Precautions before treatment for intussusception? http://www.mingyihui.net/article_464.html (I) Treatment The treatment of intussusception should be adapted to the individual. Infantile intussusception can choose colon pneumatic reduction, surgical reduction or intestinal resection and anastomosis according to the condition. Adult intussusception often has underlying diseases, so surgical treatment is required, while treating the primary disease at the same time. 1.General treatment After a clear diagnosis of intussusception, fasting, gastrointestinal decompression, intravenous fluid infusion and other supportive treatments as well as anti-infection treatment should be given immediately. 2.Air (barium enema) colonic insufflation is the first choice therapy for early pediatric intussusception, with a success rate of 77%～97%. (1) Indications: Intussusception occurs within 24-48 hours, general condition is still good, without signs of peritonitis, no significant dehydration or shock symptoms. (2) Method: To calm the child and reduce intestinal spasm, 30 minutes before air enema, compound chlorpromazine 1～2mg/kg and atropine sulfate 0.01mg/kg can be administered. If the child cries excessively, consider performing reduction under general anesthesia. After the child is calm, insert the Foley catheter into the rectum, inflate the balloon with about 40ml of air to block the anus and prevent air leakage, then connect the balloon catheter with the air enema reduction device. Before injecting air, observe under X-ray fluoroscopy whether there is free gas below the diaphragm and the distribution of gas in the intestine, then slowly inject air, starting from 8kPa and gradually increasing, generally not exceeding 12kPa. Strictly avoid injecting air too quickly or forcefully to prevent intestinal perforation. Under X-ray fluoroscopy, when the air reaches the splenic flexure or hepatic flexure of the colon, it moves more slowly, and usually stops moving at the cecum. Apply continuous pressure for several minutes, and the ileocecal region will present a larger round shadow that gradually shrinks until it completely disappears, and a large amount of gas enters the small intestine, indicating successful reduction of the intussusception. If the mass shadow disappears but little gas enters the small intestine, continue to inject air until a large amount of gas enters the small intestine. Because in the ileoileal type of intussusception, although the ileocolic intussusception may have been reduced, the ileoileal intussusception may still exist, which could cause intestinal necrosis. (3) Determination of successful reduction: The characteristic manifestations of successful intussusception reduction include: ①Under fluoroscopy, the mass shadow disappears, gas flashes into the ileum, and the amount of gas in the ileum increases; ②After removing the balloon catheter, a large amount of gas and currant jelly stool or yellow feces are discharged; ③Palpation of the abdomen shows the original mass has disappeared; ④Abdominal pain is relieved, the child stops crying, and falls asleep quietly; ⑤Oral administration of 1g of activated carbon, 6～8h later, black charcoal agent is found in the discharged stool, confirming that the intestine is completely unobstructed. If the child does not spontaneously defecate at this time, perform a digital rectal examination or enema to observe the stool situation. Children undergoing colon pneumatic reduction treatment should all be hospitalized for observation until the charcoal agent is discharged before being allowed to leave the hospital. (4) Complications: Intestinal perforation is the main complication of colon pneumatic reduction treatment, with an incidence rate of 0.42%. Improper selection of indications, or too rapid and forceful injection of air leading to excessive pressure, are the main causes of intestinal perforation. The typical manifestations of intestinal perforation are: ①During air injection, sudden appearance of "flash" changes in the abdominal cavity with gas spreading around; ②Unclear mass shadow; ③Sudden abdominal distension, hardening of the abdomen, percussion reveals significant tympany; ④Fluoroscopic examination shows elevated diaphragm and a large amount of free gas below the diaphragm; ⑤The child develops respiratory distress, cyanosis, and rapid deterioration of overall condition. At this point, stop injecting air immediately, perform abdominal puncture to release gas, and prepare for surgery quickly. (5) Reasons for failure of colon pneumatic reduction: ①Improper timing of reduction, cases lasting over 48 hours are difficult to succeed; ②Improper technical operation, excessive injected air can cause intestinal perforation, while insufficient or unstable air cannot achieve the purpose of reduction; ③Tight or long tube; ④Temperature exceeding 38°C, pulmonary infection can be excluded and cannot be explained by other reasons, consider intestinal necrosis, pneumatic reduction is prone to fail; ⑤Crying restlessly, increased intra-abdominal pressure; ⑥Secondary intussusception. (6) Key points of barium enema reduction: When there is no colon pneumatic equipment available, barium can be used instead of air for intussusception reduction. Indications include cases within 48 hours, mild obstruction on plain abdominal radiograph, and no signs of peritonitis in ileocolic type intussusception. Place the barium container about 100cm above the horizontal body position, and slowly inject the barium. Similarly, observe the reduction of intussusception under X-ray fluoroscopy. The perforation rate is 0.7%, mostly occurring in the unaffected segment of the intestine. The recurrence rate after reduction is 8%～12%. In cases lasting over 48 hours, the failure rate of barium enema reduction is 55%. 