Urinary biofeedback therapy in children with dysfunctional voiding

Levent CANKORKMAZ, Gökhan KOYLUOĞLU, Mehmet Serif ARSLAN , presented as a poster presentation at the Cengiz GÜNEY 27th National Congress of Pediatric Surgery (30 September-3 October 2009, Malatya). Cumhuriyet University Faculty of Medicine, Department of Pediatric Surgery, Sivas. Presented at the 27th National Pediatric Surgery Congress (September 30- October 3, 2009, Malatya, Turkey). Department of Pediatric Surgery, Cumhuriyet University Faculty of Medicine, Sivas, Turkey. Communication (Correspondence): Dr. Levent Cankorkmaz. Cumhuriyet University Faculty of Medicine, Department of Pediatric Surgery, 58140 Sivas, Turkey. Tel: +90 – 346 – 258 12 69 Fax (Fax): +90 – 346 – 258 13 05 e-mail (e-mail): lcankorkmaz@gmail.com OBJECTIVE Intussusception is the telescopic insertion of the proximal intestinal segment into the distal segment. The aim of the study is to share our pneumatic reduction experiences based on our intussusception cases. MATERIALS AND METHODS The files of 118 patients who were treated with the diagnosis of intussusception in the pediatric surgery clinic between 1996 and 2008 were re-examined in terms of age, gender, month of admission, findings, diagnosis/treatment methods, type of intussusception and leading points, and the findings were discussed. RESULTS: Of the patients, 76 (64%) were male, 42 (36%) were female, with a mean age of 25±34 months (range, 3-180 months). The most common complaints on admission; abdominal pain, restlessness, vomiting and bloody stools. Of the invaginations, 109 (92.3%) were ileocolic, 7 (6%) were ileoileal, and 2 (1.7%) were colocolic. Fifty-three cases (45%) were treated non-surgically, the remaining cases were treated surgically. No mortality was observed in any of the patients. Leading point was detected in 13 of 65 operated patients. The success rate of pneumatic reduction was 86%. While the onset of symptoms and bloody stool did not affect the success of pneumatic reduction, the success rate decreased with age. CONCLUSION Intussusception is a pathology that can be easily treated with non-surgical methods if diagnosed early. We think that pneumatic reduction can be tried as the first choice in all cases without perforation and peritonitis findings in the pediatric age group. Keywords: Non-surgical treatment; childhood; intussusception; pneumatic reduction. BACKGROUND Intussusception is defined as telescopic insertion of the terminal ileum in to the colon after the cecum and colon. The aim of this study was to present our experience in pneumatic reduction of intussusception. METHODS In our study, 118 intussusception cases treated between 1996 and 2008 were analyzed. Age, gender, admission time, diagnostic/treatment methods, types of intussusception including leading point, and postoperative complications were evaluated. RESULTS Of these patients, 76 (64%) were male and 42 (36%) were female. Mean age was 25±34 months (3-180 months). The most common clinical presentations were vomiting, abdominal pain/irritable crying and bloody stools. Intussusceptions were ileocolic in 109 (92.3%) patients, ileoileal in 7 (6%) patients, and colocolic in 2 (1.7%) patients. No mortality was noted. Fifty-three patients (45%) were treated by nonoperative reduction whereas the remainder were treated surgically. Among 65 patients operated, 13 leading points were detected. Pneumatic reduction success rate was 86%. Age significantly reduced the pneumatic reduction success rate; however, the duration between the beginning of symptoms and hospital admission and bloody stool were not effective. CONCLUSION Intussusception can be treated by non-operative methods when diagnosed early. Our results suggest that pneumatic reduction of intussusception in the pediatric population should be considered as a first choice. Key Words: Non-operative treatment; childhood; intussusception; pneumatic reduction. 364 July – July 2010 Ulus Travma Emergency Surgical Journal Invagination is the telescopic insertion of the proximal intestinal segment into the distal segment. It is the most common cause of intestinal obstruction in children between 3-24 months.[1-3] Its incidence is 1-4 per 1000 live births and is twice as common in men. According to their formation forms, it is divided into four as leading point, chronic, postoperative, and idiopathic intussusception. [1,2,4,5] Abdominal pain, vomiting and bloody stool are the most common symptoms (60-90%) in patients. .