Current success in the treatment of

intussusception in children
Anthony D. Kaiser, MD,a Kimberly E. Applegate, MD, MS,b and Alan P. Ladd, MD,c Indianapolis, Ind

Background. Intussusception remains a common cause of bowel obstruction in young children and
results in significant morbidity and mortality if not promptly treated. The goal of this study was to
determine the current success rate of radiologic reduction, the requirements for operative intervention,
and the effect of delay in presentation on outcome.
Methods. Children treated for intussusception over a 15-year period were reviewed after treatment at a
tertiary childrens hospital. Records were reviewed for patient outcomes from radiologic evaluation and
surgical intervention.
Results. Two hundred forty-four children with intussusception were identified. Median age was 8.2
months (range, 16 days to 12.7 years). Eighty-seven percent of patients had ileocolic or ileoileocolic
intussusception. The most common presenting symptoms were emesis (81%), hematochezia (61%), and
abdominal pain (59%). Contrasted enemas were performed in 190 children, with successful reduction
in 46%. Air-contrasted enema reduction was more successful than liquid-contrasted techniques (54%
vs 34%; P .017). Success in reduction was greater if symptom duration was 24 hours compared
with 24 hours (59% vs 36%; P .001). Despite failed prior attempts at reduction, 48% were
reduced on reattempted enema reduction. One hundred forty children required surgical intervention for
intussusception with 50% requiring bowel resection. Children with symptom duration 24 hours had
a greater risk of requiring surgery (73% vs 45%; P .001) and bowel resection (39% vs 17%;
P .001) than those with symptoms for 24 hours. Pathologic lead points were encountered in
14%. There were 2 deaths and complications occurred in 19%. Length of stay after surgical reduction
was 3.9 days, but 6.1 days if bowel resection was required.
Conclusions. Success of intussusception reduction is improved with air-contrasted techniques and is
not affected by previously failed, outside attempts. Delay in presentation decreases success in radiologic
reduction and increases risk of operative intervention and bowel resection. (Surgery 2007;142:469-77.)
From the Department of Surgery, Indiana University School of Medicinea; the Department of Radiology, Division
of Pediatric Radiology, Indiana University School of Medicine, Riley Hospital for Childrenb; and the Department
of Surgery, Division of Pediatric Surgery, Indiana University School of Medicine, Riley Hospital for Children,c
Indianapolis, Indiana

After pyloric stenosis, intussusception is the

second most common cause of bowel obstruction
in children, with annual American hospitalization
rates of at least 56 per 100,000 children.1 Intussusception occurs when a more proximal portion of
bowel, the intussusceptum, invaginates into more
distal bowel, the intussuscipiens. This results in
venous compression and bowel wall edema, eventually leading to bowel necrosis, perforation, and
death if not treated in a timely manor.

Accepted for publication July 13, 2007.

Reprint requests: Alan P. Ladd, MD, Assistant Professor of Surgery, 702 Barnhill Drive, Suite #2500, Indianapolis, IN 46202.
E-mail: aladd@iupui.edu
0039-6060/$ - see front matter
2007 Mosby, Inc. All rights reserved.
doi:10.1016/j.surg.2007.07.015

Children who develop intussusception are often

1 year of age, with a peak incidence between 4
and 7 months.2 Patients often present with a wide
range of nonspecific symptoms, including emesis,
pain, irritability, and decreased appetite. The classic symptoms of emesis, pain, and bloody stools
with or without a mass have been shown to be
present in fewer than a quarter of children, making
intussusception a difficult clinical diagnosis.3,4
Barium, and more recently air-contrasted, enemas have been the initial diagnostic and therapeutic study of choice. Publications report reduction
rates of 70% to 80% on average, and ranging from
42% to 95%.5 Although success with enema reduction has been shown to decline as duration of symptoms increases, a 34% improvement in enema
reduction rates has been reported using delayed attempts with repeated enemas.6-11 Children treated at
hospitals with 10,000 pediatric admissions yearly
SURGERY 469

