Factors determining clinical outcomes in intussusception in the developing world: Experience from Johannesburg, South Africa

Abstract

Background.Rates of open reduction of intussusception were noted to be unacceptably high during an institutional internal audit. Objectives. To determine the impact of revised protocols to better select patients for pneumatic reduction (PR), and document associated morbidity and mortality, and the factors that affect the above. Methods. Medical records of patients between 3 months and 3 years of age presenting to the Department of Paediatric Surgery at Chris Hani Baragwanath Academic Hospital, Johannesburg, South Africa, from 2007 to 2010 were reviewed. Determining factors, including duration of symptoms, admission Creactive protein (CRP) level and weight, were analysed against clinical outcomes, notably PR, bowel resection, relook laparotomy and death. Results. A total of 97 cases were suitable for inclusion. In 62 of these (63.9%), PR was attempted; this was successful in 32 cases (51.6%), giving an overall successful PR rate of 33.0%. In 7 of the 62 patients, a pneumoperitoneum was documented during the reduction attempt. Of the 65 patients who underwent surgery, 53 required intestinal resection and 12 had spontaneous or manual reduction. Ileostomy was necessary in 9 patients, and 7 required relook laparotomy. The overall mortality rate was 9.1%. Averages of 'determining factors' assessed against clinical outcome were as follows: mean weight (standard deviation (SD)) 7.4 (4.3) kg, mean duration of symptoms (DOS) 3.0 (SD 2.2) days, and admission CRP level 50.9 mg/L (range 1 249.3). Prolonged DOS and a raised CRP level predicted a poor outcome. Conclusions. Despite marked improvements in management and PR outcomes, intussusception remains associated with significant morbidity and mortality. Prolonged DOS and an elevated CRP predict worse outcomes. The use of these markers in association with clinical factors may assist management decisions, specifically with regard to operative or nonoperative management. Awareness and education are key to prompt presentation and early diagnosis. Welldefined protocols introduced at all points of contact ensure early recognition and resuscitation as well as prompt referral for definitive management.

Clinical presentation and management of childhood intussusception in South Africa

“…The high incidence of perforation as an operative finding, and the fact that resection bowel was required in two-thirds of patients operated, as well as the need for ileostomy in 5% of cases suggests that this cohort of patients are presenting with more advanced disease than those in international series. Indeed, other local studies confirm high rates of resection [2,11]. In contrast, just over one-third of patients undergoing surgical intervention required no resection, only manual reduction.…”

Management of Intussusceptions Secondary to Pathological Lead Points in Infants and Children

“…Intussusception is one of the most frequent causes of acute bowel obstruction in infants and young children, but it can also affect older children and adolescents. [1][2][3][4][5]8,9 Approximately 95% of the intussusceptions in infants and children are idiopathic in nature where there is no identifiable cause for it. 1,2,4 Secondary intussusception results when there is an identifiable cause for it, and reported to occur in 0.3 to 20% of the cases in infants and young children.…”

“…This morbidity and mortalities are directly related to the delayed diagnosis, presence of bowel gangrene, and the need for major bowel resections during the surgical therapy. [3][4][5]25 In a systematic review relating to the global epidemiology of intussusception in children under the age of 5 years revealed that in Africa, many of the children presented late, had advanced stage of illness, more number of children required surgical therapy, and also associated with higher mortality as compared to the other parts of the world. 25 Two (8.69%) deaths documented following the surgical management of intussusceptions secondary to PLPs in infants and children in present report.…”

“…1,2 In developing countries, management of intussusception in children is associated with significantly higher morbidity and mortality. [3][4][5] Approximately 95% of the intussusceptions in children are idiopathic in nature, where there is no identifiable cause for it. [1][2][3][4] Secondary intussusceptions are caused by identifiable cause/pathological lead points (PLPs) and reported to occur in up to 20% of the cases, and more likely to occur in older children.…”

Ed's Choice

“…Even in developed countries it is associated with significant morbidity and mortality, as is highlighted by Carapinha et al [13] Because management may be either non-operative pneumatic reduction (PR) or operative, the challenge lies in triaging patients correctly into those who will respond to PR, thus avoiding intestinal resection, and those who must be taken directly for laparotomy. The outcomes following the introduction of updated management guidelines at Johannesburg's CHBAH in an attempt to increase the success of PR are outlined.…”