Clinical presentation and management outcome of pediatric intussusception at Wolaita Sodo University Comprehensive Specialized Hospital: a retrospective cross-sectional study

Abstract

Objective

To assess the pattern of clinical presentations and factors associated with the management outcome of pediatric intussusception among children treated at Wolaita Sodo University Comprehensive Specialized Hospital, Ethiopia.

Methods

This retrospective cross-sectional study included the medical records of 103 children treated for intussusception from 2018 to 2020. The data collected were analyzed using SPSS 25.0 (IBM Corp., Armonk, NY, USA).

Results

In total, 84 (81.6%) patients were released with a favorable outcome. Ileocolic intussusception was a positive predictor, with a nine-fold higher likelihood of a favorable outcome than other types of intussusception [adjusted odds ratio (AOR), 9.16; 95% confidence interval (CI), 2.39–21.2]. Additionally, a favorable outcome was three times more likely in patients who did than did not undergo manual reduction (AOR, 3.08; 95% CI, 3.05–5.48). Patients aged <1 year were 96% less likely to have a positive outcome than those aged >4 years (AOR, 0.04; 95% CI, 0.03–0.57).

Conclusion

Most patients were discharged with favorable outcomes. Having ileocolic intussusception and undergoing manual reduction were associated with significantly more favorable outcomes of pediatric intussusception. Therefore, nonsurgical management such as hydrostatic enema and pneumatic reduction is recommended to reduce hospital discharge of patients with unfavorable outcomes.

Keywords

Intussusception pediatric clinical presentation management outcome Ethiopia nonsurgical management

Introduction

In the pediatric population, acute intussusception is one main cause of abdominal surgical emergencies such as severe intestinal obstruction and abdominal pain.^1,2 Following appendicitis, acute intussusception is the second most common cause of acute abdomen in children and the most common cause of small bowel obstruction in young infants.³ Acute intussusception occurs worldwide with an incidence of approximately 1 to 4 in 2000 infants and children. It can be seen in children of all ages, but 75% of cases occur within the first 2 years of life and 90% occur within 3 years of life. The occurrence rate is highest between 4 and 8 months of age.⁴

Intussusception was first described by Paul Barbette in 1674,⁵ and the Scottish surgeon James Hunter then coined the term “intussusception” in 1793.⁶ Intussusception is defined as the movement of a proximal bowel segment into a distal bowel segment. The associated mesentery is dragged within the invaginated part, leading to venous congestion and edema. This results in ischemia and eventually bowel necrosis, perforation, and peritonitis if left untreated.³ The classic clinical triad of Ombredanne consists of intermittent abdominal pain, red currant jelly stool, and a sausage-shaped abdominal mass.⁷

Many children with intussusception present late for definitive treatment, and this seems to be the norm in developing countries.⁸ Studies in Uganda⁹ and Kenya¹⁰ showed that this duration was 4.5 and 4.4 days, respectively, and the median duration of symptoms in referred and non-referred patients was 4 days and 2 days, respectively. In Ethiopia, 80% of patients visit the hospital after 2 days of illness. One study showed that the mean duration of symptoms before presentation to the hospital was 5.2 days (range, 1–21 days).² Reports from Nigeria showed that 46.3% of patients required bowel resection and that nine (23.1%) patients died, and these deaths were directly related to intussusception occurring in patients who presented after 24 hours.^11–13

In another study, most patients (89%) were <2 years old, and 78% presented at the age of 3 to 18 months. Only 11% of patients presented after 2 years of age, and the age at presentation was significantly lower in Black African patients.⁸ Intussusception also occurs more commonly in male than in female patients, with a ratio of 2:1 or 3:2.^9,10 In a study in Nigeria, most affected patients were aged 3 to 9 months, with peak incidence at 6 months.^14–17 In one of the above-mentioned studies, a radiographic modality was used to diagnose intussusception in >95% of patients in all regions except Africa, where clinical findings or surgery were used in 65% of the patients.² In other research, the diagnosis of intussusception was mainly clinical in 71.4% of patients.¹⁸

The suggested treatment modality for acute intussusception is surgery or nonsurgical therapies such as hydrostatic and pneumatic reduction under fluoroscopy or ultrasound guidance.⁴ In developing countries, a higher rate of patients undergo surgical treatment, which has higher complication and mortality rates because late presentation commonly occurs in these regions.^9,10,18

Although pediatric intussusception is a standard pediatric surgical emergency with considerable morbidity and mortality, data in Ethiopia seem to be insufficient. Therefore, the present study was performed to examine the pattern of clinical presentations, morbidity, and mortality associated with pediatric intussusception at Wolaita Sodo University Comprehensive Specialized Hospital (WSUCSH).

Methodology

Study setting and period

In this study, children diagnosed and treated for acute intussusception from January 2018 to December 2020 were retrospectively analyzed. The study was conducted from 1 to 30 November 2021 in WSUCSH, which is located in Wolaita Zone, 329 km from Addis Ababa, Ethiopia’s capital. This hospital serves as a teaching institution for health science students and residents and provides 24-hour comprehensive services for a population of more than 5.8 million people with different demographic and socioeconomic backgrounds from the entire surrounding area of the southern part of the country. It offers general surgery, internal medicine, neurology, orthopedics, neurosurgery, obstetrics and gynecology, pediatrics, radiology, dermatology, pathology, oncology, anesthesiology, and neonatal care specialty services for the entire population of eastern Ethiopia. The Department of Pediatrics has six units: the pediatric ward, pediatric intensive care unit, neonatal resuscitation unit, neonatal intensive care unit, outpatient department, and chronic follow-up unit.

