| Research backgroundAt present,ultrasound is the preferred method for the examination of intussusception,and the diagnostic accuracy is very high.However,the diagnostic accuracy for the primary cause of some secondary intussusception is very low.This leads to repeated enema operations,and extra pain for children.It is difficult to evaluate the degree of intestinal wall ischemia in intussusception.Clinically,enema or surgical treatment is often decided according to the course of disease and the general health condition of the child,which could be blind and uncertain at times.Although CDFI can evaluate intestinal wall blood flow,it is insensitive to slow blood flow,resulting in the misjudgment of non-necrotic intestine as necrotic.Consequently the child receives direct surgery without being offered enema to reverse intestinal viability,thus overtreatment.Therefore,a large number of researchers are exploring a method to accurately evaluate the degree of intestinal wall ischemia to guide the selection of clinical treatment,so as to avoid blind enema and surgical overtreatment.In the current study,the clinical characteristics of children undergoing intussusception surgery were analyzed to improve the understanding of the etiology of intestinal ischemia necrosis and secondary intussusception.At the same time,SMI technique was used to evaluate the blood supply in the intussusception mass to predict the intestinal survival and guide the clinical treatment and follow-ups.Purpose1.Retrospective analysis of clinical characteristics of intussusception in children:In recent years,Anhui Provincial Children's Hospital has retrospectively analyzed the clinical data of pediatric intussusception surgery.Through the understanding of the general characteristics of the patients and ultrasound,we found that the main cause of deepening ischemia of the intestinal wall and secondary intussusception is the preoperative intestinal activity.These provide reference for the selection of clinical treatment,avoiding overtreatment,and reducing ineffectiveness.2.Evaluation of functional status of bowel wall by SMI:To explore the feasibility of a new superb microvascular imaging technology for evaluating the blood flow in intussusception mass and its guiding value for clinical treatment selection.Materials and Methods1.Retrospective analysis of clinical characteristics of intussusception in children:Retrospective analysis was performed on the data of 120 cases of intussusception treated and finally operated in Anhui Children's Hospital from January 2017 to December 2019.Samples were divided into the intussusception with intestinal necrosis group and the intussusception without intestinal necrosis group.Retrospective analysis was performed on two groups regarding gender,age,duration of disease(time from onset to treatment),with or without vomiting,bloody stool,secondary factors,intestinal expansion,abdominal cavity effusion,bowel wall thickening,sleeve lymph nodes,sleeve effusion,blood flow,nested in the bowel wall or not,the sleeve length to diameter and concentric circles around,diameter and concentric diameter before and after surgery.Meanwhile the etiological distribution and sonographic features of secondary intussusception were analyzed.2.Evaluation of functional status of bowel wall by SMI:A total of 126 children with intussusception treated in the First Affiliated Hospital of Anhui Medical University and Anhui Children's Hospital from January 2020 to February 2021 were collected,and their clinical and ultrasonic examination data were recorded.According to the general principles of clinical experience,the patients were divided into two groups:the intussusception group(n=60)which could be reduced by itself within 2 hours and the intussusception group(n=66)which could not be reduced by itself within 2 hours.Clinical indicators(including gender,age,abdominal pain,abdominal distension,diarrhea,constipation,vomiting,fever,and hematoecia)and ultrasonic parameters(including mesenteric lymph nodes,lymph nodes inside the sleeve,long diameter of the sleeve,left and right diameter of the sleeve,anterior and posterior diameter of the sleeve)from these two groups were compared.Meanwhile SMI technology was used to image all intussusception masses.The region of interest was manually delineated on the concentric cross-section plane to measure the blood flow in the intussusception masses,and the values of Pixels,ROI and VI were recorded.Meanwhile,the blood flow in the intussusception masses was