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Contrast enema for pediatric intussusception: is reflux into the terminal ileum necessary for complete reduction?
Journal of Pediatric Surgery (2009) 44, 247–250
www.elsevier.com/locate/jpedsurg
Contrast enema for pediatric intussusception: is reflux into the terminal ileum necessary for complete reduction? Shant Shekherdimian, Steven L. Lee ⁎, Roman M. Sydorak, Harry Applebaum Division of Pediatric Surgery, Kaiser Permanente, Los Angeles Medical Center, Los Angeles, CA 90027, USA Received 5 October 2008; accepted 7 October 2008
Key words: Intussusception; Contrast enema; Nonoperative management
Abstract Purpose: Complete contrast enema reduction of intussusception is traditionally considered confirmed when contrast is seen refluxing into the terminal ileum. Operative intervention is typically indicated when the intussusception is not completely reduced. This study reviews the outcomes after symptomatic reduction of intussusception without requiring reflux of contrast into the terminal ileum. Methods: A retrospective review of all pediatric patients treated for intussusception between 1996 and 2006 was performed. Diagnostic modality, operative reports, and hospital records were reviewed. Results: One hundred sixty-eight patients were treated for intussusception during the study period. Median age was 9.9 months (59 days to 16.7 years). One hundred thirty-seven (81.5%) patients underwent contrast enema as the initial diagnostic/therapeutic modality. On contrast enema, 15 (10.9%) patients demonstrated reduction of the intussusception but without contrast refluxing into the terminal ileum. All 15 patients had improvement of symptoms. Six (40%) patients underwent operative intervention and were found to have a completely reduced intussusception. Two (13.3%) patients had repeat contrast enema the next day confirming complete reduction. The remaining 7 (46.7%) patients were observed without further radiographic studies, and all 7 patients were discharged the following day tolerating full feedings. There were no recurrent intussusceptions. Conclusion: Nonoperative management may be used in patients with reduced intussusception despite lack of contrast refluxing into the terminal ileum if symptoms resolve. © 2009 Elsevier Inc. All rights reserved.
Successful reduction of an ileocolic intussusception via a contrast enema is traditionally defined by the absence of a filling defect in the colon, in addition to reflux of contrast into the terminal ileum (TI). The failure to demonstrate reflux into the TI even in the setting of no filling defects in
Presented at the 39th annual meeting of the American Pediatric Surgical Association, Phoenix, AZ, May 27-June 1, 2008. ⁎ Corresponding author. Tel.: +1 323 783 4857; fax: +1 323 783 8747. E-mail address: [email protected] (S.L. Lee). 0022-3468/$ – see front matter © 2009 Elsevier Inc. All rights reserved. doi:10.1016/j.jpedsurg.2008.10.051
the colon has served as an indication for either repeating a contrast enema or operative exploration [1,2]. Reflux of contrast past the ileocecal valve may be difficult to achieve even after a successful reduction because of edema of the valve caused by venous congestion [3,4]. Furthermore, no data exist on outcomes of conservative management in the setting of asymptomatic patients with reduced intussusceptions who fail to demonstrate contrast reflux. The purpose of this study was to review the outcomes after reduction of intussusception without reflux of contrast into the terminal ileum.
248
S. Shekherdimian et al.
1. Materials and methods
3. Discussion
This study was approved by the Institutional Review Board at Kaiser Permanente, Los Angeles Medical Center (Los Angeles, Calif) (no. 4850). All pediatric patients (age 0-18) treated for intussusception between the years of 1996 and 2006 at all Kaiser Permanente Southern California facilities were identified using the International Classification of Diseases, Ninth Revision, diagnosis code 560.0. A retrospective chart review of imaging reports, operative reports, progress notes, and admission and discharge summaries was performed. All patients included in the study had ileocolic intussusception. Patients with other types of intussusception or incomplete records were excluded.
