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Paediatric Surgery Session: Paediatric Intussusception | Jose Modesto III Abellera

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Summary

Join Dr. Jose Modest Biel, a clinical associate professor at the Department of Surgery at the University of the Philippines Philippine General Hospital, as he presents a medical education session on Pediatric Intususception. This session provides attendees updates on the diagnosis and management of intususception, a common cause of bowel obstruction in early childhood. Moreover, Dr. Biel discusses the pathophysiology, clinical presentations, and various historical interventions associated with the condition. This session will be especially beneficial to medical practitioners and students looking to deepen their understanding of intususception.

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Description

Dive into the critical realm of paediatric abdominal emergencies with "Interventional Insights: Tackling Paediatric Intussusception," a focused segment of our Paediatric Surgery Session. Dr. Jose Modesto III Abellera, a distinguished paediatric surgeon, will lead this enlightening webinar on the acute management and treatment nuances of paediatric intussusception.

Dr. Abellera will bring his extensive expertise to the forefront, discussing diagnostic challenges, the latest reduction techniques, and long-term management strategies. Participants will gain a deep understanding of when to opt for conservative management versus when surgical intervention is necessary, including insights into the surgical approaches for this condition.

This webinar is a must-attend for paediatric surgeons, emergency medicine physicians, radiologists, and any healthcare professionals involved in the care of children with abdominal emergencies. Enhance your skills and confidence in managing paediatric intussusception, improving outcomes for the youngest of patients.

None of the planners for this educational activity have relevant financial relationship(s) to disclose with ineligible companies whose primary business is producing, marketing, selling, re-selling, or distributing healthcare products used by or on patients.

Dr. Abellera, faculty for this educational event, has no relevant financial relationship(s) with ineligible companies to disclose.

Learning objectives

  1. Understand the pathophysiology of pediatric intususception including its causes, common times of occurrence and associated viral infections.
  2. Identify the common clinical presentations of pediatric intususception in relation to the age of presentation and be able to distinguish between late and early signs and symptoms.
  3. Recognize key predictors of pediatric intususception, and have an understanding how the presenting symptoms can vary in Children older than 24 months.
  4. Grasp the disease's association with adenovirus and a practicable understanding of the relationship between intususception and rotavirus vaccination.
  5. Learn about diagnosis and management strategies for pediatric intususception, including the roles of laparotomy and non-operative reductions.
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Computer generated transcript

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The following transcript was generated automatically from the content and has not been checked or corrected manually.

Hello, everyone and welcome to our medical education event on Pediatric Interception. Um I really don't know what that is most of, you know, I'm not medical, so I really don't know what that is. So I cannot wait to hear what Jose has to say about it. Um As always, pop your questions in the chat, Jose will answer them right at the end of the talk. Um but pop your questions in the chat as you go along and at the end, uh as always again, your feedback form will be in your inbox in an hour's time for you to fill out. Once completed, your attendance certificate will be on your medal account. Please do fill out the feedback form. We really want some feedback from um from the teaching today and I will be passing that all on to Jose and maybe he might say that he might do another teaching session for us after this. OK. So again, pop your questions in the chat and I'm gonna hand you over now. OK. Thank you, Jose. Thank you. So, uh good evening everybody. Good afternoon and good morning as well. Uh uh in my area of the world. It's actually evening right now. So I'm uh Doctor Jose Modest Biel the third. I am a clinical associate professor at the Department of Surgery at the University of the Philippines Philippine General Hospital. So uh let's start uh for this talk. Uh I have no disclosures and this is the outline of uh my presentation. I am actually also looking at the chat box. So if you have questions in real time, I might be able to answer them. So I'll give a brief introduction, talk about the pathophysiology of intususception and then talk about the clinical presentation, how to diagnose the condition and the management. So basically, our objective is to present updates