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Intussusception 409

is given orally (through the NGT, if still in place). This is usually 59.1% successful reduction rates. 30
observed in the stools within 24 hours, when the patient can then be Surgical management is reserved for children with failed hydrostatic
discharged home. or pneumatic reduction of the intussusception; those who develop
If reduction fails after two to three attempts (i.e., the mass is still leakage of fluid into the peritoneal cavity during enema reduction;
palpable and its reduction is not progressing), or if there is a suspicion those in whom free air, peritonitis, or shock was present on admission;
of a perforation of the bowel (air escapes freely and easily into the or those in whom PLP (e.g., a polyp, enterogenic cyst, etc.) was
peritoneal cavity, the abdomen becomes grossly distended, and after detected during investigations or after NOR.
removing the Foley catheter no air escapes from the anal orifice), Surgical Management
the NOR procedure is immediately suspended and a laparotomy is Access into the peritoneal cavity is usually through an above or below
performed. As a precaution, the instruments for a laparotomy are transverse umbilical incision. The intussusception (Figure 68.10) is
always set on a tray, and the theatre nurse is scrubbed and gowned, delivered into the wound, and an attempt is made to reduce it manually
ready and waiting. By using this method in our institution, we have had
by a combination of milking and squeezing of the intussusceptum by
the surgeon and gentle tugging on the free limb of the intussusceptum
by the assistant. If the manual reduction is successful, the operation
ends there. Some surgeons will fix the caecum if it is found to be very
mobile, and others will perform an appendectomy, depending on which
incision was used, to prevent any future confusion should the patient
present again later with suspected appendicitis.
If an attempt at manual reduction fails as a result of tears or a
perforation in the bowel, or if the intussusception is deemed to be
gangrenous from inspection at the beginning of the surgery, or if a PLP
is found, then segmental resection is performed with re-establishment
of bowel continuity by an end-to-end anastomosis.
(A)
Another operative method for reduction of intussusception is by
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laparoscopic surgery, during which the intussusceptum is pulled out of
the intussuscipiens. All the manoeuvres carried out by the open method
can be done laparoscopically, including resection and anastomosis.
Postoperative Complications
Postoperative complications include recurrence of the intussusception,
perforation of the bowel during NOR of the intussusception, surgical
site infection, anastomotic leak, anastomotic breakdown, enterocutane-
ous fistula (especially if the patient is poorly nourished), postoperative
adhesive intestinal obstruction, and incisional hernias.
(B) Prognosis and Outcome
Prognosis is usually excellent if diagnosis is early, resuscitation is
carried out thoroughly, and treatment is started early, especially with
successful nonoperative reduction of the intussusception. Worldwide,
the overall mortality of intussusception is about 1%, and near zero with
NOR of the intussusception.
On the African continent, however, mortality is very high, ranging
from 12.1% to 35.1%. 2,3,7,9 Recurrence rates following NOR range from
5% to 20% 15,16 with a mean of about 10%. After surgical reduction,
16
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recurrence rates range from 1% to 4%.
(C)

(D)
Source: Courtesy of Francis A. Abantanga.
Figure 68.9: Theatre setup for pneumatic or air enema reduction of an
intussusception in a 7-month-old child. (A) The child is anaesthetized and
ready for AER; (B) close-up view of the setup; (C) the continuous bubbling of Figure 68.10: An intraoperative picture of an ileo-ileal intussusception in a
air into the kidney dish with water, indicating that the intussusception has been child. Note the oedematous and inflamed intussuscepiens and the enlarged
reduced; (D) the complete set of requirements. mesenteric lymph nodes.