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Operative Indications inRecurrent Ileocolic IntussusceptionJeremy G. Fisher, Eric A. Sparks, Christopher G.B. Turner, Justin D. Klein, Elliot Pennington, Faraz A. Khan, David Zurakowski, Emily T. Durkin, Dario O. Fauza, Biren P. Modi. Journal of Pediatric Surgery 50 (2015) 126130.Presenter: Y.j. LiSupervisor: dr. C.C. hsuBackgroundIleocolic intussusception: Second most common cause of bowel obstruction in pediatric patientsReduction of the intussusception by air-contrast enemaa high success ratefew complicationsfirst line therapy for the initial episodeRecurrence(s) in 9%18% of children

BackgroundIndication for surgical reduction:PeritonitisShock/sepsisPneumoperitoneumPreoperatively evident pathologic lead pointRecurrence??Surgical intervention after more than one or two episodesIntussusceptions fail to reduce with ACE or contrast enemaStudies in existence only included patients treated with BE

PurposeTo delineate operative indications for recurrent intussusception in the era of ACE: if a certain number of recurrences should warrant operative interventionconcern for PLPconcern for bowel damage requiring resectionconsideration of possible further recurrenceconcern for increasing risk of an ACE-related complicationMethodsCohort study: a retrospective reviewInclusion criteriaChildren 018 years of age with ultrasonicly-proven ileocolic intussusception between March 1997 and March 2013Data recordedtotal number of intussusception episodes within the study periodACE and operative procedure details and outcomeshistory of operation, presence of PLP, intestinal ischemia, intestinal perforation, and intestinal resectionImaging and histopathologic findingsResults

high suspicion of PLPs--> op6high suspicion of PLPs--> opResults

A higher number of episodes is a risk factor for bowel resection7ResultsHowever, when stratified by age group (5 and >5 years), recurrence was still not a risk factor for PLP in both groups (P > 0.05).Children who are age 5 or older are more likely to have a pathological lead point8Results

ResultsThe rate of recurrence increases significantly with each subsequent episode until the third10Results

A failed ACE reduction was associated with a significant increase in risk of PLP. Patients in whom the intussusception was completely reduced at ACE had a 98% chance of not having a PLP11DiscussionRecurrence of intussusception after ACE is not a risk factor for harboring a PLP.PLP rate 29% in > 5 y/o Age greater than 5 as an independent indication for surgery would likely result in a substantial number of unnecessary operations.When stratified by age group, recurrence did not appear to be a risk factor for PLP.While recurrence was a risk factor for receiving a bowel resection in this cohort, it was not associated with intestinal ischemia or perforation.

DiscussionA failed ACE reduction was associated with a significant increase in risk of PLP. A successful ACE was even more informative: patients in whom the intussusception was completely reduced at ACE had a 98% chance of not having a PLP.Children who had three ormore episodes have a greater than 50% chance of having a subsequent episode. May consider operationRepeat ACE has not been associated with a higher risk of perforation either in the present or previous studies.

ConclusionTreatment for recurrent Ileocolic Intussusception:ACE as first-line therapy and operations for those with ACE failure or with evidence of PLP or bowel ischemia.Thank you for your attention!