classified.Masses without blood-flow signal were defined as SMI0 level.Masses with dotted,thin rod blood flow signals were defined as SMI?level.Masses with linear and elongated blood flow signal were defined as SMI?level.Masses with meshy or dendritic blood flow signals were defined as SMI?level.The non-self-reduction group(61cases)underwent ultrasound-guided water pressure enema reduction and was divided into two subgroups according to enema pressure:the low-pressure subgroup(8?10k Pa)and the high-pressure subgroup(11?13k Pa).Low-pressure enema(8?10k Pa)was first implemented and the results recorded.Patients who failed low-pressure enema received increased pressure(11?13k Pa)and their results were recorded.In the mean time,the enema time was recorded.Success rates of enema reduction under different blood flow and pressure levels were then compared.Results1.Retrospective analysis of clinical characteristics of intussusception in children:among the 120 patients undergoing intussusception surgery,97 cases(80.83%)were primary and 23 cases(19.17%)were secondary.There were 72 cases(60%)of intussusception without intestinal necrosis,including 52 males(72.22%)and 20 females(27.78%).The median age was 24.00(14.00-36.00)months.There were 48 cases of intussusception with intestinal necrosis(40%),including 37 cases of males(77.08%)and 11 cases of females(22.92%).The median age was 3.00(6.50?9.50)months,and the age difference between the two groups was statistically significant(Z=5.890,P<0.001).The average course of disease was(42.23±18.06)hours for the necrotic group and(29.83±19.71)hours for the non-necrotic group,and the difference between the two groups was statistically significant(t=3.488,P<0.001).The proportion of stool blood in the necrotic bowel group was 70.83%(34/48),and that in the non-necrotic bowel group was 12.50%(9/72),with statistical significance(?~2=42.622,P<0.001).The occurrence of vomiting in the necrotic bowel group was 56.25%(27/48),and that in the non-necrotic bowel group was 19.44%(14/72).The difference between the two groups was statistically significant(?~2=17.345,P<0.001).The secondary factors accounted for33.33%(16/48)in the intestinal necrosis group and 9.72%(7/72)in the non-intestinal necrosis group,and the difference was statistically significant(?~2=42.622,P<0.001).The long diameter of the sleeve was 7.03±2.01 cm in the necrotic group and 5.88±1.08cm in the non-necrotic group,and the difference was statistically significant between the two groups(t=3.653,P<0.001).The rate of intestinal dilatation was 83.33%(40/48)for the necrotic group and 8.33%(6/72)for the non-necrotic group,and the difference was statistically significant between the two groups(?~2=68.531,P<0.001).The percentage of peritoneal effusion in the necrotic group was 87.50%(42/48),and that in the non-necrotic group was 23.61%(17/72).The difference between the two groups was statistically significant(?~2=47.035,P<0.001).The proportion of thickening intestinal wall in the necrotic group was 77.08%(37/48),and that in the non-necrotic group was41.67%(30/72),the difference between the two groups was statistically significant(?~2=14.649,P<0.001).The proportion of sleeve effusion in the necrotic group was43.75%(21/48),and that in the non-necrotic group was 13.89%(10/72).There was a statistically significant difference between the two groups(?~2=13.403,P<0.001).Among the 120 children,21 cases were directly operated,accounting for 17.5%;99cases were operated after enema failure,accounting for 82.5%;66 cases showed blood flow in the intestinal wall;54 cases showed no blood flow in the intestinal wall;48 of54 cases had intestinal necrosis,which were confirmed by operation,accounting for88.89%;6 of 54 cases had no intestinal necrosis,which were confirmed by operation,accounting for 11.11%.There were no significant differences in gender,the presence of lymph nodes in the sleeve,the left and right diameters of concentric circles and the anteroposterior diameters between the two groups(P>0.05).The secondary etiology included Meckel's diverticulum in 6 cases(26.09%),intestinal duplication in 4 cases(17.39%),intestinal polyps in 7 cases(30.43%),lymphoma in 3 cases(13.04%),adenomyoma in 1 case(4.35%),and allergic purpura in 2 cases(8.70%).Characteristics of ultrasonographic images of secondary intussusception showed that during secondary intussusception of Meckel's diverticulum,the morphology of Meckel's diverticulum in the sleeve was changeable,sometimes diverticulum in anechoic,and