in the diagnosis and management of intususception. Uh just to put a little perspective, I'm from the Philippines. It is a and it is an LM IC or lower to mid income country. We have uh five training programs in pediatric surgery for in Metro Manila, the capital and one in southern Philippines for our 2021 census. Uh There were 44 surgeries for intussusception. Only three were non operative and with a relatively low morbidity and mortality. Uh But take note that this was uh at the uh during the pandemic. So, uh most of the patients with intussusception uh were operated on rather than undergoing non-operating reduction. Uh There was one recurrence and one perforation that, that that's the two morbidities that you can see over there. And also again to put things in perspective since I'm sure uh I think some of the audience are medical students. The textbook that we usually use is SWS principles of surgery. And if you look at uh chapter 39 over there, you can see one page and that's just what is written about intususception. And it is uh important to know that in this part there. According to charts, the e enema is both diagnostic and may be curative and it is the preferred method of diagnosis and treatment of intussusception. But as we will find out later, that is not actually the case uh or, or it does, uh it's not actually true anymore. So, uh again, let's start with intususception by definition, it is the reception of one part within another or literally taking in from latinus or within and su your m taking up taking inhaler undertaking. Ok. So, OK. Historically, uh it is in the mid 16 100s as Paul Barbet of Amsterdam described an intussusception as an intestinal invagination. And at the end of the 17 100s, Hunter was the first to describe in detail what he called an introsusception. Uh Barbet actually suggested that laparotomy and manual reduction was preferable to letting these patients die. In around the 1742. It was Cornelius VLS who performed the first successful operative reduction. However, this was in an adult in those days, infants remained almost universally fatal into the early 18 100s. And in the early 18 100s, 3 separate authors, Blalack Mitchell and Gorham already described the first pneumatic air enema reduction. And in 1876 Harter reported cases of hydrostatic reduction of reception. So take note that even before uh non operative reduction was already being done, however, it should be noted that these cases were not well documented and some involved adults. So there was doubt regarding the efficacy of this uh maneuvers historically. So a picture of an ileocolic intussusception. So basically intususception is the telescoping of one segment of bowel, which is the is called the intussusceptum into an adjacent segment, which is the incipient or the recipient. And as you can see when that happens, this leads to intestinal obstruction, no intussusception. I as we all know is a common cause of bowel obstruction in early childhood and also a common cause of abdominal pain incidence wise, it's around 1 to 4 in 2074 per 100,000 worldwide. It is important to know that the the the peak incidents occurs at 5 to 9 months. And depending on uh your reference textbook, it's between three months to three years or two months to two years. It is rare at the very young or neonatal age group and it is less common beyond three years. The male to female baso is around two is to one. Another important thing to remember is that there is seasonal variation and it is said to be more common during the fall or winter, which we will find out the reason a little later on. So, uh based on this, around two thirds of cases occur before the first birthday and around 80% of cases occur less than 24 months old. So what happens again because of peristalsis approximal segment of bowel is projected into an adjacent distal segment and most commonly intususceptions are ileocolic but they can also be ileo ileal Cholo or located at other gastrointestinal tract locations. Mm. When this happens as you can as, as shown in the previous illustration, compression of the mesenteric vessels can occur as well as the lymphatics leading to venous congestion, tissue edema, bowel obstruction, and subsequently bowel ischemia and necrosis. Ok. So that that's what happens as the obstruction, uh progresses and is prolonged when necrosis occurs. This leads to third space fluid loss, hypovolemia sepsis and even death. So, what is the cause or what is the etiology? Again, majority, more than 90%. The etiology is unknown or not clearly defined. The hypothesis is is that the intussusception is triggered by inflammation of the lymphoid tissue in the bowel wall. And these are, these become enlarged and uh they, they somewhat act as a lead point. Common viral infections associated with intussusception include adenovirus, rotavirus and human herpes simplex virus. So again, remember, more than 90% is idiopathic or primary or what is called primary intususception. And they are often associated with gi or respiratory viral infections. Now, secondary intususception occurs when there is the