Contrast refluxing into the terminal ileum has traditionally been mandatory for confirming successful reduction of intussusception. No studies have been published that demonstrate the safety and efficacy of conservative management in patients who undergo reduction but fail to demonstrate contrast reflux and are otherwise asymptomatic after the procedure. Our series demonstrates that this may occur in up to 10% of patients undergoing a contrast enema for diagnosis and treatment of intussusception. These patients are typically managed either with surgical exploration or repeat enemas, both of which expose children to significant risks. Even with the introduction of diagnostic laparoscopy and laparoscopic-assisted reductions as treatment options, inherent risks to these operations still exist [5-10]. Many studies have documented the substantial risks of contrast enemas for diagnosis or treatment. Thomas et al [11] reported a median radiation dose of 55 microsievert with each enema. Compared to other imaging modalities, contrast enemas expose patients to 11 times more radiation than an abdominal computed tomography and are equivalent to the radiation exposure of 2750 chest x-rays [12]. Although the precise quantification of cancer risks from low doses of radiation exposure is not known, it is recommended that radiation exposure to children be kept to an absolute minimum [12]. Thus, the avoidance of an additional contrast enema will prevent unnecessary radiation exposure to these children. In addition, perforation of the intestine, although rare, is a known and potentially devastating complication of this procedure. When an enema reduction is not successful on the first attempt, repeat enema in a patient without peritonitis is a viable option. Several studies have shown that repeat enemas are effective in reducing intussusceptions that were only partially reduced initially. Most authors have attributed this to the resolution of venous congestion at the ileocecal valve causing adjacent edema [3,13-17]. This venous congestion may also be responsible for the difficulty in demonstrating contrast reflux even after a complete reduction. Our data show that patients who undergo reduction of ileocolic intussusceptions without residual filling defects in the colon, but in whom reflux of contrast into the TI is not demonstrated, may be considered for nonoperative management, assuming they become asymptomatic after the procedure. Treatment with overnight observation can help avoid repeat enemas or surgical exploration, along with their associated risks and morbidities. Although all of the patients managed conservatively in our trial were successfully fed and subsequently discharged, there are some disadvantages to this management strategy. First, patients can potentially be discharged before an overnight stay if they undergo a repeat enema and tolerate a diet. Second, although unlikely, the lack of contrast reflux could theoretically signify a residual intussusception. In this
2. Results One hundred seventy patients diagnosed with intussusception were identified at 11 medical centers. Two patients were found to have ileoileal intussusceptions and were excluded. Median age was 9.9 months (range, 59 days to 16.7 years). Of the patients, 71% were boys. Of the 168 patients with ileocolic intussusceptions, 137 (81.5%) underwent a contrast enema as the first diagnostic/ therapeutic intervention. The remaining 31 patients underwent computed tomographic scan (n = 16), abdominal ultrasound (n = 2), upper gastrointestinal series (n = 3), colonoscopy (n = 1), or underwent immediate operative exploration (n = 9). All of the patients (n = 31) who did not receive a contrast enema initially were eventually taken to the operating room. Of the 137 patients undergoing a contrast enema as the initial diagnostic/therapeutic modality, 64 (46.8%) had successful reduction of their ileocolic intussusceptions with demonstration of contrast in the terminal ileum at the end of the procedure. Fifty-eight (42.3%) patients had unsuccessful reduction and were taken to the operating room. The remaining 15 (10.9%) patients had reduction of the intussusception with no colonic filling defects; however, reflux of contrast was not demonstrated. All 15 patients had resolution of their symptoms. The median age of these 15 patients was 9.3 months, and 67% (n = 10) were boys. During the early study period, 6 patients were taken to the operating room for exploration. All 6 patients were found to have completely reduced intussusceptions. Subsequently, 2 patients underwent a repeat contrast enema within 24 hours that demonstrated no residual intussusceptions and confirmed reflux of contrast into the TI. The final 7 patients treated during the study interval were managed conservatively with overnight observation and reinitiation of a diet. All 7 patients remained asymptomatic and were subsequently discharged later that day. There were no recurrences in any of the 15 patients.
Contrast enema for pediatric intussusception situation, conservative management would exacerbate the situation, making subsequent reduction with a contrast enema more difficult and increasing the chances of bowel necrosis. Our study was also limited such that the basis for terminating the contrast enema was not objectively defined but rather was based on the radiologist experience. Choice of contrast enema over air enema reduction was also based on radiologist preference and experience and unlikely to have affected our results. Finally, the unsuccessful contrast enema reduction rate seemed rather high (42%) and may be due in part by the significant number of patients transferred from outlying medical centers. Furthermore, a recent analysis of the Health care Cost and Utilization Project Kid's Inpatient Database demonstrated more than 50% of patients with ileocolic intussusception required operative intervention [18]. We recognize that many children with intussusception can be treated with contrast enema reduction and will demonstrate ileal reflux. In addition, patients with nonreducible intussusceptions or with peritonitis will require operative intervention. On the basis of our experience, we believe that asymptomatic patients undergoing a successful contrast enema reduction that fails to demonstrate contrast reflux into the TI may be safely observed and restarted on a diet, thereby, avoiding operative risk and further radiation exposure.
