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Postoperative intussusception: report of 2 cases and review of the literature

 

Marijana Krstic, Ana Kostic, Andelka Slavkovic, Mirjana Mihajlovic
Clinic of Pediatric Surgery and Orthopedics
Clinical Centre Nis, Serbia

 

Correspondence

Ana Kostic, MD
Clinic of Pediatric Surgery and Orthopedics
Clinical Centre Nis, Serbia
E-mail: This email address is being protected from spambots. You need JavaScript enabled to view it.

 

Abstract

The purpose of the paper is to draw attention to postoperative intussusception by presenting 2 cases (emphasis is on the different clinical and radiological presentation, despite similar operative finding) and review scanty literature on the subject.

key words: postoperative intussusception

 

 

Postoperative intussusception (POI) is uncommon postoperative complication, with a unique clinical presentation [1]. POI does not include recurrent intussusception [2]. Making the diagnosis of POI is often very difficult, due to the insidious onset of symptoms, that are usually attributed to the postoperative course and paralytic ileus.

Case 1

A 9-year-old boy was admitted due to the abdominal pain, located in the right iliac fossa, vomiting and fever. There were signs of abdominal wall contracture in the lower part of the abdomen. After blood samples and ultrasound examination which didn’t show any specific pathological data, the child was operated on. Appendix showed no signs of inflammation. However, firm cecal mass occuping most of its lumen was discovered and right hemicolectomy performed ( fig. 1). Results of the histopathology showed Burkitt lymphoma. Child’s immediate postoperative course was uneventful; he even passed gas on the 3 rd postoperative day. On the 4 day after surgery an important drainage on the naso-gastric tube was noticed. He had no abdominal pain. On the following day abdominal distention was impressive. The abdominal X-ray showed multiple air-fluid levels. A relaparotomy was performed on the 5 postoperative day ( fig. 2). Anastomotic suture was intact, but ileo-ileal intussusception was found (approximately 20 cm from the anastomosis), that had been easily reduced manu- th th ally ( fig. 3). After the second operation, the patient recovered successfully.

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Figure 1: Operative finding presenting intraluminal cecal mass 

 

 

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Figure 2: Abdominal X ray, performed on the 5th postoperative day Figure 3: Ileo-ileal intussusception found during the 2nd laparotomy

 

Case 2

A 5- year-old boy was admitted for abdominal pain, fever and vomiting. Laboratory tests showed leucocytosis, as well as elevated C-reactive protein levels. Ultrasound examination was negative. He was operated on: acute inflammation of appendix vermiformis was found, but no enlarged mesenterial lymphnodes. His postoperative course was uneventful till the 5 day, when he started to complain of the severe abdominal cramping of periumbilical localisation; pain subsided spontaneously. On the following days he also had several episodes of the abdominal cramping, but didn’t vomit and was afebrile. On the 10 th th postoperative day his clinical condition deteriorated rapidly: abdominal pain was severe, he started to vomit. Abdominal X ray (performed twice) however, showed no signs of the intestinal obstruction. Abdominal ultrasound was negative. Decision to perform relaparotomy was made because of the child’s worsening clinical state; ileo-colic intussusception was found and reduced easily ( fig 4). After the second surgery, the patient recovered smoothly.

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Figure 4: Ileo-colical intussusception found during the relaparotomy 

 

Discussion

POI is often forgotten and easily overlooked postoperative complication. Unlike idiopathic intussusception (well known clinical entity) abdominal pain may not always be present, rectal hemorrhage is absent, vomiting is rare [3]. It affects children of both sexes equally and it may be noticed in any age. Reported incidence is 1: 200-1000 of all operated children [4].

Even though the majority of postoperative intestinal obstructions are attributed to the formation of adhesions and strangulation bands, POI has beeen reported in 5-15% [5]. Puzzling feature of POI is that it may follow even after some extraabdominal surgery. It has been reported after appendectomy, blunt abdominal trauma, after extensive retroperitoneal dissection of neuroblastoma [6,7,8,9]. Interesting point is that previously performed Ladd procedure predisposes a child for development of POI [10].