470 Kaiser et al

have higher rates of nonoperative reduction than

children treated at other nontertiary facilities.12
Transabdominal ultrasound is gaining popularity
as a screening test in children because of its decreased cost and reduced radiation exposure.6 Despite these recent improvements in radiologic
technique, the diagnosis of intussusception and
success in its nonoperative reduction has been suboptimal in tertiary care facilities.
This review attempts to delineate current outcomes for the treatment of intussusception in children at a tertiary care, childrens hospital. The
study aims to determine whether previous enema
reduction attempts at outside facilities and type of
enema medium affect reduction success. This analysis also examines whether improvement in enema
reduction rates has occurred over time and the
impact of current reduction techniques and delays
in presentation on rates of bowel resection, postoperative complications, and length of stay.
METHODS
Patients treated for intussusception at Riley Hospital for Children from January 1, 1990 through
December 31, 2004, were reviewed for this study. A
hospital admissions database was searched for patients with either a primary or secondary International Classification of Disease, 9th revision code for
intussusception (560.0). Electronic and paper medical records were reviewed for data on demographics,
comorbidities, presenting signs and symptoms, imaging procedures, results of reduction techniques,
surgical procedures, postoperative complications,
pathologic lead points (PLP), intussusception recurrences, length of stay, as well as short- and long-term
morbidity. Patient identification and data extraction
were performed under Institutional Review Board
approval, study 0506-79.
For inclusion in data analysis, the diagnosis of
intussusception must have been verified by either
imaging (ultrasound, enema, computed tomography [CT]) or surgical exploration. Patients were
excluded from the study if records could not validate the diagnosis of intussusception. Patients with
unknown symptom duration were included for
study but were excluded from analysis of duration
of symptoms.
All radiologic reduction techniques were performed under fluoroscopy. The choice of reduction technique of air versus liquid (barium or
iodinated contrast) and number of attempts were
at the discretion of the radiologist of record. A
rectal catheter was inserted and the buttocks were
taped to prevent air or liquid escape. Pneumatic
reduction was attempted using an air insufflation

Surgery
October 2007

device that delivered a maximal mean pressure of

110 mmHg. Liquid reduction was attempted using
either barium or water-soluble diatrizoate meglumine18% (Cystografin; SICOR, Irvine, Calif), prepared with routine methods. A column of contrast
was established 1 meter above the table. Reduction
attempts were followed using real-time fluoroscopic
guidance with the patient in a prone position. The
prone position was utilized in this technique to provide an adequate manual seal of the rectum through
opposition of the buttocks in these infants and children. This is an attempt to avoid the use of a balloontipped catheter and the inherent, potential risk of
balloon overinflation and resultant colon or rectal
perforation. Typically, 3 consecutive attempts of 3
minutes each were performed. If the type of enema
was switched during consecutive attempts, the final
type of enema medium was recorded for analysis.
Conscious sedation was not utilized in the nonoperative, radiologic-guided attempts at intussusception reduction.
De-identified data were collected on standardized
data sheets and transferred to a spreadsheet for analysis. The website www.statpages.net was used for statistical analysis. A Pearson 2 test was used for analysis
of ordinal data and a Students t-test was used in
evaluating nominal data. P .05 was considered significant.
RESULTS
Population. Two hundred forty-four children
were diagnosed and treated for intussusception
over the 15-year period. There were 162 boys and
82 girls (2:1) who ranged in age from 16 days to
12.7 years (median, 8.2 months). Thirty-four percent were 6 months old, 68% were 1 year, and
79% were 2 years at the time of diagnosis. There
were 16 (7%) children over the age of 4. Eighty-two
percent of children were Caucasian and 16% were
African American.
Signs and symptoms. The most common presenting sign or symptom in children with intussusception was emesis, occurring in 81% of children
(Table I). Presenting temperature 38C and abdominal distension were more common in children with symptoms of 24 hours duration (18%
vs 8%, P .04; 34% vs 16%, P .003, respectively).
The classic triad, consisting of emesis, pain, and
bloody stools, was found in 53 of the 228 (22%)
children. Only 6% had both the classic triad and an
abdominal mass on examination. Ileocolic or ileoileocolic intussusception accounted for 87% of the
cases (Table II).
Enema reduction. One hundred ninety children
with intussusception underwent diagnostic and ther-

