Neonatal intestinal Obstruction_ Intussusception.pptx

intussusception is one of the most common causes of neonatal intestinal obstruction. Understanding its presentation and different modes of management can be essential in the survival of these neonates

1. MAKERERE UNIVERSITY SCHOOL OF MEDICINE DEPARTMENT OF PAEDIATRIC SURGERY INTUSSUSCEPTION Supervisor: Dr. Nimanya Stella Paediatric surgeon Paul Ssempebwa Mmed surgery 2 Sunday 28 th may 2023

2. outline Background Aetiopathogensis C linical presentation Investigations management Complications Follow up and prognosis

3. case 3/12 M, referral from kawempe NRH where he was managed for AWD,severe dehydration 2/7 history of dark currant, intermittent colicky abdominal pain Associations: fevers, bilious vomiting. Failure to breast feed. Delivered by SVD, to P4+0 mother. Weaned at 2/52 on dry tea and cows milk. Bwt 2.5kg O/E: Syndromic baby, wt. 7kg,flattened fascial appearance, low set ears, protruding tongue, flat nasal bridge, short neck, Irritable, D+++, moderate pallor, in pain. Febrile 39.0 cvs: pansystollic murmur in the mitral area p/a: Scaphoid, empty right iliac fossa with a palpable mass in the left lumbar region DRE: normal anal sphincter tone, bloody mucoid stools in the rectum.

4. B ackground Telescoping of proximal bowel (intussusceptum) into the adjoining distal bowel.(intussusceptien). First described 1674 Paul Barbette of Amsterdam; surgery by John Hutchinson 1873. Incidence 2-3: 1000; M>F 3:2 age of 2 months – 2 years(Africa); 3 – 9 months Europe( Huppertz HI,et al,2006),peak at weaning 6months 3 years; associated with pathological lead point(PLP); 12% of the cases In preterm and intra uterine life, linked to intestinal atresia Mortality < 1% world wide , Africa -12.1 %(Bode CO,2008)

5. aetiopathogensis Primary/idiopathic (90-95%) no PLP. hypertrophy of mural payers patches due to viral Infections;(adenovirus, rotavirus) prodrome of flue and GE 10 – 30% attributed to mobile cecum in < 3 years Secondary intussusception(PLP) The risk incidence increases with age. Most common; Meckel's diverticulum and Polyps Others: intestinal duplications, lymphomas, hemangiomas, lymph sarcomas, enteric cysts, Henoch-Schönlein purpura, submucosal hematomas', cystic fibrosis, inspissated meconium, benign intestinal neoplasms, Peutz-Jeghers familial polyposis, ectopic gastric mucosa, ectopic pancreatic mucosa, and worm infestations.

6. Clinical presentation Usually well nourished infant/toddlers (occurrence in the malnourished is 10%) Sudden intermittent crying calm intervals Prior history of diarrhea or flue like illness Prior history of Rota Vaccination Dark currant stools, Vomiting; later symptom. Clinical exam: Calm to irritable, weak/lethargic Antalgic posturing i.e extending the head and back or flexing the limbs Dehydrated, Dancing sign Guarding and rebound tenderness DRE: see/ palpate the intussusceptum, blood at the examining finger

7. I nvestigations Serological: Full haemogram Anemia Thrombocytopenia Leukocytosis Urea, creatinine: Raised in AKI Serum electrolytes: hypokalemia Lfts: hypoalbuminemia X-ray Non diagnostic; dilated bowels & air fluid levels Sometimes a mass may be seen USS (Sv.92% Sp.100%,Domen et al,2020) D iagnostic: target sign/ doughnut sign, pseudo kidney CT/MRI: not routinely done but can be used to asses the PLP. Used incase of equivocal findings Fluoroscopy/enema: Crescent sign, spring sign

8. Left to right: pseudo kidney sign, target sign, meniscus sign on fluoroscopy and spring sign on fluoroscopy

9. Management RESCUCITATION: Ngt decompression,NPO Urinary catheter Rehydrate ; 20ml/kg boluses of crystalloids until target urine output then maintenance fluids. Correct anemia, correct electrolyte derangements 0xygen; if in distress Multidisciplinary team DIFFINITIVE MANAGEMENT Non Operative management laparoscopic surgery Open laparotomy