[6,7] Invagination can be treated with minimally invasive methods when diagnosed early, while complications such as intestinal necrosis, perforation and sepsis may develop in those with late diagnosis. The general approach in the treatment of intussusception is to try one of the non-surgical treatments accompanied by fluoroscopy with barium, air (pneumatic) or saline (SF)/radiopaque liquid (hydrostatic) or ultrasonography (USG) with SF.[8] MATERIALS AND METHODS The study included 118 cases treated with the diagnosis of intussusception in our clinic between 1996 and 2008. The file records of the cases were retrospectively analyzed in terms of age, gender, complaints (abdominal pain, vomiting and bloody stool), findings (bloody stool, abdominal mass, restlessness), month of admission, diagnosis and treatment methods, type of intussusception, gripping point and postoperative complications. analyzed and the findings were discussed. In the pneumatic reduction process, air was introduced from the rectum at a rate not exceeding 120 mmHg. Sedation was not applied during the procedure. When the passage of air into the small intestines was seen on the scopy, it was decided that the procedure was successful, and control USG was performed and the patients who achieved reduction were followed up for 24-48 hours. Failure to see the air passage into the small intestines even though the inhaled air did not advance at all or a little advance, or an invaginated segment in the control USG was considered as a failure. Data are presented as mean ± standard deviation (SD). Students t test and Mann-Whitney U test were used as statistical methods, p<0.05 was accepted as the significance limit. RESULTS: Of the cases, 76 (64%) were male, 42 (36%) were female, and the mean age was 25±34 months (range, 3-180 months). In 96% of the cases, at least one of the symptoms of colic abdominal pain or restlessness, bile/non-bilious vomiting and bloody stool was present. Of the cases, 34 (28%) presented in spring, 37 (32%) in summer, 28 (24%) in autumn, and 19 (16%) in winter. On physical examination, abdominal mass was detected in 27 cases (23%). In standing direct abdominal radiographs (ADBG), air-fluid levels in the small intestines were observed in 25 cases (20%). In 94 cases (80%), the diagnosis of intussusception was made by USG. Two of the five cases with suspicious findings on USG were diagnosed with pneumatic enema and reduced in the same session. Of our cases, 109 were ileocolic, seven were ileoileal, and two were colocolic invagination. Direct surgery was performed on 57 patients who presented with signs of peritonitis, poor general condition or when the appropriate mechanism and personnel could not be provided for non-surgical reduction. Non-surgical reduction was tried first, regardless of the onset of symptoms, in 61 patients with a suitable general condition, who applied during the period when there was a suitable mechanism for non-surgical treatment. Barium reduction was attempted in one case, hydrostatic reduction in two cases, and pneumatic reduction in 58 cases. While hydrostatic reductions with barium and USG were successful, reduction was achieved in 50 of 58 cases (86.2%) in whom pneumatic reduction was attempted. Surgery was performed in eight cases that could not be reduced. The number of cases accompanied by bloody stool was 45 (38.1%). There was no difference between the success rates of pneumatic reduction in cases with or without bloody stool (p=0.34). While the mean duration of symptoms was 43.7±31.6 hours in patients who underwent direct surgery without attempting non-surgical reduction (n=57), it was 19.8±16.5 hours in patients who were successful after non-surgical reduction (n=53) (p). <0.001). The mean symptom duration of the eight patients who underwent surgery because pneumatic reduction was attempted and failed, was 22.3±16.9 hours, and it was shorter than the mean symptom duration of the patients who underwent direct surgery (p=0.028); There was no difference between the mean symptom duration of the patients who were successful after non-surgical treatment (p=0.68). In one case, the second pneumatic reduction was successful due to the recurrence of