Kaiser et al 471

Surgery
Volume 142, Number 4

Table I. Signs and symptoms in patients with spontaneous intussusception

Signs and
symptoms

Overall (%)
(n 228)

24 hours duration
(n 87)

24 hours duration
(n 134)

Emesis
Bloody stool
Pain
Irritability
Distension
Lethargy
Mass
Temp 38C

185 (81)
139 (61)
134 (59)
79 (35)
63 (28)
61 (27)
55 (24)
31 (14)

67 (77)
51 (59)
55 (63)
35 (40)
14 (16)
22 (25)
22 (25)
7 (8)

113 (84)
82 (61)
76 (57)
43 (32)
46 (34)
38 (28)
32 (24)
24 (18)

.17
.70
.34
.22
.003*
.62
.81
.04*

*P .05.

Table II. Classification of intussusception

Table III. Enema reduction rates*

n (%)

Ileocolic
Ileoileocolic
Ileoileal
Jejunojejunal
Unknown

190 (78)
21 (9)
21 (9)
11 (5)
1

apeutic attempts at enema reduction under fluoroscopic guidance. There were no perforations. Enema
reduction was successful in 87 of the 190 patients
(46%; Table III). Children who had symptoms for
24 hours had a reduction rate that was significantly better than those with a longer symptom
duration (59% vs 34%; P .001). In 5 children, the
duration of symptoms was unable to be identified.
Air enema was performed in 125 children and had
a significantly higher rate of reduction than liquid
enema (52% vs 34%; P .02). Broken down by
duration of symptoms, air reduction was not significantly better than liquid reduction with symptoms
1 day (56% vs 65%; P .45) but was better when
symptoms were present for 24 hours (46% vs
17%; P .002). Liquid enema reduction rates
dropped significantly when duration of symptoms
increased to 24 hours (65% vs 17%; P .001),
but rates of air enema reduction were not significantly affected (56% vs 46%; P .27). Children
with documented abdominal distension had lower
rates of successful enema reduction than those
without (23% vs 53%; P .001).
Forty-two of the children who underwent attempted enema reduction at our institution had
undergone a previous unsuccessful reduction attempt at an outside hospital (OSH). Success in
reduction was not different in these children versus
those who had not undergone a previous reduction
attempt (48% vs 45%; P .79).
Surgical outcomes. One hundred fifty-five children with intussusception underwent surgery

Overall
Symptoms 24 hrs
Symptoms 24 hrs
Unknown
Air enema
Symptoms 24 hrs
Symptoms 24 hrs
Unknown
Liquid enema
Symptoms 24 hrs
Symptoms 24 hrs
Previous attempt at OSH
Symptoms 24 hrs
Symptoms 24 hrs
Unknown
No previous enema
Symptoms 24 hrs
Symptoms 24 hrs
Unknown

Attempted

Successful (%)

190
80
105
5
125
57
63
5
65
23
42
42
22
19
1
148
58
86
4

87 (46)
47 (59)
36 (34)
4 (80)
65 (52)
32 (56)
29 (46)
4 (80)
22 (34)
15 (65)
7 (17)
20 (48)#
14 (64)
6 (32)
0 (0)
67 (45)#
33 (57)
30 (35)
4 (100)

*Excludes patients with postoperative intussusception.