presence of a pathological lead point. This is more likely in Children older than five years old and it is 2 to 10% in incidence. It increases with the age of the pediatric patient. Ok. So what are the common pathological points? Uh This table I uh shows the common pathological lead points. Maker diverticulum, the appendix usually intestinal polyps, duplication, cysts, neoplasms, foreign bodies including feeding tubes, intraluminal insta, inspissated stool, intramural hematomas in HSP celiac disease. Now, this article uh divides pathologically points into benign focal bowel abnormalities, malignant lead points as well as systemic diseases. But basically, it's also the same list as the previous one. So, uh again, let's remember that as a child falls and in, in an older age group, the likelihood that there is a pathological lead point is higher. Ok. So how does intususception usually present? They are usually healthy? Well, nourished infants or toddlers with an anticipated viral illness, but the onset is not easily determined or the association is not easily determined, they usually present with abdominal pain which can be sudden, severe and crampy, intermittent or colicky. So, because of the peristalsis and the obstruction. So this is found in nearly all Children, vomiting initially. Nobilo is one of the most next, most common presenting symptoms. Bloody mucoid or chant jelly stool is a late sign and lethargy is less common. Basically, the symptoms can be wide-ranging nonspecific. Yeah. And sometimes the history and physical examination can be unreliable. Ok. So what about other signs? Ok. So if these are the symptoms and these are the common signs, that sign is a flat or empty, right, lower quadrant, sometimes it's associated with the presence of a sausage shaped mass in the right upper quadrant, which is basically the into suction. Ok. In Children with a very thin abdominal wall, you can sometimes palpate the mass, the classic triad, the pain, the palpable abdominal mass and the jelly stool is seen in less than 25%. But the first, if you have the triad, then it's most likely an intussusception late signs, well as as the condition, uh a late presentation or late consult, the patient may already have dehydration, pa marked abdominal distension. If the intussusception uh progresses until a more distal portion. Sometimes you can palpate a rectal mass. Already fever points to an ongoing infection, possible start of sepsis or uh bowel ischemia. And of course, later on you can have your hypovolemia, hypotension and peritoneal peritoneal signs due to necrosis and perforation. So, again, somewhat wide-ranging and nonspecific. But the the one of the most important things to consider is that when a patient presents in the age range of two months or 32 to 3 months, up to 24 months, then intususception is a uh you should have a high index of suspicion that an intussusception might be the problem. OK. Just to show you a picture of the corange stool. Basically, this is a slough of intestinal mucosa as well as a uh a prolapse of the intussusceptum through the anorectum. Ok. So, no, in this study, a retrospective cross sectional study of five years, there's noted variation in the presentation of intususception by AIDS. Ok. So what did he find out? They found out that uh abdominal pain m SMS, lethargy and rectal bleeding as well as irritability. I mean rectal bleeding and irritability were found to be predictors in those younger than 24 months. Ok. The cutoff that they found was 24 months. However, in older Children. Ok. It it does not seem to be the case and the only predictor that they found in older Children was uh male gender. So, in this age group, in cases where abdominal radiographs were obtained, any abnormality on abdominal radiograph was found to be predictive in both age groups in, in younger as well as in older Children. What does this imply? Uh This implies that uh sorry, traditional clinical predictors of intussusception should be interpreted with coan when assessing Children older than two years old? Ok. Uh What about this study? A review of literature with the association of intussusception with adenovirus provirus and other pathogens. In uh in this study, 17 evaluations from 15 countries that evaluated 52 pathogens that were included in the analysis showed that there is a consistent association of intususception with adenovirus. Ok. But no relation between wild type rotavirus. They suggest future research focusing on better and understanding the mechanism of intussusception with infectious pathogens including rotavirus vaccination. Why? Why is this important? Uh when the rotavirus vaccine was first developed in the late 19 nineties, it was promptly removed a year later because there was significantly higher incidence of intususception. So upon further development, they, the second generation vaccines underwent excessive extensive testing and there is a small increase in risk after 1 to 7 days. But the benefits were felt to outweigh the risk. So what they found was that administering the first dose of rotavirus at birth rather than at