Perhaps the only similarity between idiopathic intussusception and POI is that etiology still remains unknown. It is speculated that long-lasting operations and intestinal hipoperfusion and dessication may contribute to the development of POI as well as enlarged Peyer plaques [11, 12]. Neurotoxic effect of hemotherapy on the intestine may also cause POI [13]. Administration of opioid analgetics in the postoperative course may also alter intestinal motility [14]. Preoperative diagnosis of POI has been made in only 5%, probably because most of the clinical features of POI which are attributed to the postoperative course, analgetics for postoperative pain, inserted naso-gastric tube to prevent vomiting [15]. Also, it is very difficult to exemine the abdomen of an operated child [16].

Worth noticing the fact that many of the widely used diagnostic methods (such as abdominal X ray, ultrasound examination) do not always detect the intussusception [17,18]. There are no literature data whether reduction of POI can be feasible by hydrostatic reduction. One thing is certain, ileo-ileal invagination can not be reduced using this method. Herein reported cases prove that diagnosis of POI is rarely made preoperatively. The abscence of abdominal pain in the first patient may be explained by postoperative analgesia; abdominal distention and important naso-gastric aspirate were, at first, attributed to the adynamic ileus. However his abdominal X-ray was very illustrative and showed marked air-fluid levels.

Our second patient did have episodes of intermittent pain for several days prior to the relaparotomy, which could attibuted to spontaneous reduction of intussusceptions. The child did not vomit, and even passed stool. Even though the POI was operative finding, no suggestive signs of intestinal obstruction could be no- ticed on his abdominal X ray and even on the ultrasound investigation. Hopefully, intusssception was easily reduced manually and postoperative course uneventful. Common findings in both patients were that immediate postoperative course after first surgery was running smoothly and that peristalsis recovered very soon after operation. High index of suspicion is necessary to diag- nose POI preoperatively.

Diagnosis rests on the awareness of this postoperative complication. POI should be considered in any patient who develops signs of the intestinal obstruction early, after relatively uneventful postoperative period.

 

 

References 

  1. Raffensperger JG, Baker RJ. Postoperative intestinal obstruction in children. Arch Surg 1967; 94:450-4
  2. Hays DM. Intussusception as a postoperative complication in paediatric surgery. Surg Gynecol Obst 1961;112:583-9
  3. Mollitt DL, Ballantine TVN, Grosfeld JL. Postoperative intussusception in infancy and childhood: Analysis of 119 cases. Surgery 1979; 86: 402-8
  4. West KW, Stephens B, Rescorla FJ. Postoperative intussusception: Experience with 36 cases in children. Surgery 1983; 104:781-7
  5. Holcomb GW, Ross AJ, O’Neill JA. Postoperative intussusception: increasing incidence or increasing awareness? South Med J 1991; 84:1334-9
  6. Arora A, Caniano DA, Hammond S, Besner GL. Inversion appendectomy acting as a lead point for intussusception. Ped Surg Int 2008; 24:1261-4
  7. Erichsen D, Sellstorm A, Andersson A. Small bowell intussusception after blunt abdominal trauma in a 6-year–old boy. J Ped Surg 2006; 41:1930-2
  8. Humbyrd CJ, Baril DT, Dolgin SE. Postoperative retrograde intussuscep- tion in an infant: a rare occurrence. J Ped Surg 2006; 41:13-5
  9. Tank ES. Postoperative intussusception. J Urol 1980;123:603
  10. Kidd J, Jackson R, Wagner CW, Smith SD. Intussusception following Ladd procedure. Arch Surg 2000;135:713-5
  11. Dammert G, Votteler T. Postoperative intussusception in the pediatric patient. J Pediatr Surg 1974; 9:817-20
  12. Cox JA, Martin LW. Postoperative intussusception. Arch Surg 1973;106: 263-6
  13. Cohen MO, Baker M, Griosfeld JL, Siddiqui A. Postoperative intussusception in children with neuroblastoma. Br J Radiol 1982; 55:197-200
  14. Velin P, Dupont D, Parizot P, Puig C, Grinda A. Postoperative intussusception in children. Ann Fr Anesth Reanim 1992;11:584-6
  15. Bodycomb JL, Spencer WB, Auldist AW. Postoperative intussusception. Ped Surg Int 1987; 2:108-9
  16. Linke F, Eble F, Berger S. Postoperative intussusception in childhood. Pediatr Surg Int 1998;14:175-7
  17. De Vries S, Sleebom C, Aronson C. Postoperative intussusception in children. Br J Surg 1999; 86:81-3
  18. Carnevale E, Graziani M, Fasanelli S. Postoperative ileo-ileal intussus- ception: a sonographic approach. Pediatr Radiol 1994; 24:161-3