2 10.986; P .001.
2 5.678; P .02.
2 1.233; P .27.
2 15.646; P .001.
#2 .073.

over the study period. Fifteen of these children

underwent surgery for a postoperative intussusception and were excluded from analysis. Thirtyfour patients proceeded to surgery without
enema attempted at our own institution and 106
children had surgery after failed enema reduction (Table IV). A significantly greater number of
patients with symptom duration 24 hours required surgical intervention (73% vs 45%; P
.001). Sixty-nine of 140 (49%) children required
bowel resection. Rate of bowel resection was significantly higher when symptoms had been
present for 24 hours (53%) than if symptom
duration was 24 hours (38%; P .001). Chil-

472 Kaiser et al

Surgery
October 2007

Table IV. Outcomes of surgical intervention

Surgical intervention only

Failed enema attempt

Overall

34 (24)
11
22
1
21
7
13
1
13 NS
4
9
0
9 NS
2
7
0
6 NS
2
4

106 (76)
28
76
2
50
17
33
0
56
11
43
2
37
8
27
2
26
5
21

140
39 (28)*
98 (70)*
3
71 (51)
24
46
1
69 (49)
15 (38)
52 (53)
2
46 (33)
10
34
2
32 (23)
7 (18)
25 (26)

All patients undergoing surgery

Symptoms 24 hrs
Symptoms 24 hrs
Unknown
Patients without bowel resection
Symptoms 24 hrs
Symptoms 24 hrs
Unknown
Patients with bowel resection
Symptoms 24 hrs
Symptoms 24 hrs
Unknown
Bowel resections without PLP
Symptoms 24 hrs
Symptoms 24 hrs
Unknown
Patients with PLP
Symptoms 24 hrs
Symptoms 24 hrs
NS, not significant difference; PLP, pathologic lead point.
*2 17.9; P .001.
2 11.6; P .001.
2 4.80; P .03.

dren with abdominal distension had higher rates

of bowel resection than those without (data not
shown; 46% vs 24%, P .001).
Thirty-four children underwent operations without attempted enema reduction at our own institution. Twelve of these children had undergone a
failed enema reduction at an OSH and 2 had multiple recurrences after enema reduction. Two children were identified with either chronic abdominal
pain or multiple previous abdominal operations
with a low preoperative suspicion for intussusception. This group also included a patient with barium peritonitis after perforation at an OSH and 2
children transferred from an OSH in septic shock.
These latter patients succumbed to their illness and
died 24 hours after presentation and operative
intervention. The child with barium peritonitis had
no additional complications after exploration with
bowel resection. In total, 19 of these 34 (55%)
children underwent bowel resection during surgical exploration, among which 11 PLP were found.
Pathologic lead points. There were a total of 32
PLP (14%) in the 228 children with spontaneous
intussusception, 23% of those undergoing operative intervention. Thirty-one were diagnosed during surgery with the remaining patient diagnosed
by CT. The etiology for each of the PLP is summarized in Table V, with Meckels diverticulum being
the most common PLP. Two of 7 children with a

Table V. Etiology of pathologic lead points

n
Meckels diverticulum
Duplication cysts
Hamartomatous polyps
Burkitts lymphoma
Leukemic infiltrate
Intestinal adhesion
Inverted appendix
Intestinal hematoma
Total

18
4
3
3
1
1
1
1
32

history of intussusception reduced at an OSH were

found to have a PLP. PLPs were more common
among children with duration of symptoms 24
hours (26% vs 18%; P .029).
Postoperative intussusception. In 16 children,
intussusception occurred within 2 weeks of an abdominal operation. The diagnosis occurred between postoperative days 3 and 14, with a mean of
6.6 days. Diagnosis was made in 12 children while
they remained hospitalized after their original procedure. An increase in nasogastric tube output or
emesis was noted in 15 children. Worsening abdominal pain and tenderness were found in 4 children and distension in 5. Grossly bloody stools were
not present in any child, but hemoccult positive