six weeks would avoid nearly all vaccine related cases of intussusception. So in this, in this paper published in 2019, basically, they just uh saying that intususception incidents varies substantially by country and region highlighting the need to assess the benefits and risks of rotavirus vaccination at the national rather than the global level. And that has been mentioned, administering the first dose at birth rather than at six weeks could avoid nearly all vaccine related cases of intussuception. Uh Remember when we, when I showed you the, the Philippine training programs, tally of cases of intususception during the pandemic. Uh there was a significant number. So these are just the ones that are documented. And in in this article, they found that COVID-19 can cause severe interception in infants. So basically, uh these are the following case reports that were found they are more or less the same age. They were predominantly male and had initial intussusception symptoms. Four of them also had respiratory symptoms in the series that I showed during my introduction, six patients with intussusception were actually COVID positive out of 21 in in in uh the National Children's Hospital where I am connected. So is there elevation between the COVID virus and intususception In this uh paper that looked at the mesenteric lymph nodes isolated from patients with intussusception, they found the virus in the lymph node. Ok. So they conclude that as knowledge of the COVID virus is still evolving, we cannot actually completely define the nature of this association. But it is certainly important to know that intussusception can be an unconventional manifestation of COVID-19. It's even more important to suspect intususception when a COVID-19 patient presents with abdominal pain, vomiting, constipation or even blood in the stool. Yeah. Ok. So we now proceed with how to diagnose. Basically, the possibility of intussusception is usually raised clinically, but the diagnosis is established. Radiologically. Laboratory tests are not that specific, but we can always request for our complete blood count and electrolytes and if they have respiratory symptoms, then the COVID test may be also warranted. Remember when I showed you the page from Swartz, it says that the, the, the enema is both diagnostic and therapeutic. But nowadays, ultrasound has become the method of choice for detecting intususception at almost all institutions, the abdominal radiograph uh now becomes just an adjunct and you can usually show obstruction, the fluoroscopy or the contrast enema is there, which was historically used to be the gold standard is still used as a diagnostic or a therapeutic maneuver. But uh the ultrasound is still the imaging of choice. The equivocal ultrasound and a high clinical suspicion can warrant a contrast enema for further evaluation. And since we are dealing with Children, the routine use of CT or MRI should not be done. Yeah. So what are original graphic findings concerning for intussusception? Of course, in your x-ray, you can have signs of intestinal obstruction or you can see in an abdominal mass. Of course, the target sign is an ultrasonographic finding absence of air in the cecum obscured liver margin and laterization of the ilio. The next few images I I'll, I'll just be showing some X rays the from literature that uh shows exactly this. So for example, in this picture, you can see a mass or a mass like lesion in the right upper quadrant. OK. And in this, which is uh contrast enema, you can see the CRE and sign on your left and a coiled spring sign on your right, the one that is encircled. OK. So basically this is showing the intussusceptum within the intussuscipiens. What about the ultrasound? So basically the one on the upper picture is the target sign and the one on the lower picture is the pseudo kidney sign. The pseudo kidney sign is a longitudinal sonographic uh picture. Excuse me showing the interseptum within the intercipient. Why is uh ultrasound? The imaging of choice because it is safe, it is non invasive. It is simple and fast and does not require the use of a contrast agent. Moreover, it allows real time assessment. If you use the Doppler function of the ultrasound, you can actually see if there is a uh problem with the vascularity of the intussusceptum. So what is the evidence uh in this systematic review and meta analysis published in 2019, uh 30 status is with the total number of 5249 patients. The sensitivity is 98. The specificity is 98. OK. And uh meta regression suggested there is no significant difference in diagnostic accuracy for intussusception between point of care, ultrasound and radio radiologist performed ultrasound. OK. I there is no difference. And what about the point of care ultrasound done in the emergency department in this paper published in 2020 total of 1303 Children. OK. Ultrasound sensitivity 94.9 sensi specificity. 