10. Non operative management Hydrostatic reduction Agents: saline, barium, water-soluble contrast. Under US Scan guided or Fluoroscopy Reduction is stopped when there if flow past the ICJ. Pneumatic reduction Should be considered before hydrostatic reduction Under Fluoroscopy Safer, faster, cleaner, less ionizing radiations Pressures are between 80 to 120mmhg Non operative Management success rates of up to 95% less invasive short hospital stat< 24hours However: perforation rates 1-3% recurrence rates 10%-15%;50% within 24hrs the rest within 10months (incomplete reduction, PLP)

11. Series of fluoroscopy guided pneumatic reduction

12. Series of hydrostatic ultrasound guided reduction Sonographic features of reducibility : Target sign (100%)> doughnut sign(depends on the thickness of the hypoechoic mass ) Thickness of the hypoechoic mass >or = 7.2mm(100%), 7.5 to 11.2mm(68.9%) > 14 surgical reduction Fluid at the tip of intussuptum_unsuccessfull Free peritoneal fluid had no association ( Mirilas P, et al ,Eur Radiol. 2001)

13. Air enema reduction Success rates of 60% Success was associated with early presentation and presence of an abdominal mass Failure was associated with rectal mass and late presentation No perforations, no mortalities Recurrence rates 6.7% (Dung ED,et al,J West Afr Coll Surg,2018)

14. Operative management Indications: Failed non operative i.e. 3 or more attempts Pathological lead point Pneumoperitoneum Peritonitis Shock Long duration of symptoms > 24 hours Complex intussusception e.g. illeo_illeo colic intussusception Evidence of gangrene expertise

15. Open laparotomy Transverse abdominal incision Gentle milking of gut of intussusception has been identified Warm the gut to reduce edema and try to reinstate reperfusion Gangrene; resection & stoma placement **Cecopexy,illeopexy,and incidental appendectomy are controversial

16. Laparoscopic reduction Initially diagnostic with 70% conversion rates, now 30%(Wei CH,et al, Surg Endosc. 2015 ) Now it’s the first choice; short hospital stay cosmetic outcome post operative pain management firster wound healing Contraindications: hemodynamic instability peritonitis evidence of pneumoperitoneum, severe bowel distention that limits visualization Lead point beyond the ascending colon (33% of the times associated with conversion) Criticisms: serosal tears lack of the tactile sense of the PLP .

17. complications recurrence of the intussusception perforation of the bowel surgical site infection anastomotic leak anastomotic breakdown enter cutaneous fistula postoperative adhesive intestinal obstruction incisional hernias . Stomas and their complications Short bowel syndrome

18. References 1 . Huppertz HI, Soriano- Gabarró M, Grimprel E, Franco E, Mezner Z, Desselberger U, Smit Y, Wolleswinkel -van den Bosch J, De Vos B, Giaquinto C. Intussusception among young children in Europe. Pediatr Infect Dis J. 2006 Jan;25(1 Suppl ):S22-9. doi : 10.1097/01.inf.0000197713.32880.46. PMID: 16397426 . 2.   American Journal of Roentgenology . 2020;215: 1449-1463. 10.2214/AJR.19.22445,   https://www.ajronline.org/doi/full/10.2214/AJR.19.22445 3. Mirilas P, Koumanidou C, Vakaki M, Skandalakis P, Antypas S, Kakavakis K. Sonographic features indicative of hydrostatic reducibility of intestinal intussusception in infancy and early childhood. Eur Radiol. 2001;11(12):2576-80. doi : 10.1007/s003300100883. Epub 2001 Aug 2. PMID: 11734961. 4. Dung ED, Shitta AH, Alayande BT, Patrick TM, Kagoro B, Odunze N, Rikin C, Chirdan LB. PNEUMATIC REDUCTION OF INTUSSUSCEPTION IN CHILDREN: EXPERIENCE AND ANALYSIS OF OUTCOME AT JUTH, JOS, A TERTIARY HEALTH CENTRE IN NORTH CENTRAL NIGERIA. J West Afr Coll Surg. 2018 Oct-Dec;8(4):45-66. PMID: 33553051; PMCID: PMC7861193 . 5. . Wei CH, Fu YW, Wang NL, et al. Laparoscopy versus open surgery for idiopathic intussusception in children. Surg Endosc. 2015;29:668–672 . 6. Holcomb and Ashcraft’s Pediatric Surgery , George.W.Holcomb III,etal , 7 TH edition,2020. 7. Paediatric Surgery: A Comprehensive Text for Africa, Emmanuel Ameh,et al Volume II ,2011