Surgery
Volume 142, Number 4

stools were passed by 1 child. Postoperative intussusception occurred most commonly after pullthrough procedures (n 3), fundoplication with
or without G-tube placement (n 3), and appendectomy (n 2). Individual cases of intussusception followed retroperitoneal dissections from
adrenalectomy, nephrectomy, renal fossa dissection, and sacrococcygeal teratoma resection. Intussusception also occurred after single cases of
Ladds procedure, Meckels diverticulectomy, gastrojejunostomy tube placement, and colostomy formation. In all but 1 instance, the children returned
to the operating room for manual reduction of a
small bowel to small bowel intussusception. None
required bowel resection. One patient with an ileocolic intussusception was successfully diagnosed
and reduced with a fluoroscopic-guided enema.
There was 1 second recurrence 1 week after surgical reduction of a jejunojejunal intussusception;
the recurrence was found to be ileoileocolic.
Recurrences. There were 13 recurrent intussusceptions in 13 children, 11 (11/87, 13%) after
enema reduction and 2 (2/156, 1%) after surgery.
The mean time to recurrence was 8.5 months (median, 3 weeks) and ranged from 1 day to 3 years.
Enema reduction was successful in treating 10 of
the 11 children with recurrence after prior enema
reduction. Both recurrences after previous operative interventions were identified during re-exploration for bowel obstruction. No recurrences were
due to PLPs.
Length of stay. The length of stay was calculated
for the 226 children with complete data. Overall,
the median length of stay was 66 hours. Children
with successful enema reduction had a median
length of stay of 29 hours, which was not affected by
whether or not initial enema reduction attempts
had been performed at an outside facility. The
median length of stay in those undergoing surgery
was 94 hours (3.9 days). Bowel resection conferred
nearly a 2-day longer stay than in those with primary operative reduction (4.7 vs 3.0 days).
Complications. Postoperatively, there were 29
(21%) documented early complications in 25 children. The most common complication was fever in
16 children, with 10 of these patients having undergone intestinal resection. Six children developed postoperative infections or abscess formation,
1 had wound dehiscence, and 2 died. Each of these
children had undergone bowel resection. Minor
complications of skin rash (n 2), prolonged ileus
(n 1), and oral thrush (n 1) were also identified. Delayed morbidity occurring 1 month after
surgery included 6 children who developed small
bowel obstruction from adhesions (6/156, 4%).

Kaiser et al 473

Five of these children required lysis of adhesions;

one was managed medically. Anastomotic stricture,
volvulus, and an incisional hernia occurred in single cases. One child suffered from postoperative
chronic abdominal pain of uncertain etiology for 1
year before it spontaneously resolved.
DISCUSSION
Intussusception is a common childhood problem that results in serious morbidity and mortality
throughout the world. In developing nations, the
mortality may be as high as 20%.13 The diagnosis of
intussusception continues to rely on a high clinical
suspicion owing to a large portion of children presenting with nonspecific signs and symptoms. In
fact, the classic triad of emesis, pain, and bloody
stools is reported to occur in fewer than one quarter of patients.3,4 This is echoed in the present
study, where only 22% of patients were noted to
have this triad. Although most symptoms occurred
with a frequency consistent with other reports, 61%
of our patients had bloody stools. This incidence is
higher than that reported in previous studies with
rates ranging from 32% to 53%.3,8,14-16 Only half of
the children with a Meckels diverticulum and intussusception presented with hematochezia. Bloody
stools were not more prevalent in children with symptoms of longer duration. Thus, neither the higher
prevalence of Meckels diverticulum nor the larger
proportion of children with increased duration of
symptoms can account for the noted higher rate of
hematochezia.
Fever and abdominal distention occurred more
commonly in our patients with intussusception with
increased duration of symptoms. These nonspecific
signs are no more prevalent in children with intussusception than in those without it.16 Because of
the often nonspecific and diverse presenting signs
and symptoms, clinicians must continue to have a
high index of suspicion to diagnose children with
intussusception. These nonspecific presenting signs
and symptoms of patients have been addressed by
some pediatric radiologists through the use of ultrasound to screen for intussusception before invasive
techniques.17
The success rate of enema reduction varies
widely in the published literature. Reported rates
of successful enema reduction average 75%.5,17
Successful reduction was lower in our study at 46%
and did not significantly change from that previously reported of 42%.14 One explanation for this
lower success rate may be the noted delay in presentation of patients to a tertiary care facility.
Nearly 80% of our patients were first seen at an
OSH or emergency room before referral for evalu-

