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Brief Reports Indian Pediatrics 2002; 39:660-662 |
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Post Operative Intussusception |
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Devendra Kumar
Postoperative intussusception (POI) is a recognized but uncommon cause of intestinal obstruction in the children during the early postoperative period. It is reported to occur after 0.08% to 0.8% of all laparotomies(1) and to account for 5% to 15% of post-operative intestinal obstructions in children(2). Diagnosis may be delayed due to nonspecific nature of the symptoms, which resemble a prolonged postoperative ileus. At re-operation, most intussusceptions can be manually reduced, and no lead point is found. Delay in diagnosis may result in the need for bowel resection and an increased risk of death(3). Subjects and Methods Case records of 450 children who underwent laparotomies between July 1999 and June 2001 at the Advanced Pediatric Center, Chandigarh were reviewed. Thirty-four patients were admitted with the diagnosis of classical intussusception. Of these 34 patients only 6 patients had lead point. Barium reduction was performed successfully in 8 patients, laparotomy and reduction in 11, and 15 patients required resection and anastomosis. POI was identified in four other cases; and case records of these children were reviewed. Table I summarizes the clinical details of these 4 patients. Although all the patients started to have bilious vomiting or had an increase in their nasogastric aspirate, all but one had no abdominal distension together with increased or obstructive bowel sounds. None of the children had a palpable mass. It was difficult to distinguish between post-operative adynamic ileus and small intestinal obstruction on plain abdominal radiograph. The upper gastrointestinal contrast study was done in all cases except Case 1 and were only suggestive of jejunal obstruction. The definitive diagnosis of POI was made only at operation and the lesions were confined to the proximal small intestine. All the intussusceptions could be reduced manually, and resection of bowel was not required. All four patients made an uneventful recovery after their second operation, and none had any related morbidity. Discussion POI is a well recognized though uncommon entity in the pediatric age group, occuring after approximately in 1 in 1000 laparotomies, and constituting between 1.4% to 15% of all intussusceptions(1,2). In our series the incidence of POI was 10.52% of all intussusceptions during the study period. The mean age of affected children is 2 years, older than that for primary intussusception. Various etiologies of POI, both surgical and pharmacological, have been suggested. It may follow any procedure(4) but is most commonly seen after abdominal operations. Children undergoing a Ladd procedure are now defined as a high-risk group for POI(5). Disordered motility through excessive handling or bruising of the bowel has been implicated as a cause. Chemotherapy, notably vincristine(6) and radiotherapy, by altering intestinal motility, have also been implicated. That it is more common in children than adults must be borne in mind when an apparently favourable postoperative course is complicated by intestinal obstruction. Table I- Clinical Details of Four Children with POI
The four cases described here occurred within 2 weeks of surgery, as do nearly all. This helps differentiate POI from adhesive obstruction, which usually occurs later. The classic features of intussusception (colic, abdominal mass, blood per rectum) are uncommon in POI, which tends to present insidiously. Initial symptoms of colic may be masked by postoperative analgesic administration. Reflex vomiting or increased nasogastric bilious aspirates are a late phenomenon in POI. Distension is not marked as the pathology is generally in the proximal small intestine; thus the only positive evidence may be an increase in the volume of nasogastric aspirate. The diagnosis of POI is difficult. In a group of collected series, the diagnosis was made before re-exploration in only 3% to 5% cases(7). In our series, upper gastrointestinal contrast study done in 2 children showed complete obstruction in one and partial small intestinal obstruction in other child. Other investigators report good results with abdominal ultrasound. In one series(7), ultrasound was 80% sensitive for POI. However, intussusception can not be ruled out by a negative ultrasound finding(8). Laparotomy is the only definitive test and should not be delayed. Clinical suspicion of POI should be confirmed by laparotomy; as radiological investigations are not of much use in these children(5). Children tolerate early re-operation better than prolonged nasogastric suction. At surgery manual reduction of intussusception is nearly always possible, as noted in all our four children and intestinal resections rarely required. Multiple intussuscepted lesions have been reported in 5-10% of cases, implying thereby the need for inspection of whole length of the small intestine. The postoperative recovery is usually rapid, and in one series there were no recurrences on long-term follow-up(1). Delay in recognition and treatment of POI may lead to an increased mortality, reported as high as 7.6% in one collected series(3). POI should be considered in children who have undergone extensive intra-abdominal or retroperitoneal procedures and who show evidence of obstruction or ileus in the first 2 weeks after initial return of gastrointestinal function. Contributors: DK, was involved in the collection of data and drafted the paper; SC coordinated the study particularly its design and interpretation; he will act as guarantor for the paper. KLNR contributed to the study design and writing. Funding: None. Competing interests: None stated.
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