References [1] Ashcraft K. Pediatric surgery. Saunders; 2004. [2] Mallory B. Intussusception. Oper Tech Gen Surg 2004;6:330-4. [3] Saxton V, Katz M, Phelan E, et al. Intussusception: a repeat delayed gas enema increases the nonoperative reduction rate. J Pediatr Surg 1994;29:588-9. [4] Collins DL, Pinckney LE, Miller KE, et al. Hydrostatic reduction of ileocolic intussusception: a second attempt in the operating room with general anesthesia. J Pediatr 1989;115:204-7. [5] Abasiyanik A, Dasci Z, Yosunkaya A, et al. Laparoscopic-assisted pneumatic reduction of intussusception. J Pediatr Surg 1997;32: 1147-8. [6] Burjonrappa SC. Laparoscopic reduction of intussusception: an evolving therapeutic option. JSLS 2007;11:235-7. [7] Hay SA, Kabesh AA, Soliman HA, et al. Idiopathic intussusception: the role of laparoscopy. J Pediatr Surg 1999;34:577-8. [8] Poddoubnyi IV, Dronov AF, Blinnikov OI, et al. Laparoscopy in the treatment of intussusception in children. J Pediatr Surg 1998;33: 1194-7. [9] Schier F. Experience with laparoscopy in the treatment of intussusception. J Pediatr Surg 1997;32:1713-4. [10] 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;15:373-6. [11] Thomas RD, Fairhurst JJ, Roberts PJ. Effective dose during screening monitored intussusception reduction. Clin Radiol 1993;48:189-91. [12] Rice HE, Frush DP, Farmer D, et al. Review of radiation risks from computed tomography: essentials for the pediatric surgeon. J Pediatr Surg 2007;42:603-7. [13] Gonzalez-Spinola J, Del Pozo G, 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;34:1016-20.
249 [14] Gorenstein A, Raucher A, Serour F, et al. Intussusception in children: reduction with repeated, delayed air enema. Radiology 1998;206: 721-4. [15] Rohrschneider WK, Troger J. Hydrostatic reduction of intussusception under US guidance. Pediatr Radiol 1995;25:530-4. [16] Sandler AD, Ein SH, Connolly B, et al. Unsuccessful air-enema reduction of intussusception: is a second attempt worthwhile? Pediatr Surg Int 1999;15:214-6. [17] Guo JZ, Ma XY, Zhou QH. Results of air pressure enema reduction of intussusception: 6,396 cases in 13 years. J Pediatr Surg 1986;21: 1201-3. [18] Jen HC, Shew SB. Impact of hospital type and experience on the risk of operation for children with intussusception: a nationwide study. American Pediatric Surgical Association Annual Meeting Proceedings; 2008.
Discussion Speaker: One of our challenges is the radiologist cannot tell you whether it is reduced or not and there is a residual mass at the ileocecal valve, and they will say we are not sure whether it is reduced or not. How were you able to tell in those patients you observed that it was reduced but there was no reflux? Shant Shakhermidian, MD (response): For the majority of the patients, we have dealt with a pediatric radiologist who has been able to tell us with some confidence that there is no residual intussusception and it was just difficulty in obtaining the reflux in these patients. Robert Carachi, MD, (Glasgow, UK): I enjoyed your presentation, and I agree with your conclusion. In our institution, we use air enemas to reduce these, no longer contrast. We stopped doing that several years ago now, and I think our results are very similar to yours. Just a couple of points. We have reported ages ago about the value of using recurrent enemas to reduce intussusception successfully. I think provided you see some movement there and the patient is well, it is safe enough to do. That is our experience. Daniel Aronson, MD (Amsterdam, The Netherlands): Do you have an explanation as to why in these 7 patients ultrasound was never tried to distinguish, whereas you show that there was another subgroup of patients where ultrasound was applied because you can distinguish easily intussusception from an edema of the ileocecal valve. Shant Shakhermidian, MD (response): I do not have an explanation as to why ultrasound was not employed in these particular patients. From the prior slides, however, ultrasound was only
250
S. Shekherdimian et al. employed as an initial diagnostic, and the patients either went on to undergo the contrast enema or to the operating room. In our experience, it has never been used to evaluate for residual intussusception vs edema of the ileocecal valve.
Morini, MD (Rome, Italy): Do you have the diagnosis and the causes of intussusception in your patients?