474 Kaiser et al

ation and definitive treatment. Twenty-eight percent of our patients had symptoms for 24 hours
but 2 days, and another 31% had symptoms for
2 days. This is in contrast to 4 comparable studies
whose patients had symptoms for 24 hours only
20% to 48% of the time.3,8,15,18 In each of these
studies, the enema reduction rates were higher, at
65% to 84%, implying that earlier diagnosis and treatment improve outcomes in these children. Additionally, a retrospective chart review may underestimate
the actual duration of symptoms recorded in these
children from presentation to intervention.
Two prospective randomized trials have compared
air enema reduction rates with liquid enema.19,20 In
both studies, rates of success with air enema were
higher than with liquid enema reduction, but this
was statistically significant in only one.19 Our current results are consistent with those 2 studies,
showing an improved success rate with air enema
reduction in the patient population as a whole.
However, when the study group was segregated by
duration of symptoms, there was no difference in
the method of reduction in children whose symptom duration was 24 hours. Our data do suggest that air enema may be better for cases with
symptom length 24 hours. Although not elucidated by the current study, this improved outcome
for air medium has been attributed to higher intraluminal pressures generated by air contrast enemas as compared with standard liquid enema
reduction techniques.21,22 Considering these data,
we support the use of air enema reduction of intussusception rather than liquid medium, in skilled
hands.
Despite a delay in presentation, prior OSH attempts at enema reduction of intussusception did
not confer a lower rate of success in our population. The 42 children in this defined subset analysis
had a similar rate of reduction at 48% compared
with children receiving their first enema at our
institution. The success rate in this subset of children showed the same dependence on duration of
symptoms as the whole group. These data suggest
that children may benefit from additional, nonsurgical reduction attempts at referral centers, unless
absolute contraindications are present.
Surgical reduction is still needed in 6% to 53%
of children, including patients with failed enema
reduction, with PLP, or with contraindications to
attempted enema reduction.3,12,18,19,23,24 Contraindications to attempted enema reduction include clinical signs of peritonitis, shock, or free intraperitoneal
air on abdominal radiographs. Children requiring
operative reduction have 3 to 4 times longer stays and
almost 5 times higher hospital charges.12 A large per-

