better than simple manual reduction in prevention of recurrence of ileocolic intussusception in pediatrics. In addition, Wei et al. [27] found that in ileocolic intussusception, ileopexy provides no benefit on recurrence prevention but contributes to longer operative time. Furthermore, Koh et al. [12] found that in ileocolic intussusception, ileopexy is not superior to manual reduction for prevention of the recurrence of ileocolic intussusception in children. They explained these finding by the assumption that a fixed distal ileum might disturb the regular peristalsis wave and let the proximal intestine drive into the distal part more feasibly. The effect of ileopexy to prevent terminal ileum pushing into colon is counteracted by the probability of proximal segment pushing into the fixed terminal ileum. The final result is that, when compared with simple reduction, ileopexy potentially reduce the risk of recurrent intussusception.

In short, fixation of terminal ileum was potentially better than simple reduction in minimizing recurrence of intussusception in children. However, the difference was statistically nonsignificant, and future studies with larger sample of patients are needed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
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    Figures

  [Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5]
 
 
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