Shant Shakhermidian, MD (response): We have actually started to look at the data and evaluate the frequency of pathologic lead points as well as the necessity of small bowel resection during operative intervention. We do not have that data available yet but we are looking into those.
www.elsevier.com/locate/jpedsurg
Contrast enema for pediatric intussusception: is reflux into the terminal ileum necessary for complete reduction? Shant Shekherdimian, Steven L. Lee ⁎, Roman M. Sydorak, Harry Applebaum Division of Pediatric Surgery, Kaiser Permanente, Los Angeles Medical Center, Los Angeles, CA 90027, USA Received 5 October 2008; accepted 7 October 2008
Key words: Intussusception; Contrast enema; Nonoperative management
Abstract Purpose: Complete contrast enema reduction of intussusception is traditionally considered confirmed when contrast is seen refluxing into the terminal ileum. Operative intervention is typically indicated when the intussusception is not completely reduced. This study reviews the outcomes after symptomatic reduction of intussusception without requiring reflux of contrast into the terminal ileum. Methods: A retrospective review of all pediatric patients treated for intussusception between 1996 and 2006 was performed. Diagnostic modality, operative reports, and hospital records were reviewed. Results: One hundred sixty-eight patients were treated for intussusception during the study period. Median age was 9.9 months (59 days to 16.7 years). One hundred thirty-seven (81.5%) patients underwent contrast enema as the initial diagnostic/therapeutic modality. On contrast enema, 15 (10.9%) patients demonstrated reduction of the intussusception but without contrast refluxing into the terminal ileum. All 15 patients had improvement of symptoms. Six (40%) patients underwent operative intervention and were found to have a completely reduced intussusception. Two (13.3%) patients had repeat contrast enema the next day confirming complete reduction. The remaining 7 (46.7%) patients were observed without further radiographic studies, and all 7 patients were discharged the following day tolerating full feedings. There were no recurrent intussusceptions. Conclusion: Nonoperative management may be used in patients with reduced intussusception despite lack of contrast refluxing into the terminal ileum if symptoms resolve. © 2009 Elsevier Inc. All rights reserved.
Successful reduction of an ileocolic intussusception via a contrast enema is traditionally defined by the absence of a filling defect in the colon, in addition to reflux of contrast into the terminal ileum (TI). The failure to demonstrate reflux into the TI even in the setting of no filling defects in
Presented at the 39th annual meeting of the American Pediatric Surgical Association, Phoenix, AZ, May 27-June 1, 2008. ⁎ Corresponding author. Tel.: +1 323 783 4857; fax: +1 323 783 8747. E-mail address: [email protected] (S.L. Lee). 0022-3468/$ – see front matter © 2009 Elsevier Inc. All rights reserved. doi:10.1016/j.jpedsurg.2008.10.051
the colon has served as an indication for either repeating a contrast enema or operative exploration [1,2]. Reflux of contrast past the ileocecal valve may be difficult to achieve even after a successful reduction because of edema of the valve caused by venous congestion [3,4]. Furthermore, no data exist on outcomes of conservative management in the setting of asymptomatic patients with reduced intussusceptions who fail to demonstrate contrast reflux. The purpose of this study was to review the outcomes after reduction of intussusception without reflux of contrast into the terminal ileum.
248
S. Shekherdimian et al.
1. Materials and methods
3. Discussion
This study was approved by the Institutional Review Board at Kaiser Permanente, Los Angeles Medical Center (Los Angeles, Calif) (no. 4850). All pediatric patients (age 0-18) treated for intussusception between the years of 1996 and 2006 at all Kaiser Permanente Southern California facilities were identified using the International Classification of Diseases, Ninth Revision, diagnosis code 560.0. A retrospective chart review of imaging reports, operative reports, progress notes, and admission and discharge summaries was performed. All patients included in the study had ileocolic intussusception. Patients with other types of intussusception or incomplete records were excluded.
