A research report submitted to the Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, in partial fulfilment of the requirements for the degree of Master of Medicine in Diagnostic Radiology Johannesburg, 2017 / INTRODUCTION: Intussusceptions may cause significant morbidity and mortality if not treated timeously. One method of conservative management is pneumatic reduction, the outcome of which is dependent on a number of factors. AIM: To determine the proportion of children with intussusception who have evidence of bowel obstruction on initial abdominal radiograph, and the failure rate of pneumatic reduction in patients with and without bowel obstruction. The study also looked into whether there were any associations between the radiological presence or absence of bowel obstruction and pneumatic reduction outcome, the finding of necrotic bowel at surgery, and CRP and WCC levels. METHOD: A retrospective study was performed using an existent paediatric surgery intussusception database. Three different readers read the baseline abdominal radiographs and subjectively determined whether bowel obstruction was present or not. Treatment choices, outcomes of the pneumatic reduction, and if available, clinical presentation and lab results were captured from the patient’s discharge summary and NHLS portal. RESULTS: A sample size of 45 patients was studied. The median age of presentation was 7 months, with 83% of the patients having had symptoms for 3 days or less. 80% of patients had bowel obstruction on initial X-ray, and of these patients, only 17% had successful pneumatic reduction. No significant association was found between bowel obstruction and the presence/absence of necrotic bowel. 64% had their symptoms documented, and only 26 % and 42 % had CRP and WCC documented respectively, which did not meet sample size requirements. CONCLUSIONS: Even though a strong association was shown between evidence of bowel obstruction and pneumatic reduction outcome, the sample study was too small to make between-group comparisons. Due to this limitation, it is recommended that further investigation be done, possibly by including patients from other South African tertiary hospitals in order to obtain statistically significant results. / MT2018

In view of the recent implementation of a publicly funded rotavirus vaccination program in Ontario, we undertook studies to help guide the design of a safety evaluation of the vaccine with respect to intussusception. We used administrative data to develop and validate an algorithm for intussusception, and quantified its incidence in Ontario. We also conducted a systematic review of study designs used to evaluate post-licensure vaccine safety, and discussed each design’s strengths and weaknesses. The validated algorithm for intussusception was sensitive (89.3%) and highly specific (>99.9%). We observed the highest mean incidence (34 / 100,000) in males <1 year of age. While other designs are more robust, the inability to ascertain individual vaccination status from Ontario’s administrative data dictated our selection of an ecological design for safety evaluation of rotavirus vaccine. Data assimilated from this thesis represent a critical step toward the timely evaluation of rotavirus vaccine safety in Ontario.

In view of the recent implementation of a publicly funded rotavirus vaccination program in Ontario, we undertook studies to help guide the design of a safety evaluation of the vaccine with respect to intussusception. We used administrative data to develop and validate an algorithm for intussusception, and quantified its incidence in Ontario. We also conducted a systematic review of study designs used to evaluate post-licensure vaccine safety, and discussed each design’s strengths and weaknesses. The validated algorithm for intussusception was sensitive (89.3%) and highly specific (>99.9%). We observed the highest mean incidence (34 / 100,000) in males <1 year of age. While other designs are more robust, the inability to ascertain individual vaccination status from Ontario’s administrative data dictated our selection of an ecological design for safety evaluation of rotavirus vaccine. Data assimilated from this thesis represent a critical step toward the timely evaluation of rotavirus vaccine safety in Ontario.

Percutaneous endoscopic gastrostomy (PEG) tube placement is one of the methods of providing enteral nutrition support and is often used in critically ill patients. There are several complications of PEG tube placement, including intussusception. Jejunojejunal and retrograde jejunoduodenogastric intussusception are well-documented complications of PEG tube placement. Here we describe the case of a 25-year-old female who was diagnosed with anterograde gastroduodenal intussusception with the PEG tube acting as a lead point. Our case is unique as, to the best of our knowledge, there are no documented cases of PEG tube-related anterograde gastroduodenal intussusception. The reported patient was found to have extensive gastric pneumatosis and portal venous gas concerning for acute ischemia. Such cases warrant immediate surgical intervention. However, in our case, the patient's family opted for comfort care measures.