Surgery
October 2007

centage of children required surgical reduction in

our study. Our finding that 61% of our population required surgical intervention is much higher
than that published in recent series, which is 8% to
34%.3,8,15,19,24 Presumably, the largest impact on this
high rate of surgical intervention was the significant
number of children with prolonged symptom duration. One hundred thirty-four (59%) of the children in our series had symptoms for 1 day, and
34% required bowel resection. Many children in
this group had complicating, unusual, or late presentations, or a complex past medical history. Although not reviewed in this current study, a
potential intervention to further reduce the need
for surgical reduction of intussusception is the delayed repeat enema. Five publications report improved reduction rates of 50% to 82%, in children
not initially reduced by enema, by waiting 30 minutes to 24 hours before further attempts at enema
reduction.7-10,25 The true etiology for our high level
of surgical intervention remains unclear.
Thirty-two children in this series were found to
have a PLP. The prevalence of PLPs in our current
series of 14% reflects a similar rate of occurrence
over the 20-year span before this review and is
higher than the literature average of 5% to 6%.14,17
Despite essentially all of these PLPs being discovered during surgical intervention in children who
failed radiologic reduction, 1 child had successful
enema reduction of a PLP, thereby avoiding surgery. This child was diagnosed with a colonic hematoma by CT scan after blunt abdominal trauma,
which served as a lead point. Reduction of the
intussusception in this latter case was confirmed by
fluoroscopic techniques and verified by surveillance abdominal examinations and the patients
eventual tolerance of an enteral diet. This higher
prevalence of PLPs in our series may have partially
contributed to the higher rate of surgery.
When comparing our data with those of a previous
study (1970 to 1986) from the same facility, success of
enemas to reduce intussusception is relatively unchanged (46% vs 42%, respectively) leading to similar
laparotomy rates. The rate of bowel resection has
decreased slightly from 51% to 44% of children
treated over that last 35 years.14 Improvements have
also been identified in the lower rate of postoperative
complications compared with the previous time period. Additionally, the utilization of a diverting ostomy with subsequent takedown illustrated in the
previous study has largely been abandoned reflecting
advances in surgical techniques, medical advances,
and changes in surgical practice.14 Hospital length of
stays were an average of 5 and 7 days shorter after
manual reduction and bowel resection, respectively,

Kaiser et al 475

Surgery
Volume 142, Number 4

when compared with the 1970 to 1986 data. However,

the prior study reported no mortality among the
treated patients in contrast with 2 deaths in the current study. This point continues to reflect the need
for a higher index of suspicion of intussusception and
an earlier time of intervention to avoid the devastating complications that can arise from compromised
intestine and the development of overwhelming sepsis and a systemic inflammatory response. Overall,
there has been improvement in the treatment of
children with intussusception, especially those who
require surgical intervention.
In conclusion, the diagnosis of intussusception
continues to require a high index of suspicion. Most
children present with an assortment of nonspecific
signs and symptoms; fewer than one quarter presenting with the classic triad. Increased duration of symptoms leads to poorer nonoperative and operative
outcomes, results in longer lengths of stay, and leads
to greater morbidity. Air enema seems to convey
higher reduction rates in our pediatric population.
Although success in reduction was markedly lower
than average in our patients, this may be partly due to
the longer duration of symptoms and higher prevalence of PLPs. Many children who fail enema reduction at an OSH may benefit from additional attempts,
if not contraindicated. Additionally, our results show
that outcomes in children requiring surgical reduction of intussusception have improved over the last
few decades.

11.

12.

13.
14.

15.
16.
17.

18.

19.

20.

21.

22.

23.

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Dr Daniel Saltzman (Minneapolis, Minnesota): I

congratulate the authors on an impressive series of
244 children with intussusception over a 15-year
period. I was surprised to find out that 25% of
your children presented with the classic triad of
emesis, pain, and bloody stools. And this study also
reaffirms the fact that an early diagnosis fares much
better in children whether they are treated operatively or nonoperatively. I have 3 questions.
In the late 1990s, a strong association of intussusception was seen with an RFC vaccine. Did you
see this association or note a change with the new
generation of vaccine?
Second, concerning your overall rate of radiologic reduction of only 46%, your data are very