Contrast refluxing into the terminal ileum has traditionally been mandatory for confirming successful reduction of intussusception. No studies have been published that demonstrate the safety and efficacy of conservative management in patients who undergo reduction but fail to demonstrate contrast reflux and are otherwise asymptomatic after the procedure. Our series demonstrates that this may occur in up to 10% of patients undergoing a contrast enema for diagnosis and treatment of intussusception. These patients are typically managed either with surgical exploration or repeat enemas, both of which expose children to significant risks. Even with the introduction of diagnostic laparoscopy and laparoscopic-assisted reductions as treatment options, inherent risks to these operations still exist [5-10]. Many studies have documented the substantial risks of contrast enemas for diagnosis or treatment. Thomas et al [11] reported a median radiation dose of 55 microsievert with each enema. Compared to other imaging modalities, contrast enemas expose patients to 11 times more radiation than an abdominal computed tomography and are equivalent to the radiation exposure of 2750 chest x-rays [12]. Although the precise quantification of cancer risks from low doses of radiation exposure is not known, it is recommended that radiation exposure to children be kept to an absolute minimum [12]. Thus, the avoidance of an additional contrast enema will prevent unnecessary radiation exposure to these children. In addition, perforation of the intestine, although rare, is a known and potentially devastating complication of this procedure. When an enema reduction is not successful on the first attempt, repeat enema in a patient without peritonitis is a viable option. Several studies have shown that repeat enemas are effective in reducing intussusceptions that were only partially reduced initially. Most authors have attributed this to the resolution of venous congestion at the ileocecal valve causing adjacent edema [3,13-17]. This venous congestion may also be responsible for the difficulty in demonstrating contrast reflux even after a complete reduction. Our data show that patients who undergo reduction of ileocolic intussusceptions without residual filling defects in the colon, but in whom reflux of contrast into the TI is not demonstrated, may be considered for nonoperative management, assuming they become asymptomatic after the procedure. Treatment with overnight observation can help avoid repeat enemas or surgical exploration, along with their associated risks and morbidities. Although all of the patients managed conservatively in our trial were successfully fed and subsequently discharged, there are some disadvantages to this management strategy. First, patients can potentially be discharged before an overnight stay if they undergo a repeat enema and tolerate a diet. Second, although unlikely, the lack of contrast reflux could theoretically signify a residual intussusception. In this
2. Results One hundred seventy patients diagnosed with intussusception were identified at 11 medical centers. Two patients were found to have ileoileal intussusceptions and were excluded. Median age was 9.9 months (range, 59 days to 16.7 years). Of the patients, 71% were boys. Of the 168 patients with ileocolic intussusceptions, 137 (81.5%) underwent a contrast enema as the first diagnostic/ therapeutic intervention. The remaining 31 patients underwent computed tomographic scan (n = 16), abdominal ultrasound (n = 2), upper gastrointestinal series (n = 3), colonoscopy (n = 1), or underwent immediate operative exploration (n = 9). All of the patients (n = 31) who did not receive a contrast enema initially were eventually taken to the operating room. Of the 137 patients undergoing a contrast enema as the initial diagnostic/therapeutic modality, 64 (46.8%) had successful reduction of their ileocolic intussusceptions with demonstration of contrast in the terminal ileum at the end of the procedure. Fifty-eight (42.3%) patients had unsuccessful reduction and were taken to the operating room. The remaining 15 (10.9%) patients had reduction of the intussusception with no colonic filling defects; however, reflux of contrast was not demonstrated. All 15 patients had resolution of their symptoms. The median age of these 15 patients was 9.3 months, and 67% (n = 10) were boys. During the early study period, 6 patients were taken to the operating room for exploration. All 6 patients were found to have completely reduced intussusceptions. Subsequently, 2 patients underwent a repeat contrast enema within 24 hours that demonstrated no residual intussusceptions and confirmed reflux of contrast into the TI. The final 7 patients treated during the study interval were managed conservatively with overnight observation and reinitiation of a diet. All 7 patients remained asymptomatic and were subsequently discharged later that day. There were no recurrences in any of the 15 patients.
Contrast enema for pediatric intussusception situation, conservative management would exacerbate the situation, making subsequent reduction with a contrast enema more difficult and increasing the chances of bowel necrosis. Our study was also limited such that the basis for terminating the contrast enema was not objectively defined but rather was based on the radiologist experience. Choice of contrast enema over air enema reduction was also based on radiologist preference and experience and unlikely to have affected our results. Finally, the unsuccessful contrast enema reduction rate seemed rather high (42%) and may be due in part by the significant number of patients transferred from outlying medical centers. Furthermore, a recent analysis of the Health care Cost and Utilization Project Kid's Inpatient Database demonstrated more than 50% of patients with ileocolic intussusception required operative intervention [18]. We recognize that many children with intussusception can be treated with contrast enema reduction and will demonstrate ileal reflux. In addition, patients with nonreducible intussusceptions or with peritonitis will require operative intervention. On the basis of our experience, we believe that asymptomatic patients undergoing a successful contrast enema reduction that fails to demonstrate contrast reflux into the TI may be safely observed and restarted on a diet, thereby, avoiding operative risk and further radiation exposure.
