Pereyaslov, Dvorakevych, and Dvorakevych: Laparoscopy in the Treatment of Children with Intussusception



Problem statement and analysis of the recent research

Idiopathic intussusception (in case of the causative factor absence) is one of the most common causes of intestinal obstruction in children at the age between 5 month and three years [5, 9]. The etiology of idiopathic intussusception is not clear but an association with virus infection has been proved [2]. According to the literature data, an annual incidence of intussusceptions constitutes 38, 31, and 26 cases per 100,000 living newborns during the first, second, and third year of life, respectively [11]. The therapeutic reduction of intussusception by the hydrostatic enemas with barium or air is the main method of treatment of children with idiopathic intussusception [7]. Despite of the high efficacy of therapeutic reduction, some of patients need surgery, especially in cases with symptoms of peritonitis or data of ultrasonography/radiology that indicated ineffective therapeutic reduction [6]. Right iliac area laparotomy with the manual reduction of the intussusception was the gold standard of treatment during the long time [5]. Minimally invasive pediatric surgery has expanded dramatically over the last decade and has been applied to the surgical management of intussusception [3]. The results of laparoscopic reduction of the intussusception are controversial – its success rate ranges between 30% and 91% [5], some authors suggested that children older than 3 years would not benefit from the laparoscopic approach [4], although others have stated that laparoscopy should be the standard of care for pediatric intussusception after failure of therapeutic reduction [3].

The objective of the research was to summarize own experience of laparoscopy in children with an intussusception.

Materials and methods

The research was grounded on the results of treatment of 28 children operated in the first surgical department of the Lviv Regional Children’s Clinical Hospital «OHMATDYT» during 2008-2015. There were 19 (67.9%) children under one year of age and 9 (32.1%) children older than one year of age (from one till 13 years).

Optical system Strayker 1088 HD (Germany) with the 3-, 5-mm laparoscopic equipment was used for laparoscopy. The pneumoperitoneum was applied according to the Hasson technique in the our modification with the working pressure of 5-7 mm Hg. Visual port was inserted into the umbilical region and working ports were inserted into the left mesogaster and hypogastrium due to the fact that ileo-cecal intussusception was diagnosed in most patients. The reduction of intussusception was performed by the retrograde traction of small intestine with the sliding catches.

Results and Discussion

Intussusception is one of the most often causes of intestinal obstruction in infants up to one year old [1], and ileo-cecal intussusception is most frequent its type [6, 12]. According the results of our research, the ileocecal intussusception was observed in 24 (85.7%) patients, and complex ileo-cecal-transversum intussusception was detected in 4 (14.3%) cases. Ideopathic intussusception (without the causative factor) was established in all patients less than one year old. This coincides with the literature data [8]. Ideopathic intussusception was noted in 2 patients older one year, intussusception was caused by polyp near ileocecal valve in 3 patients, by mesenterial lymphatic nodules in 2 cases, and by the appendix in 2 patients. The presence of the pathologic causative factor is typical for intussusception in older children [4, 8].

Choosing the method of surgery in children with the intussusception is individual for each patient. Absolute contraindication for the laparoscopic reduction is the cardio-respiratory disorders, in case of which the application of pneumoperitoneum may aggravate these disorders [3]. The presence of peritonitis symptoms before surgery is considered an indication for laparotomy [10], however, due to the results of our research, the presence of peritonitis without signs of intestinal perforation was not a contraindication for laparoscopy. Thus, 200 ml of effusion in abdominal cavity was identified in 8 (28.6%) children during laparoscopy, and after laparoscopic reduction of intussusception (6 patients), intestine was viable in 5 of them. In general, laparoscopic reduction of intussusception was effective in 19 (67.9%) children.

Conversion was observed in 9 (32.1%) children after diagnostic laparoscopy. Indications for conversion were the necrosis of intestinal loop that needed its resection (2 patients), presence of complex intussusception (4 patients), and presence of polyp in ileocecal valve region (3 patients). According to the literature, factors of conversion in cases of intussusception are the inability to perform laparoscopic reduction of intussusception (14.5%), bowel ischemia requiring resection (6.5%), technical difficulties (5.1%), presence of causative factor (2.2%), and bowel injury (0.4%) [1]. The frequency of conversions of 25-30% was not a lack of urgent minimally invasive surgery and could be seen as a common practice during laparoscopy. This coincides with the literature [1]. During the last year, in cases of intestine resection need, video-assisted operations were applied, during which the mobilization of intestine was done by laparoscopy with using of LigaSure® system and anastomosis was applied extraperitonealy (2 children).

The use of Doppler sonography and ultrasonography for intussusception diagnosis provided an opportunity to more clearly define indications for choosing method of intussusception surgical reduction, which reduced the conversion rate from 38.1% (in 2008-2014) to 14.3% (in 2015). Based on our research results and literature data, we can determined next risk factors of conversion during minimally invasive treatment of children with intussusception: presence of exudate between intussusceptum layers and absence of blood flow inside the intussusceptum (according to ultrasonography); child’s age – causative factor is often detected in children older than one year that may lead to the necessity of intestinal resection; inability of laparoscopic reduction of intussusception, often in cases with complex forms [3, 6, 10].

Difficulty of intussusceptum reduction occurred in 3 (10.7%) children during laparoscopic treatment of intussusception. In these patients, small intestine traction was supplemented by per rectum pneumoreduction with the help of Richardons’ system, resulting in intussusceptum smoothing.

Conclusions

Laparoscopy is safe and effective method of patients with an intussusception treatment. Thorough selection of patients for laparoscopic intussusception reduction provides an opportunity to decrease the rate of conversions.

Prospects for further research

Despite the well-known advantages of minimally invasive surgery, randomized researches are necessary to determine the precise indications for laparoscopic reduction of intussusception as a method of treatment of children with various forms of intussusception.

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Copyright (c) 2017 A A Pereyaslov, A O Dvorakevych, O M Nykyforuk

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