intussusception. Leading point causing intussusception was detected in 13 (20%) of 65 operated cases. This rate corresponded to 11% of our total cases. The causative agent was lymphadenopathy in six cases, polyps in two cases, Henoch-Schonlein purpura in two cases, Meckel’s diverticulum in two cases, and ectopic pancreas in one case. Peutz-Jeghers syndrome was diagnosed in one of the patients with polyps. Two patients had a history of blunt abdominal trauma, but it could not be fully associated with intussusception. Postoperative intussusception developed in both patients, one of whom had cleft palate-lip and the other one had abdominal surgery. Although the first patient was diagnosed with intussusception by USG, the preoperative diagnosis of the second patient was brit ileus. Manual reduction was performed in both patients. The mean hospital stay in patients who underwent successful non-surgical reduction was 3.02±2.55 days, 5.93±2.01 days in patients who underwent surgical reduction, and the length of stay was shorter in patients who underwent pneumatic reduction. 16 Issue – No. 4 365 cases of childhood intussusception and pneumatic reduction were counted (p<0.001). The hospital stay was even longer (7.88±6.08 days) in eight patients who underwent surgery because pneumatic reduction was unsuccessful. There were 18 cases over the age of five in our series. Pneumatic reduction was attempted in five of these cases, while complete reduction was achieved in three cases, and surgery was decided because partial reduction was achieved in two cases. Hospital stay was 5.9±2.0 in patients who underwent manual reduction; in patients who underwent non-surgical reduction, it was 3.0±2.5 and the difference was significant (p<0.001). In the postoperative period, perforation and resection anastomosis occurred in one of the cases who underwent manual reduction, and anastomotic leakage occurred in one of the cases. Perforation developed in one of our cases after pneumatic reduction (2%). DISCUSSION 64% of the cases in our series were male and 36% were female, their mean age was 25±34 months, and their mean age and gender ratios were consistent with the literature. It has been reported that the first peak of intussusception occurs in spring and summer due to enteritis, and the second peak occurs in winter months due to respiratory tract infections.[6,9] There are also authors who say that this impression is purely coincidental.[10,11] In our series, the highest incidence of admission is in the spring and summer months. it was in the summer. Approximately 90% of the cases are idiopathic, and 5-60% of them have a recent history of gastroenteritis or upper respiratory tract infection.[6,12] While a trailing point is encountered in 3% of intussusceptions under one year of age, this rate is 57% in those older than five years of age. in adults it is 75-90%.[13] In our series, the leading point was detected in 20% of the operated cases and 11% of the total cases. In the literature, about 80-90% of the cases are ileocolic, 15% are ileoileal and 2-3% are colocolic.[14] 92.3% of our cases were ileocolic, 6% ileoileal, and 1.7% colocolic. On USG, pseudokidney (pseudokidney) or target sign appearance consisting of concentric lamellar echogenic structures belonging to invaginated intestinal segments is typical. The sensitivity of USG in the diagnosis of intussusception is 98-100%, its specificity is 88%, and its negative predictive value is 100%.[15-17] 90% of the cases in our series were diagnosed by USG, which is consistent with the literature. Although dilated bowel loops can be observed in ADBG, it is not a finding specific to intussusception. In recent years, non-surgical reduction has been recommended in suitable cases for intussusception. Success rates are between 36 and 85%.[1,2,14,18] It has been reported that this rate decreases in children younger than three months or older than five years, whose symptoms started before 48 hours, and who have bloody stools and obvious signs of dehydration.[7,19] ] While bloody stool is the first finding in half of the cases, it is seen 2-12 hours after the onset of intussusception in most of the cases.[13] Bloody stool was present in 45 of our cases, and this finding did not affect the success rate of non-surgical treatment. Therefore, we think that bloody stool alone does not reduce the success rate of non-surgical treatment. In non-surgical treatment, we prefer pneumatic reduction, which is a cheap, safe, effective, easy to apply and learn method in our clinic.