476 Kaiser et al

similar to your data 20 years ago, as you noted. Also,

the large studies performed here in the United
States are vastly different from the European data
of almost 90% success. Can you speculate as to the
etiology of this disparity?
Third, now that you have had a chance to thoroughly review your data, if you were to receive a call
from a practitioner who had a child who was approximately 2 to 4 hours away from your institution, say in Cincinnati, would you recommend a
radiologic reduction at that institution or transfer
to your institution?
Again I applaud you on this very nice study and
awesome manuscript.
Dr Alan P. Ladd (Indianapolis, Indiana): Unfortunately, with our data being retrospective, we were
not able to pull the points of whether or not they
had received the RFC vaccination or the newer
generation vaccinations. That was a great question.
We do not have an answer for this.
We only can speculate with regard to our continued success rate with the individuals treated in the
state of Indiana at our medical center. I think that
what stands dramatically out compared with those
other contemporary studies is that 60% of our patients presented to our facility 24 hours after the
initiation of their symptoms. This observation may
provide an explanation for the discrepancy between
our numbers and those better success rates published
elsewhere.
As far as my overall clinical management of intussusception from a referral, I think it really comes
down to the outside institutions comfort level in
dealing with these children. Clearly, if they have a
large number of admissions, as I alluded to, they
may be more capable of reducing these individuals
in their own radiologic department. However, if
they do not feel a level of comfort, or if they are
calling to begin with, they most likely are not comfortable dealing with these children and I would
prefer their transfer to our facility.
Dr Dennis P. Lund (Madison, Wisconsin): This
is a disease that is still fairly common and, in fact,
has a very real mortality associated with it. You saw
2 deaths in your series. In the 8 years I have been in
Madison, we have had 2 children who have died
from this problem. These are generally fairly spectacular deaths.
They come in with cardiovascular collapse and
they need to be aggressively resuscitated. This is not
a disease that you kind of just call your intern and
say, Hey, just take care of this for me. These can
come in and be remarkably sick kids. So I think

Surgery
October 2007

early resuscitation and IV antibiotics are all very

important. I have a couple questions for you.
One is, do you have a protocol for recurrences?
Did you have a protocol for when you will take your
recurrences to the operating room and when you
will try to reduce them radiographically?
A corollary to that is, when you do operate on
your children, do you do an incidental appendectomy and does that affect whether or not you want
to take them back and do them operatively or
radiologically? Are you doing any laparoscopic reductions in intussusception? They have been reported in the pediatric literature.
The other question is this: Are you able to correlate at all where you encounter the intussusception radiologically with your likelihood of being
able to reduce it?
Dr Alan P. Ladd (Indianapolis, Indiana): With
regard to our protocol for recurrence, those individuals who would not show evidence of acute abdomen or toxic shock I think it would be left with
the attending of record right now. We do not have
a formal protocol for recurrence matters and
whether or not those will be undertaken. Clearly,
our radiologists are amenable to perform repeat
procedures for recurrence.
With regard to the performance of incidental
appendectomy, unfortunately we did not review the
percentage of patients who underwent incidental
appendectomy. Again it is left to the attending of
record. But personally, I would perform such a
procedure for open technique.
Laparoscopic reductions have been attempted less
than a handful of times at our institution and this
procedure was not encountered during this review
before 2005. But clearly there are upcoming data
showing that it is as effective in reduction of intussusception, although clinically the reverse maneuver
compared with how we would do this manually.
As far as your last question regarding location, in
the majority of cases, we are able to discern the
point with utilization of enema techniques. However, those patients who present in the small intestine clearly cannot be. They are often not well
defined by enema techniques.
Dr Michael W.L. Gauderer (Greenville, South
Carolina): The comment I would like to make is
that your success rate is really a reflection of the
diagnostic skills of the pediatricians and emergency room physicians in your area. So maybe
what we need to do as surgeons is to continue to
educate these individuals so that they have a very
high index of suspicion and we have a very low
threshold for transfer to our institutions. I mean,

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Volume 142, Number 4

a lot of this is really preventable, and it is really a

shame that so many years later the success rate of
nonoperative reduction is still fairly low in some
centers. So I think we really need to address our
colleagues in the nonsurgical specialties.
Dr Alan P. Ladd (Indianapolis, Indiana): I appreciate your comments and I wholeheartedly

Kaiser et al 477

agree with the continuing education of our outlying pediatricians in this endeavor. And clearly, as
illustrated by our signs and symptoms at presentation, rarely do you get a palpable mass or bloody
stools that give away that this might be intussusception and that an index of suspicion is clearly in the
childs best interest.