99.1 done by emergency physicians is highly sensitive and specific for the identification of interoception in the emergency department. Again, another study. OK. Ultrasonography has high sensitivity and specificity in the diagnosis of intussusception. So what what, what am I trying to say? Ultrasound in the hand of a uh uh resident or even a uh medical student or an intern. Once you have the experience, you know what to look for. OK? There's a high sensitivity and specificity, OK? You don't need to bring the patient anymore to the suit for a, for a contrast enema. So basically the patient comes in, you assess, there's an index of suspicion, there's uh there's intususception, you do the ultrasound. So basically, that's it and you can manage accordingly. Ok? You give your fluids, you try to decompress if there's obstruction, ba basically put the patient on an NPO inside your nasogastric tube, especially if there's vomiting or virus vomiting. Now you can start your antibiotics depending on the condition of the patient, especially if the there is peritonitis or signs and symptoms of obstruction. And you need to uh referred to your pediatrician for risk stratification. No, what do we do? Uh Although there is chance for spontaneous reduction that can occur within 5 to 20% uh there's widespread agreement that you should prepare for a double set up wherein you start with uh nonoperative reduction. Yes. In the well hydrated child and prepare in case the nonoperative reduction fails. That's when you need to operate on this patient and there shouldn't be a lab. So if nonoperative reduction fails, you should be prepared to go into surgery. Ok. Uh In this uh 2017 Cochrane Library Review uh which basically talks about uh enema and uh management. OK. The use of glucagon versus enema alone, the results are uncertain glucagon basically uh helps because it is an antispasmodic way and produces transient paralysis of the intestines. So that you can easily uh of course, attempt to reduce the use of dexamethasone, which is uh believed to alleviate the lymphoid diplasia. Well, they use of the adjunct may be beneficial but this is just in reducing recurrence. In 2017 e enema seemed to be more successful than liquid enema. OK. But in that review, no studies exclusively showed or studied surgical management. Basically, there was low quality of evidence with high risk of bias and they implied that further research should be done. So uh in this more recent 2021 article, OK. I interception in hemodynamically stable Children without critical illness, prereduction, antibiotics are unnecessary and nonoperative outpatient management should be optimized. OK. Minimally invasive techniques may also be used to avoid laparotomy. So based on what the history that I showed a while ago, there seems to be a shift back to the use of uh nonoperative or enema reduction. OK, rather than arthri operations. And with the advent of minimally minimal surgery techniques. So you have another useful tool. So nowadays, therapeutic enema or non operative reduction has become a mainstay of management contraindications to doing this of course, is evidence of instability, peritonitis, perforation or necrotic bowels. We don't use barium anymore, but we use water soluble contrast just as an aside, uh when I was a trainee barium was the one that we use. And unfortunately, we had the patient who had the perforation during the nonoperative reduction using barium barium. Once it goes into the peritoneal cavity is almost impossible to clean. Ok. There are several options, water soluble contrast, you can use air and of course, you can use saline. Some centers advocate the repeated attempts at non operative reduction before operative intervention if there is suspicion of partial reduction. So the success however, depends on the experience of the radiologist or surgeon performing the procedure. If there is a pathologically point or if this is an older child, then the likelihood of success of the non operative reduction is much lower. And finally, the length of time and the bowel involved, the likelihood of non operative reduction also declines. So for example, in the picture that I showed wherein there is already prolapse of the intussusceptum outside the anorectum, then the chance of non operative reduction in those patients is almost uh is is very low. So some pictures showing barium reduction, you can see the intussusceptum in the picture on the left. And after reduction, there is flow of dye all uh up to the proximal colon and into the distal ileum and fluoroscopy guided air reduction will look like this. So they're more or less similar except in this. You are looking at the, the air. What about saline reduction? Basically, you're using the ultrasound and you're looking at the, so the kidney or the target sign and uh as you use your saline, you see if there's a resolution and in the right picture, it's already showing the valve. So basically in non operative management, you follow the rule of threes. Uh this is for hydrostatic reduction, the hydrostatic column should be 3 ft above the patient no more than three attempts at reduction and each attempt should be less than three minutes long. Ok. Yeah. So again, uh this is a previous article showing pneumatic reduction to be superior to hydrostatic. You