00:01
Welcome back.
00:02
Thanks for joining me
on this discussion of intussusception
in the section of pediatric surgery.
00:10
Intussusception,
why does it happen?
We don't exactly know,
but there are some theories.
00:17
Most intussusception are idiopathic
and they occur at the
terminal ilium to the cecum.
00:23
This is also known as ileocolic.
00:26
This is the type that often
happen in infants and toddlers.
00:30
Here, you see another anatomy picture
of the terminal ilium
actually invaginating itself into the colon.
00:39
There may be some truth behind
probably lymph node hypertrophy.
00:44
Why?
Because commonly this follows
a recent respiratory infection.
00:50
We think with a systemic infection
that the lymph nodes may actually hypertrophy
and creating itself a lead point
or idiopathic ileocolic intussusception.
01:03
Here is a picture of, intraoperatively,
what we find in intussusception.
01:07
As you can see from this image,
a segment of small intestines
is invaginating into another.
01:13
This is the reason why
it may cause obstruction
and/or abdominal pain.
01:20
How does the intestines become
ischemic during this process?
I’ll show you using this image
and the next few slides.
01:29
First,
recognize that the lymphatic obstruction
is actually what occurs first.
01:34
Commonly, when people think
about intestinal ischemia,
they think that the arterial
supply is actually compromised first.
01:41
But there's a protective mechanism
whereby the arterial blood pressure
is usually the last to go.
01:47
After lymphatic obstruction,
the venous side drainage is obstructed.
01:52
And now you can imagine,
with lymphatics and venous obstruction,
the inflow
or arterial supply
is subsequently obstructed.
02:01
This is like a multiple car accident.
02:04
There's going to be a pylon.
02:06
And towards the end of that
scenario is arterial obstruction,
and subsequently ischemia.
02:12
This is also a reason
why, intraoperatively,
you often see ischemic bowel very dilated.
02:17
That's because of the venous
and lymphatic congestion.
02:22
Let's take a look at the schematic
of what happens during an intussusception.
02:26
On the left side of the screen,
as we already previously discussed,
are potential etiologies of intussusception.
02:33
Remember,
the vast majority of these
are still idiopathic in kids.
02:37
Enlarged Peyer’s patches,
particularly as associated with
a viral upper respiratory infection,
increases the chance of a lead point.
02:45
Additionally,
some children may have
an inflamed appendix,
demonstrated in the left side of the screen.
02:51
As you can see on the
right top half of the screen,
the intestines proximally actually invaginates
into the proximal small bowel.
02:59
And as a result,
in the right lower quadrant of the screen,
you notice that the intussusceptum,
or the portion of the bowel
that enters the proximal bowel,
now appears edematous.
03:10
Upstream of this edematous bowel
can present with small bowel obstruction.
03:15
As you can imagine,
when venous and lymphatic drainage is obstructed,
it may need to ultimately arterial obstruction
and subsequent bowel ischemia.
03:25
Remember,
lead points may not
always be present.