References [1] Ashcraft K. Pediatric surgery. Saunders; 2004. [2] Mallory B. Intussusception. Oper Tech Gen Surg 2004;6:330-4. [3] Saxton V, Katz M, Phelan E, et al. Intussusception: a repeat delayed gas enema increases the nonoperative reduction rate. J Pediatr Surg 1994;29:588-9. [4] Collins DL, Pinckney LE, Miller KE, et al. Hydrostatic reduction of ileocolic intussusception: a second attempt in the operating room with general anesthesia. J Pediatr 1989;115:204-7. [5] Abasiyanik A, Dasci Z, Yosunkaya A, et al. Laparoscopic-assisted pneumatic reduction of intussusception. J Pediatr Surg 1997;32: 1147-8. [6] Burjonrappa SC. Laparoscopic reduction of intussusception: an evolving therapeutic option. JSLS 2007;11:235-7. [7] Hay SA, Kabesh AA, Soliman HA, et al. Idiopathic intussusception: the role of laparoscopy. J Pediatr Surg 1999;34:577-8. [8] Poddoubnyi IV, Dronov AF, Blinnikov OI, et al. Laparoscopy in the treatment of intussusception in children. J Pediatr Surg 1998;33: 1194-7. [9] Schier F. Experience with laparoscopy in the treatment of intussusception. J Pediatr Surg 1997;32:1713-4. [10] 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;15:373-6. [11] Thomas RD, Fairhurst JJ, Roberts PJ. Effective dose during screening monitored intussusception reduction. Clin Radiol 1993;48:189-91. [12] Rice HE, Frush DP, Farmer D, et al. Review of radiation risks from computed tomography: essentials for the pediatric surgeon. J Pediatr Surg 2007;42:603-7. [13] Gonzalez-Spinola J, Del Pozo G, 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;34:1016-20.
249 [14] Gorenstein A, Raucher A, Serour F, et al. Intussusception in children: reduction with repeated, delayed air enema. Radiology 1998;206: 721-4. [15] Rohrschneider WK, Troger J. Hydrostatic reduction of intussusception under US guidance. Pediatr Radiol 1995;25:530-4. [16] Sandler AD, Ein SH, Connolly B, et al. Unsuccessful air-enema reduction of intussusception: is a second attempt worthwhile? Pediatr Surg Int 1999;15:214-6. [17] Guo JZ, Ma XY, Zhou QH. Results of air pressure enema reduction of intussusception: 6,396 cases in 13 years. J Pediatr Surg 1986;21: 1201-3. [18] Jen HC, Shew SB. Impact of hospital type and experience on the risk of operation for children with intussusception: a nationwide study. American Pediatric Surgical Association Annual Meeting Proceedings; 2008.
Discussion Speaker: One of our challenges is the radiologist cannot tell you whether it is reduced or not and there is a residual mass at the ileocecal valve, and they will say we are not sure whether it is reduced or not. How were you able to tell in those patients you observed that it was reduced but there was no reflux? Shant Shakhermidian, MD (response): For the majority of the patients, we have dealt with a pediatric radiologist who has been able to tell us with some confidence that there is no residual intussusception and it was just difficulty in obtaining the reflux in these patients. Robert Carachi, MD, (Glasgow, UK): I enjoyed your presentation, and I agree with your conclusion. In our institution, we use air enemas to reduce these, no longer contrast. We stopped doing that several years ago now, and I think our results are very similar to yours. Just a couple of points. We have reported ages ago about the value of using recurrent enemas to reduce intussusception successfully. I think provided you see some movement there and the patient is well, it is safe enough to do. That is our experience. Daniel Aronson, MD (Amsterdam, The Netherlands): Do you have an explanation as to why in these 7 patients ultrasound was never tried to distinguish, whereas you show that there was another subgroup of patients where ultrasound was applied because you can distinguish easily intussusception from an edema of the ileocecal valve. Shant Shakhermidian, MD (response): I do not have an explanation as to why ultrasound was not employed in these particular patients. From the prior slides, however, ultrasound was only
250
S. Shekherdimian et al. employed as an initial diagnostic, and the patients either went on to undergo the contrast enema or to the operating room. In our experience, it has never been used to evaluate for residual intussusception vs edema of the ileocecal valve.
Morini, MD (Rome, Italy): Do you have the diagnosis and the causes of intussusception in your patients?
Shant Shakhermidian, MD (response): We have actually started to look at the data and evaluate the frequency of pathologic lead points as well as the necessity of small bowel resection during operative intervention. We do not have that data available yet but we are looking into those.