O objetivo do presente trabalho foi avaliar a preservação da inervação de porções intestinais macroscopicamente viáveis em cães portadores de intussuscepções. Para tanto, realizou-se comparação entre segmento intestinal proveniente deste grupo de animais (G1) e segmentos intestinais de animais sem qualquer distúrbio do aparelho digestório (G2). Avaliações histológicas e imunoistoquímicas foram realizadas em sistema computadorizado (Image Pro-Plus®) além da avaliação tardia da qualidade de vida e função digestiva. As variáveis analisadas foram: densidade média das camadas musculares circular e longitudinal, relação entre as camadas musculares, número média de plexos mioentéricos, densidade celular média dos plexos mioentéricos, grau de degeneração neuronal nos plexos mioentéricos, imunoreatividade à sinaptofisina e ao NSE além de existência de distúrbios de defecação. Com exceção da densidade celular média da camada longitudinal, relação entre as camadas musculares e imunoreatividade à sinatpofisina, todos os demais parâmetros apresentaram diferença estatisticamente significativas entre os grupos testados. Foram observadas correlações entre densidade celular média dos plexos mioentéricos e densidade celular média da camada muscular circular; grau de vacuolização dos plexos mioentéricos e imunoreatividade ao NSE; além de grau de vacuolização dos plexos mioentéricos e densidade celular média dos plexos mioentéricos. Quanto aos anticorpos utilizados, o NSE apresentou melhor padrão de marcação quando comparado à sinaptofisina. Dos 13 cães pertencentes ao G1, três foram a óbito no pós-operatório inicial. No período pós-operatório tardio, três cães apresentaram alterações de consistência e freqüência de defecação, além de episódios diarréicos agudos intermitentes. O tempo de segmento foi de 6 meses após intervenção cirúrgica. Os achados deste estudo sugerem que porções intestinais macroscopicamente viáveis podem apresentar lesões de inervação eventualmente traduzidas em sintomatologia clínica futura. Assim sendo, deve-se avaliar de maneira cuidadosa a margem cirúrgica preservada durante o procedimento de enterectomia/enteroanastomose bem como realizar acompanhamento da função digestória tardia. / The purpose of this study was to evaluate the preservation of the innervation of macroscopically viable bowel segments of dogs with intussusceptions. This group (G1) was compared to bowel segment of normal dogs (G2). Histological and immunohistochemical analysis were performed using computed system (Image Pro-Plus®). Late assessment of the quality of life and digestive function were also evaluated. Analyzed variables included: mean density of circular and longitudinal muscular layers cells, ratio between muscular layers, mean of myenteric plexuses, mean density of myenteric cells, neuronal degeneration degree in myenteric plexus, synaptophysin and NSE immunoreactivity and defecatory disorders. All tested parameters, except mean density of longitudinal muscular layers cells, ratio between muscular layers and synaptophysin immunoreactivity, showed statistical differences when group G1 was compared with group G2. Correlations between mean density of myenteric cells and mean density of circular muscular layers cells; neuronal degeneration degree in myenteric plexus and NSE immunoreactivity; neuronal degeneration degree in myenteric plexus and mean density of myenteric cells were observed. Regarding the immunohistochemical antibodies, NSE showed better staining pattern than synaptophysin. Three animals of G1 (n=13) died during the initial post-operative period. During the late post-operative period, three animals presented disorders in fecal consistency, frequency of defecation and acute intermittent diarrheal episodes. The follow-up time was 6 months. These findings showed that macroscopically viable bowel segments can present innervation damage eventually translated in clinical symptoms in the future. So, a careful evaluation of the preserved surgical margin during enterectomy and enteroanastomosis must be carried out as well as monitoring of the late digestive function.

O objetivo do presente trabalho foi avaliar a preservação da inervação de porções intestinais macroscopicamente viáveis em cães portadores de intussuscepções. Para tanto, realizou-se comparação entre segmento intestinal proveniente deste grupo de animais (G1) e segmentos intestinais de animais sem qualquer distúrbio do aparelho digestório (G2). Avaliações histológicas e imunoistoquímicas foram realizadas em sistema computadorizado (Image Pro-Plus®) além da avaliação tardia da qualidade de vida e função digestiva. As variáveis analisadas foram: densidade média das camadas musculares circular e longitudinal, relação entre as camadas musculares, número média de plexos mioentéricos, densidade celular média dos plexos mioentéricos, grau de degeneração neuronal nos plexos mioentéricos, imunoreatividade à sinaptofisina e ao NSE além de existência de distúrbios de defecação. Com exceção da densidade celular média da camada longitudinal, relação entre as camadas musculares e imunoreatividade à sinatpofisina, todos os demais parâmetros apresentaram diferença estatisticamente significativas entre os grupos testados. Foram observadas correlações entre densidade celular média dos plexos mioentéricos e densidade celular média da camada muscular circular; grau de vacuolização dos plexos mioentéricos e imunoreatividade ao NSE; além de grau de vacuolização dos plexos mioentéricos e densidade celular média dos plexos mioentéricos. Quanto aos anticorpos utilizados, o NSE apresentou melhor padrão de marcação quando comparado à sinaptofisina. Dos 13 cães pertencentes ao G1, três foram a óbito no pós-operatório inicial. No período pós-operatório tardio, três cães apresentaram alterações de consistência e freqüência de defecação, além de episódios diarréicos agudos intermitentes. O tempo de segmento foi de 6 meses após intervenção cirúrgica. Os achados deste estudo sugerem que porções intestinais macroscopicamente viáveis podem apresentar lesões de inervação eventualmente traduzidas em sintomatologia clínica futura. Assim sendo, deve-se avaliar de maneira cuidadosa a margem cirúrgica preservada durante o procedimento de enterectomia/enteroanastomose bem como realizar acompanhamento da função digestória tardia. / The purpose of this study was to evaluate the preservation of the innervation of macroscopically viable bowel segments of dogs with intussusceptions. This group (G1) was compared to bowel segment of normal dogs (G2). Histological and immunohistochemical analysis were performed using computed system (Image Pro-Plus®). Late assessment of the quality of life and digestive function were also evaluated. Analyzed variables included: mean density of circular and longitudinal muscular layers cells, ratio between muscular layers, mean of myenteric plexuses, mean density of myenteric cells, neuronal degeneration degree in myenteric plexus, synaptophysin and NSE immunoreactivity and defecatory disorders. All tested parameters, except mean density of longitudinal muscular layers cells, ratio between muscular layers and synaptophysin immunoreactivity, showed statistical differences when group G1 was compared with group G2. Correlations between mean density of myenteric cells and mean density of circular muscular layers cells; neuronal degeneration degree in myenteric plexus and NSE immunoreactivity; neuronal degeneration degree in myenteric plexus and mean density of myenteric cells were observed. Regarding the immunohistochemical antibodies, NSE showed better staining pattern than synaptophysin. Three animals of G1 (n=13) died during the initial post-operative period. During the late post-operative period, three animals presented disorders in fecal consistency, frequency of defecation and acute intermittent diarrheal episodes. The follow-up time was 6 months. These findings showed that macroscopically viable bowel segments can present innervation damage eventually translated in clinical symptoms in the future. So, a careful evaluation of the preserved surgical margin during enterectomy and enteroanastomosis must be carried out as well as monitoring of the late digestive function.