[20] Reduction is monitored by fluoroscopy while air is introduced into the rectum with a pressure not exceeding 80-120 mmHg.[18,21] The success rate is between 80-92%.[22-25] Absolute contraindication for pneumatic reduction is only peritonitis and perforation. In hydrostatic and pneumatic reductions, the risk of perforation is 0.1-3%, and the risk of recurrence is 6-10%.[1,14,18] The recurrence rate is 10% in conservative surgical treatment.[26]Compared to barium reduction, the duration of fluoroscopy is shorter, and the rate of recurrence and perforation is low.[27,28] While the absence of radiation exposure and high success is a positive feature in USG-guided hydrostatic reduction, it is a disadvantage that an experienced radiologist is required for USG.[29] Success was achieved in hydrostatic reduction with barium in one case and with USG in two cases. Tander and friends[30] They reported an 80% success rate in USG-guided hydrostatic reduction. In our study, reduction was achieved in 50 (86.2%) of 58 patients who were tried for pneumatic reduction. After the recurrence of intussusception in one of the cases, a second pneumatic reduction was also successful. In the literature, it is stated that in case of recurrence, non-surgical reduction can be tried again if the patient’s clinical condition is appropriate.[2,14,18] Manual reduction was performed in six of eight patients in whom pneumatic reduction was unsuccessful. There was no difference between the onset of symptoms in patients who were successful in pneumatic reduction and the onset of symptoms in those who were unsuccessful. Those who underwent non-surgical reduction stayed in the hospital approximately three days shorter than those who underwent surgery (p<0.001). Postoperative intussusception occurs in the first week after surgery. Although it is mostly seen after abdominal surgeries, it can also develop after extra-abdominal surgeries. It is difficult to differentiate from postoperative ileus. [1,31] One of our two postoperative intussusception cases was cleft palate-lip and the other was abdominal surgery. Although the first patient was diagnosed with intussusception by USG, the preoperative diagnosis of the second patient was brit ileus, and the patients underwent manual reduction. Saxena et al.,[32] stated in our series that pneumatic reduction with a high success rate in ileocolic intussusceptions can also be successful in cases of ileoileal intussusception with an early diagnosis. Ulus Trauma Emergency Surgery Journal 366 July – July 2010 In addition to the non-surgical treatment option of intussusception, laparoscopic surgery is one of the methods discussed. In the series of Kia et al. in which they compared open surgery and laparoscopic surgery, they did not detect a significant difference between the duration of the operation, the cost, the length of hospital stay, and the complication rate.[33] There are publications stating that laparoscopic surgery is a safe and effective treatment in stable cases that do not respond to non-surgical treatment.[33,34] We did not have any cases treated laparoscopically in our series. Pneumatic reduction in intussusception reduces the rate of surgery; It is a safe method with a high success rate in the pediatric age group. Although there are factors that can negatively affect the success rate, we think that it can be the first choice when there is no contraindication. SOURCES 1. Hamby LG, Fowler CL, Pokony WJ. intussusception In: Donellan WL, editor. Abdominal surgery of infancy and childhood. 2nd edition. Luxembourg: Harwood academic publishers; 2001. p. 42/1-42/19. 2. Beasly SW, Hutson JM, Auldist AW. Essential pediatric surgery. 1st ed., London: Arnold; 1996. p. 45-51. 3. Tangi VT, Bear JW, Reid IS, Wright JE. Intussusception in Newcastle in a 25 year period. Aust NZJ Surg 1991;61:608-13. 4. Page AC, Price JF, Salisbury JR, Howard ER, Karani J. Chronic intussusception. Arch Dis Child 1990;65:134-5. 5. Kilic N, Kiristioglu I, Kirkpinar A, Dogruyol H. A very rare cause of intestinal atresia: intrauterine intussusception due to Meckel’s diverticulum. Acta Paediatr 2003;92:756-7. 