2.Surgical reduction method (1)Indications: ①Disease duration exceeds 48 hours, or less than 48 hours but severe conditions with suspected signs of intestinal necrosis; ②Failure of colon pneumatic (or barium enema) reduction; ③Multiple recurrences suspected of organic lesions, surgical reduction can both confirm the diagnosis and serve as treatment; ④Small bowel type intussusception. (2)Method: After laparotomy, locate the site of intussusception, manually squeeze out the intussuscepted part from the distal end of the intussusception. In most cases, complete reduction can be achieved. Avoid forcibly pulling the proximal segment of the intussusception. Use gentle squeezing techniques. When necessary, during the final part of the reduction, slightly traction can be applied to the intussuscepted part to achieve complete reduction. If difficulty persists, use the tip of the little finger to expand the narrow neck ring, slightly separate adhesions between the intussuscepted part and the sheath wall, making reduction easier. This method is called the Cope method. Duncan reported 6 cases of post-abdominal trauma intussusception, 5 of which were small bowel type and 1 was ileocolic type. All were successfully reduced manually, with no recurrence or complications. West proposed that early postoperative intestinal dysfunction should raise suspicion for postoperative intussusception, allowing timely laparotomy and manual reduction. Delayed diagnosis can lead to intestinal necrosis. After reduction, carefully observe the vitality of the intestinal segments and presence of organic lesions. If intestinal necrosis is present, perform intestinal resection and anastomosis. If the appendix shows significant lesions after reduction, appendectomy can be performed. 3.Resection of the intussusception segment and intestinal anastomosis (1)Indications: ①Intussusception that cannot be surgically reduced; ②Intussusception accompanied by intestinal necrosis; ③Intestinal perforation and necrosis due to pneumatic enema reduction; ④Intussusception secondary to organic lesions. (2)Method: Depends on the cause, location, extent, length of affected intestinal segment, presence of intestinal necrosis, and overall patient condition. For malignant lesions where the intestine has lost vitality, strive for one-stage resection, especially in adult colonic intussusception, which has the highest malignancy rate and should be resected. Right-sided colonic intussusception can undergo right hemicolectomy. Those involving the descending colon or sigmoid colon can undergo left hemicolectomy. Sigmoid colon-rectal intussusception with lesions in the lower rectum should undergo abdominoperineal resection. If there are no rectal lesions, perform anterior resection after reducing the intussusception. Most colonic intussusceptions present with incomplete obstruction, and adequate preoperative preparation facilitates one-stage resection and anastomosis. In cases of complete intestinal obstruction caused by colonic intussusception, staged surgery is generally recommended. First perform a stoma proximal to the obstruction, then elective surgery after the condition stabilizes. In summary, intussusception caused by malignant tumors should follow surgical principles, widely resect the intussusception segment and related mesenteric lymph nodes, avoiding tumor dissemination inside and outside the intestinal cavity or hematogenous spread due to venous cancer emboli detachment. If the cancer has metastasized, perform local resection and anastomosis after manual reduction to restore intestinal continuity. Appendiceal intussusception is relatively rare and often presents as a cecal mass, making it difficult to differentiate from cecal cancer. Local resection or cecum resection can be performed, but strict indications must be followed. For small bowel intussusception without intestinal necrosis, manual reduction can be attempted first, followed by careful palpation of the intestinal wall. Resection should be performed if organic lesions are found. Weibaecher believes that there has been a significant increase in recent years in small bowel intussusception associated with malignant tumors, thus advocating one-stage resection of the lesion's anatomical site without reduction. For acute jejunojejunal intussusception after gastric surgery, early surgery is recommended. The most commonly used method is reduction or resection of the intussusception segment, and if necessary, repeat gastrectomy and convert to Billroth I anastomosis to remove the output loop prone to intussusception. Alternatively, after reduction, suture or reduce the size of the gastrojejunostomy. If the original procedure was a gastrojejunostomy, add pyloroplasty after reduction. For recurrent primary ileocecal intussusception, surgical reduction can be performed again, and simultaneously fix the terminal ileum to the cecum to prevent recurrence. (II) Prognosis In recent years, the mortality rate of intussusception has significantly decreased, with literature reports ranging from 5% to 10%. The mortality rate for irreducible intussusception is higher, ranging from 40% to 90%. http://www.mingyihui.net/article_464.html