Les progrès continus de la recherche scientifique dans le domaine de la santé ont entraîné une augmentation de l'espérance et de la qualité de vie. Ainsi, le développement de nouveaux médicaments et des dispositifs médicaux a permis d'améliorer les conditions sanitaires et la prise en charge des patients au prix d'une inflation des dépenses de santé. Ces évolutions ont eu pour conséquences d'inciter les états à mettre en place des procédures d'évaluation de l'efficacité et de la gestion des risques liés à ces nouvelles approches thérapeutiques. Plus récemment, les restrictions budgétaires liées à la crise économique dans de nombreux pays de l'OCDE ont contraint les états à diminuer la part de leur budget consacré à la santé. Cette situation les a conduits à mettre en place des politiques de santé basées sur l'optimisation des ressources.En ce sens, l'évaluation médico-économique et la pharmaco-épidémiologie constituent pour les acteurs de santé et pour les décideurs politiques un outil d'analyse décisionnelle particulièrement légitime. Ils sont aujourd'hui de plus en plus intégrés dans les réflexions sur les stratégies de soins et dans la mise en place des programmes de santé. L'objectif de notre travail de recherche a été à travers deux projets, d'étudier l'intérêt de l'évaluation médico-économique et de la pharmaco-épidémiologie en chirurgie pédiatrique. Ainsi, dans une première partie plus théorique, une synthèse des différentes études de pharmaco-économie, de pharmaco-épidémiologie a été conduite et un état des lieux des études d'évaluation médico-économiques dans la chirurgie de l'enfant a été réalisé. Dans une seconde partie plus pratique, les deux projets concernant la chirurgie pédiatrique sont présentés :- Le projet 1 (pharmaco-économie) présente l'évaluation et l'analyse coût-efficacité dutraitement du reflux vésico-urétéral de grade modéré chez l'enfant.- Le projet 2 (pharmaco-épidémiologie) est une étude multicentrique prospective surl'épidémiologie de l'invagination intestinale aiguë de moins de 1 an (EPIstudy) / The continuing progress of scientific research in the field of health have led to increasingexpectancy and quality of life. Thus, the development of new medicines and medical deviceshave improved the health conditions and treatment of patients at the cost of inflation inhealth spending. These developments have effects for encouraging states to implementprocedures of effectiveness assessment and management of risks associated with these newtherapeutic approaches.More recently, budget cuts due to the economic crisis in many OECD countries havecompelled states to reduce the proportion of their budgets on health. This led them todevelop health policies based on resource optimization.In this sense, the health econoic evaluation and pharmacoepidemiology are for healthcarestakeholders and policy makers a tool for decisional analysis. They are now increasingly integrated into reflection on care strategies and the implementation of health programs. The objective of our research has been through two projects, to study the interest of the health economic evaluations and pharmacoepidemiology in pediatric surgery. Thus, in a first, theoretical part, it is a synthesis of various studies of pharmaco-economics, pharmacoepidemiology was conducted and an inventory of economic evaluation studies in pediatric surgery was performed. In the second part more convenient, both projects are presented in pediatric surgery :- Project 1 (pharmacoeconomic) presents evaluation and cost-effectiveness analysis oftreatment of moderate grade of vesicoureteral reflux in children.- Project 2 (Parmacoepidemiology) is a prospective multicenter study of theepidemiology of acute intussusception among infants (EPIstudy)