can either use the ultrasound or the fluoroscopy. If initial attempts uh fail, delayed repeat enema may be successful. There is a chance of occurrence but it should be treated as if it were an initial episode of intussusception. Ok. In our experience, we use the ultrasound and hydrostatic saline reduction and uh of 13 patients, 11 were successfully reduced. However, two under two failed and underwent laparotomy. Yeah. In this paper, a prospective multicentric study done in China, the total number of 2001, another 24 patients hydrostatic seems to be better or slightly better than pneumatic but with more or less the same recurrence sleep and incidence of bowel perforation. So basically what I'm saying is uh it somewhat depends on your expertise, your preference, the capability of your institution. If you are uh adept at using the ultrasound and it is available, then why not use the ultrasound and line or if the radiologist or the fluoroscopy is available or easier to use or more available than the ultrasound, then you could probably use the pneumatic fluoroscopic guided. Basically, it seems that they both are safe. And uh, however, I see sign by towards the ultrasound, there's no radiation risk and uh basically, that's it. Ok. I've slightly mentioned this a while ago. Some predictors have failed enema reduction r the presence of symptoms over 24 hours, diarrhea, lethargy, and the distal extent of intususception, which is logical. So the longer the intususception, the more difficult it would probably be to be able to reduce it. OK? OK. Uh In this more recent article, asserted the reason was associated with increased pro the success uh age less than one year. The presence of fever, rectal bleeding, vomiting, ascitis, left-sided, intussusception or trapped fluid on ultrasound were associated with decreased probability of success. So, looking at these parameters, when you have your patient would help identify those that would most likely fail, thereby necessitating more preoperative preparation. OK. So you don't do the reduction right and left or you need to look at the patient, look at parameters that would predict success. OK. And if there are parameters that could point towards failure, then all the more you should prepare these patients for possible surgical intervention. So patient selection is very important. So if you look at this uh algorithm from Cincinnati Children's uh basically use the ultrasound. If there's negative or you don't see intususception, then you look for other causes of the the signs and symptoms. If it's positive, refer to surgery and you can do in this, these Children, they do a enema. OK. So you can also make your own algorithm in your institution depending on your capabilities, your uh your instruments, the availability of expertise, etcetera. Yeah. So perforation is a dreaded complication. In this picture, you can show extravasation and that is uh barium using barium. And in this video which I will show this is a fluoroscopic guided air reduction. So, trying to reduce, using air inflating air into the. OK. Did you see that suddenly there was a perforation? And now you have your pneumoperitoneal. OK. So once that happens, then this emphasizes the need for the double setup wherein you're already prepared to go to the operating room, especially if you're doing it in the radiology suite. So what are the indications for operative management? Of course, failed nonoperative reduction, persistent hypotension, uh signs and symptoms of perforation or peritonitis, evidence of a pathological lead point and recurrent intususception. So you can do a co uh where in you can do manual reduction. You, you might need to do resection or you might need to do ostomy depending on the patient's condition, you can do it laparoscopically. Initially, it was used as an adjunct, but now it is both diagnostic and therapeutic. So check for the viability of your bowel. Try to look for pathological points. And what about, uh, the appendix? Do you remove it? Uh, we'll answer that a little later. So this is just showing the manual deduction should an incidental appendectomy be performed? Ok. Uh, in this, uh, study. Yeah. So, uh, there is a higher mean length of stay and the cost in the patients who underwent, uh, surgery with appendectomy group. So, basically, this study suggests that appendectomy during surgery for uncomplicated intususception should be reconsidered and may require further investigation. Ok. But this is just a uh uh database or based on uh 2019 pediatric care information system database in the US. OK. So you might need to reconsider laparoscopic reduction. Uh is a safe alternative depending on surgeon experience and preference. It is a safe and efficacious as the open approach with benefit to a certain length of stay. However, you, the approach is counterintuitive because traction is usually required proximal to the incipient to complete the reduction. Whereas in manual reduction, gentle pressure is placed on the intercipient gently milking it away from the intercept, pulling the two ends apart is classically avoided because