sometimes only diverticulum sample high echo visible.In intestinal lymphoma secondary to intussusception,the intestinal wall was inhomogeneously thickening with very low echo,and the intestinal wall structure was unclear.Intestinal polyp secondary to intussusception was accompanied with solid mass within the sleeve connected with the intestinal wall,and multiple small anechoic can be seen in the mass.CDFI showed radiating blood flow signal in the mass.When there was intestinal necrosis,CDFI showed no blood flow signal in the polyp.In the case of intussusception secondary to intestinal duplication,there was circular anechoic appearance in the sleeve,which was similar to the structure of intestinal obstruction and the wall of digestive tract.2.Evaluation of functional status of bowel wall by SMI:SMI imaging was implemented successfully on all 126 cases of intussusception.Among the 66 cases in the group of non-spontaneous reduction,large intestine intussusception accounted for 59/66 and small intestine intussusception 7/66.In the 60 cases of self-reduction group,large intestine intussusception accounted for 3/60 and small intestine intussusception accounted for 57/60.In the non self reduction group,5 cases were treated by direct operation,and the blood flow signal was SMI 0 level.All of the 5 patients had intestinal necrosis confirmed by operation.61 patients who could not reset by themselves were treated with enema,4 cases of which failed and recovered well after surgical treatment.The mean value of intussusception VI in the group without spontaneous reduction was9.12±2.19,and the mean value of intussusception VI in the group with spontaneous reduction was 15.56±4.52,and the difference between the two groups was statistically significant(t=9.744,P<0.001).SMI?level consisted 6 cases,the average value of VI was 1.65±0.65.When the pressure was 8?10 k Pa,the successful reduction rate was33.33%.When the pressure was 11?13 k Pa,the successful reduction rate increased to50%;SMI?level consisted 14 cases,the VI of which was 3.83±0.69.When the average pressure was 8?10 k Pa,the successful reset rate was 35.71%.When the pressure increased to 11?13 KPa,the successful reset rate increased to 92.86%;SMI?included 41 cases,the VI of which was 9.02±2.56.When the average pressure was8?10 k Pa,the successful reset rate was 70.73%.When the pressure increased to 11?13k Pa,the successful reset rate increased to 100%.Under the reduction pressure of 8?10k Pa,the successful reduction rate increased linearly with the increase of blood flow classification and VI value(?~2=6.081,P=0.014).Under the reduction pressure of 11?13k Pa,the successful reduction rate increased linearly with the increase of blood flow grade and VI value(?~2=9.736,P=0.002).Blood flow grading in intussusception mass was positively correlated with VI value(r=0.847,P=0.000),and VI value was negatively correlated with the time taken for enema reduction(r=-0.783,P=0.000).There was a negative correlation between the blood flow grade and the time of enema reduction(r=-0.813,P=0.000).The successful reduction rate was 59.02%under the reduction pressure of 8?10 k Pa,and 84%under the reduction pressure of 11?13 k Pa.The difference in the reduction rate between the two groups was statistically significant(?~2=4.952,P=0.026).There was no statistical significance in gender,age and sleeve length diameter between the low pressure group and the high pressure group(P>0.05).Conclusion1.Retrospective analysis of clinical characteristics of intussusception in children include:children at young age,long course of disease,vomiting,blood in stool,secondary factors,long diameter of the sleeve,fluid in the sleeve,abdominal fluid,intestinal wall thickening,intestinal dilatation.CDFI showed no blood flow in the intestinal wall,and recurrent nodal intussusception children were susceptible to intestinal necrosis.Children with such clinical characteristics should be treated as soon as possible to avoid the worsening vitality of the intestine and improve the prognosis.CDFI can predict intestinal wall ischemia well,but there is still a certain misdiagnosis rate.2.Evaluation of functional status of bowel wall by SMI:SMI technique can be used to quantitatively evaluate the blood supply in the intussusception of large intestine and small intestine intussusception mass.It objectively evaluates the vitality of the intussusception,guides clinical treatment and follow-ups,and avoids blind enema and excessive surgical treatment. |
PDF Full Text Request