6. Aschcraft K. Intussusception. In: Aschcraft K, Holter T, editors. Pediatric surgery. Philadelphia: WB Saunders Co; 1993. p. 416-9. 7. Yang CM, Hsu HY, Tsao PN, Chang MH, Lin FY. Recurrence of intussusception in childhood. Acta Paediatr Taiwan 2001;42:158-61. 8. Kırıştıoğlu I. Treatment approach in invaginations. Current Pediatrics 2004;2:131-3. 9. Crankson SJ, Al-Rabeeah AA, Fischer JD, Al-Jadaan SA, Namshan MA. Idiopathic intussusception in infancy and childhood. Saudi Med J 2003;24:18-20. 10. Hutchison IF, Olayiwola B, Young DG. Intussusception in infancy and childhood. Br J Surg 1980;67:209-12. 11. Mulcahy DL, Kamath KR, de Silva LM, Hodges S, Carter IW, Cloonan MJ. A two-part study of the aetiological role of rotavirus in intussusception. J Med Virol 1982;9:51-5. 12. Ong NT, Beasley SW. The leadpoint in intussusception. J Pediatr Surg 1990;25:640-3. 13. Virgo AC. Surgical and urological diseases of infants and children. 1st edition. Ankara: Palme; 2006. 14.Zorludemir Ü, Yücesan S and Olcay I. Invagination: Clinical evaluation of 168 patients. Journal of Pediatric Surgery 1987;2:81-9. 15. Byrne AT, Geoghegan T, Govender P, Lyburn ID, Colhoun E, Torreggiani WC. The imaging of intussusception. Clin Radiol 2005;60:39-46. 16.Munden MM, Bruzzi JF, Coley BD, Munden RF. Sonography of pediatric small-bowel intussusception: differentiating surgical from nonsurgical cases. AJR Am J Roentgenol 2007;188:275-9. 17. Tiao MM, Wan YL, Ng SH, Ko SF, Lee TY, Chen MC, et al. Sonographic features of small-bowel intussusception in pediatric patients. Acad Emerg Med 2001;8:368-73. 18.Meyer JS, Dangman BC, Buonomo C, Berlin JA. Air and liquid contrast agents in the management of intussusception: a controlled, randomized trial. Radiology 1993;188:507-11. 19.Ikeda T, Koshinaga T, Inoue M, Goto H, Sugitou K, Hagiwara N. Intussusception in children of school age. Pediatr Int 2007;49:58-63. 20. Kirks DR. Air intussusception reduction: “the winds of change”. Pediatric Radiol 1995;25:89-91. 21.Shiels WE 2nd, Maves CK, Hedlund GL, Kirks DR. Air enema for diagnosis and reduction of intussusception: clinical experience and pressure correlates. Radiology 1991;181:169-72. 22.Lui KW, Wong HF, Cheung YC, See LC, Ng KK, Kong MS, et al. Air enema for diagnosis and reduction of intussusception in children: clinical experience and fluoroscopy time correlation. J Pediatr Surg 2001;36:479-81. 23. Sandler AD, Ein SH, Connolly B, Daneman A, Filler RM. Unsuccessful air-enema reduction of intussusception: is a second attempt worthwhile? Pediatr Surg Int 1999;15:214-6. 24. Hadidi AT, El Shal N. Childhood intussusception: a comparative study of nonsurgical management. J Pediatr Surg 1999;34:304-7. 25.Ein SH, Alton D, Palder SB, Shandling B, Stringer D. Intussusception in the 1990s: has 25 years made a difference? Pediatr Surg Int 1997;12:374-6. 26.Çalışkan B, Güven A, Atabek C, Demirbağ S, Sürer İ, Öztürk H. Childhood invaginations. Gulhane Medical Journal 2007; 49:236-9. 27. Rubí I, Vera R, Rubí SC, Torres EE, Luna A, Arcos J, et al. Air reduction of intussusception. Eur J Pediatr Surg 2002;12:387-90. 28.Bai YZ, Qu RB, Wang GD, Zhang KR, Li Y, Huang Y, et al. Ultrasound-guided hydrostatic reduction of intussusceptions by saline enema: a review of 5218 cases in 17 years. Am J Surg 2006;192:273-5. 29.Guo JZ, Ma XY, Zhou QH. Results of air pressure enema reduction of intussusception: 6,396 cases in 13 years. J Pediatr Surg 1986;21:1201-3. 30.Tander B, Baskin D, Candan M, Basak M, Bankoglu M. Ultrasound guided reduction of intussusception with saline and comparison with operative treatment. Ulus Journal of Trauma Emergency Surgery 2007;13:288-93. 31.Dammert G, Votteler TP. Postoperative intussusception in the pediatric patient. J Pediatr Surg 1974;9:817-20. 32. Saxena AK, Seebacher U, Bernhardt C, Höllwarth ME. Small bowel intussusceptions: issues and controversies related to pneumatic reduction and surgical approach. Acta Paediatr 2007;96:1651-4. 33.Kia KF, Mony VK, Drongowski RA, Golladay ES, Geiger JD, Hirschl RB, Coran AG, Teitelbaum DH. Laparoscopic vs open surgical approach for intussusception requiring operative intervention. J Pediatr Surg 2005;40:281-4. 34.Bailey KA, Wales PW, Gerstle JT. Laparoscopic versus open reduction of intussusception in children: a single-institution comparative experience. J Pediatr Surg 2007;42:845-8.

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