What is the treatment for intussusception?

Surgical Management of Intussusception

For intussusception, the first-line treatment is non-operative reduction via pneumatic or hydrostatic enema, while surgical intervention is indicated when non-operative reduction fails or complications such as peritonitis, perforation, or shock are present. 1

Diagnosis and Initial Management

• Diagnostic approach:

  • Abdominal plain X-ray as initial imaging (diagnostic in 50-60% of bowel obstruction cases) 1
  • Ultrasound is highly accurate (100% diagnostic accuracy in some studies) and should be the preferred diagnostic method 2
  • CT scan is preferred for adult patients, particularly post-bariatric surgery cases 1

• Initial management:

  • Intravenous fluid resuscitation
  • Nasogastric tube insertion for decompression
  • Anti-emetics as needed
  • Foley catheter placement to monitor urine output
  • Appropriate antibiotic therapy if indicated 1

Non-Operative Reduction

• First-line treatment: Pneumatic or hydrostatic reduction under radiologic guidance

  • Success rates of air-enema reduction can reach 94.2% 3
  • Ultrasound-guided hydrostatic reduction shows 85% success rate 4
  • Consider sedation during third reduction attempt if initial attempts fail (65.1% success rate with sedative reduction) 5

• Important considerations:

  • Immediate on-site surgeon availability may not be necessary during radiologic reduction if:
    • The attending physician can manage complications (e.g., percutaneous needle decompression)
    • Surgical care can be arranged expeditiously 6
  • Complications requiring immediate intervention occur in only 1.6% of cases 6

Surgical Management

• Indications for surgery:

  • Failed non-operative reduction
  • Signs of peritonitis
  • Evidence of perforation
  • Hemodynamic instability
  • Presence of pathologic lead point (more common in adults) 1

• Surgical approach:

  • Hemodynamically stable patients: Laparoscopic approach preferred
  • Unstable patients: Open surgical approach
  • Severely unstable patients: Damage control procedure 1

• Surgical techniques:

  • Manual reduction of intussusception if bowel is viable
  • Resection of non-viable segments or when underlying lesions are present
  • Resection of invaginated segment to prevent recurrence
  • Consider anchoring techniques (Noble enteropexy) in recurrent cases 1

Special Considerations

Pediatric vs. Adult Intussusception

• Pediatric: Usually idiopathic, primarily ileocolic, often amenable to non-operative management
• Adult: Usually has pathologic lead point, primarily small intestinal, typically requires surgical management 1

Post-Bariatric Surgery Patients

• Consider intussusception as potential cause of small bowel obstruction
• Retrograde (anti-peristaltic) intussusception is most common after laparoscopic Roux-en-Y gastric bypass
• For recurrent cases, consider reversal of gastric bypass or conversion to sleeve gastrectomy 1

Timing Considerations

• Delay in surgical intervention beyond 48 hours significantly increases mortality 1
• Patients with symptoms >24 hours have higher rates of surgical intervention 2
• Mean time to surgery after complications: 1.3 hours after perforation, 2.2 hours after hemodynamic instability without perforation 6

Management Algorithm

1. Diagnosis: Ultrasound or appropriate imaging based on patient age/condition
2. Initial assessment: Evaluate for surgical indications (peritonitis, perforation, shock)
3. If no surgical indications: Attempt non-operative reduction (pneumatic/hydrostatic)
4. If first reduction fails: Consider second attempt
5. If second attempt fails: Consider sedative reduction or proceed to surgery
6. Surgical approach: Based on hemodynamic status and suspected pathology
7. Intraoperative decision: Reduction vs. resection based on bowel viability

Timely diagnosis and appropriate treatment are crucial, as delayed diagnosis leads to increased need for surgical intervention and potential complications 2.