of the friability of the bowel and possible perforation. However, in the laparoscopic approach. Ok. Uh you both require traction and gentle pressure. Ok. Yeah. So in this study, comparing lap and open surgery, uh they did 52 patients 26 in each group. Ok. Conversion rate was 31%. And five cases in the lap surgery and four cases in the open surgery needed bowel resections. The operating time was longer in the lap surgery group, but the POSTOP complication rate was higher in the open surgery group. Uh What does this mean? Basically, they conclude that lap laparoscopy is a screening tool to determine the need for open surgery in surgical intususception patients. Because laparoscopy reduces the incidence of open surgery and its complications. They are suggesting to use laparoscopy as a front line treatment in hydrostatic reduction, resistant intususception in pediatric surgery center. So they're suggesting if non operative reduction is unsuccessful, you do the laparoscopic first. Ok? If it's successful then well and good. But if it looks uh difficult, then you proceed with open. Ok. No, what happens? Postreduction or POSTOP. Most patients who undergo enema reduction can be started immediately on a liquid diet within the 1st 24 hours. Yeah. Uh but you need to remember or you need to inform the parents that there is a chance of recurrence. The POSTOP course of course varies widely depending on the severity of the intussuscept zone. Uh Can you discharge the patient according to this study published in 2022 if you have a quality improvement initiative for the management of intussusception, ok, you have a standard protocol. It reduces hospital length of stay costs and it is that it is safe. Ok. But uh the key here is that there is a quality improvement protocol. So this is their protocol where you have your suspected intususception, you do your ultrasound. If it's positive, you attempt an Mr reduction if it's successful. Ok. After four hours observation, you can discharge or admit depending on the situation. OK. Just to reiterate, do the ultrasound if it's positive, do your enema reduction. OK? If it's successful, observe and then you can send home, especially if the family is reliable with appropriate return precautions and then admit accordingly if you have the following signs and symptoms. Now we're almost at the end of complications. You should also inform the family regarding possible bowel per section, the possible incidental appendectomy, the possibility of having to do an ostomy or repeat exploration and of course postoperative adhesions. Some early complications include infection, bleeding, anastomotic, like if you did resection anastomosis, ill use. Late complications include bowel adhesions and the currents that is extremely rare and usually related to access care or delay in management. If there is occurrence about a third occurs within 24 hours and a majority within six months and is said to be less likely after operative reduction or resection. Uh Just to mention the possibility of postoperative intussusception in cases where the patient was operated on for another indication. Ok. It's there following laparotomy and it usually involves the small intestine as such. The use of non operative reduction is limited. So the child can be discharged after successful management after they have tolerated feeding after proper monitoring and mortality is extremely low for uncomplicated intususception. Like I've mentioned, deaths are related to access to care and delay in seeking treatment. So, prognosis is usually excellent if the diagnosis is early resuscitation is carried out thoroughly and the treatment is started early, especially with respect to a successful nonoperative reduction. Ok. Uh In this old uh reference published 2003, they said I mentioned that interception was one previously one that imposed radiation. There was concerned over the best operation was a serious technical challenge with the surgeon and a source of significant morbidity and mortality. However, in this present day and age diagnosis and treatment in most cases requires no potentially detrimental procedure. The treatment is noninvasive or nonoperative in the surgical sense, there is improved knowledge and understanding of fluid and electrolyte balance and the morbidity and mortality is very low. Ok. But failure to recognize the disorder still occurs and has dark consequences. Lastly, some takeoff points, high index of suspicion here, especially when it falls during the age group, 2 to 3 months to 2 to 3 years old. Ok. Limit delay. You still need to resuscitate the patient, especially if the symptoms are more than 24 hours. Ultrasound point of care, ultrasound or emergency physician performed ultrasound has high sensitivity and specificity. Always do it double set up. I mean the non operative reduction. Ok. That is the initial therapy, especially if diagnosed early. So you should always take into consideration that there are predictors of failure in non operative reduction. And of course, especially for the surgeons, operative management may sometimes be required. Ok. So these are some of my additional references. So we have more or less time for some questions if you have any. Uh I'll stop sharing and perfect. Perfect. So, wow, that was really informative. Thank you so much. Does anyone have any questions, please pop them in the chat? Um And we can ask them, I'm really hoping that you might have. So Jose you might have answered this already. Is that uh procedure, is that issue common in any particular country or is it, is it all sort of under two because it's mainly babies, isn't it? It's not, it's not older Children, it's babies that have it. Is that right? Ok. Common in any particular country or uh there's, there's uh I don't think there's uh any country, I mean, it's relatively seen in uh around the world. OK. But uh again, uh just to emphasize, you know, for example, in, in the Philippines, in, in, in the hospital where we have uh four different hospitals for different training programs. Each training program has a specific uh preference for doing the non operative reduction in the National Children's Hospital. We do ultrasound guided saline reduction in the Philippine General Hospital usually do air fluoroscopic, guided air reduction. So again, because of preference uh availability of, uh, equipment and, uh, yeah. Yeah. Yeah, I suppose if it's not something as a, uh, uh, if it's not, it's not something if you haven't come into contact with somebody that, you know, as a, as a, not a medical person at all, if you haven't come into contact with somebody who their child has had it, then I suppose it's something that you would just be completely oblivious to, um, obviously in the medical world, you would know all about it but not for not for us meals that aren't. So basically for, for, I think uh uh what, what, what causes delay usually in, in uh in Children is that uh the parents uh are not particularly keen or, or, or not thinking or, or thinking that it's just something that will uh tide over. So that causes potential delay or sometimes the first doctor who sees it was not thinking about it. So uh gives uh medication that might not work and later on the the condition progresses and by the time it's referred to an appropriate institution or, or to the surgeon, uh there's already progression or a more severe condition. So yeah, and is in the Philippines, is it dealt with quite quickly? So if a if a child comes in with that, is it dealt with quite quickly or is there a long waiting list or is it? So this is I've been as, as an LM IC O low to mid income country. I'm sure some of the participants here are also from the same bones. The problem is that uh in LM I CS there is usually uh limit limited resources. So there are limited institutions, limited number of institutions where they can go to. Yeah. And these institutions are usually uh government institutions that have a lot of other patients. So there's, there's uh and the health human resource for, for example, the pediatric surgeon, we are also far and few. Yeah. Yeah. So, I mean, it, it's a whole problem sometimes and even though in, in, in probably in high income countries it would be dealt with easily. Mhm. I, in the LM IC setting it becomes a problem. There's much delay. Mhm. Such that the, as compared probably to high income plan is there is a higher incidence of morbidity and mortality for these conditions, which really shouldn't be the case. Yeah. And is a child in any discomfort or pain or anything like that or uh for, for, for the first part, the pain is actually the most common presenting symptom because of the, the, the bowels are trying to, to move but there's an obstruction. So they have this crampy colic abdominal pain, uh inters with uh times of uh relative come. Yeah. But as the condition progresses, you have those other problems that are, and I suppose if it is colicky, most parents assume their baby is going to be colicky anyway. So maybe they dismiss that, that they've just got a really colicky baby, um, and dismiss it until it's then worse, I suppose. So, does anyone have any questions? The, after the col it happens, the child sometimes becomes calm. They think it, um, it's over but then it again happens. Yeah. Yeah. Ok. So, I don't think we have any questions. No one's putting anything in. Um, so they're either, they're either eating their lunch or their dinner or, uh, they haven't got any questions. So what I'm gonna do, um, I think we've given it enough time for questions to appear. Um, so we will say goodbye to our delegates. Now, like I said, in a few, when the clock hits, er, the hour, you will get your feedback form in your inbox. So please fill that out and I will be passing it on to Jose and you can actually, um, get your 10 certificate then on your med account. So if that's us, I'm going to wish everyone, uh, I'm going to say goodbye to everyone and hopefully we'll see you at another medical education event. Thank you. Hope, uh I was of help to everybody and you learned something and thank you very much for, uh, thanks for helping us. Thank you for coming along. It was greatly appreciated. Thank you. Thank you.