Study design and population

This retrospective cross-sectional study included all medical records of children admitted and treated for acute intussusception at WSUCSH from January 2018 to December 2020. Medical records with missing data and uncertain treatment outcomes were excluded from the study. The reporting of this study conforms to the STROBE guidelines.¹⁹

Sample size and sampling techniques

The study sample comprised pediatric patients who underwent surgical treatment of intussusception. The sample size was calculated using a single population proportion formula based on the findings of the Jimma University Medical Center study,²⁰ with a p value of 0.157 and calculation of the 95% confidence interval (CI). Odds ratios (ORs) and Z-scores (Z = 1.96²) were also considered, resulting in an initial sample size of 203. After applying the finite population correction, the final calculated sample size was adjusted to 128. We included all patients who underwent an operation for intussusception.

Dependent variable

The dependent variable in this study was the surgical management outcome of pediatric intussusception (favorable or unfavorable).

Measurements/operational definitions

Cure: Telescoping of the bowel has been resolved and the patient is no longer experiencing symptoms

Recurrence: Symptoms reappear after successful treatment

Failure of treatment: Symptoms reappear or worsen after repeated nonsurgical treatment attempts

Positive/favorable outcome: Patient has been cured of intussusception and is discharged from the hospital

Negative/unfavorable outcome: Patients discontinue treatment against medical advice, develop in-hospital recurrence or failure of treatment, or die after discharge

Diagnosis of intussusception

The initial diagnostic criterion was the clinical triad of abdominal pain, bloody diarrhea/stool, and a palpable abdominal mass. However, abdominal ultrasonography findings such as a target sign, pseudo kidney, or doughnut sign were used for patients who did not exhibit the classic triad and did not require urgent surgical intervention, such as patients with peritonitis. The findings of the clinical triad and/or ultrasonography were confirmed by intraoperative identification of the intussusception.

Data collection tools and methods

Data were collected using a validated pretested structured data extraction checklist adopted from relevant literature and modified to the study variables. First, the surgical and admission records were reviewed to develop a list of patients presenting with acute intussusception from January 2018 to December 2020. Next, data were extracted from the medical records of children taken from the examination room upon arrival, operating room records, postsurgical evaluation and monitoring sheets, intensive care records, and discharge records. Data were collected by trained data collectors and supervisors. Additional data collected included sociodemographic characteristics, delay in presentation, clinical signs and symptoms, interventions, surgical procedures, and the duration of hospitalization.

To avoid selection bias, we included all patients who underwent surgical operations for intussusception.

Data quality management

We used a pretested, validated, structured data collection tool prepared in simple English after a review of the related literature to ensure data quality. The data collectors and supervisors received 1 day of training on the purpose of the study, the contents of the data collection tools, where to find the records, how to extract the required data from the medical records, and how to appropriately record the data. A pretest was conducted on 5% of the sample before the actual data collection period to assess the reliability and validity of the data collection tools. The questionnaires were reviewed and checked for completeness, accuracy, and consistency by the principal investigator and amended accordingly based on the pretest results. The supervisors and the principal investigator carefully checked the collected data for completeness, accuracy, and consistency daily. Two individuals performed double data entry to minimize errors.

Data processing and analysis

The collected data were validated for completeness and accuracy. They were then categorized, coded, and entered into EpiData version 3.1 (EpiData Association, Odense, Denmark) and analyzed using SPSS version 25.0 (IBM Corp., Armonk, NY, USA). Descriptive statistics were used for the frequency, mean and median, standard deviation, and percentage. The results were summarized using graphs, charts, and tables, and data interpretations were based on the main objectives of the study. Variables with a p-value of <0.25 at a 95% CI were candidates for the final multivariate logistic regression. The features included in the final model were the length of hospital stay, age, sex, residence, abdominal distension, eagerness to drink, type of intussusception, sunken eyes, and the operative procedure performed. Logistic regression analyses were utilized, and a p-value of <0.05 was considered statistically significant.

Ethical considerations

This study was approved by the Institutional Research Review Committee of the College of Health Sciences and Medicine, Wolaita Sodo University, Ethiopia (Certificate Ref. No: CHSM/ERC/02/2014). A written official letter of cooperation was submitted to WSUCSH before the commencement of data collection. Informed consent was voluntarily provided by the heads of the hospital and the department after they had been informed of the aim, purpose, and benefits of the study. The confidentiality of the information was maintained throughout the data collection and information dissemination process. We also de-identified all patient details in the chart review. Because of the anonymous nature of the data analysis, the requirement for informed consent from the patients’ guardians was waived by the ethics committee.

Results

Patients’ sociodemographic characteristics

Among 128 eligible patients, we excluded 25 (19.5%) because of incomplete records. Therefore, the study included the remaining 103 (80.5%) patients. Of these 103 patients, 68 (66%) were male and 43 (42%) were aged <1 year (minimum age, 2 months; mean age, 3.55 ± 3.62 months). Ninety-two (89%) patients resided in rural areas.

Clinical presentations and findings

Seventy-six (74%) patients visited our hospital through a referral from another health institution. The clinical presentations included abdominal pain in 75 (72.8%) patients, vomiting in 83 (80.6%), abdominal tenderness in 36 (35.0%), bloody stool in 53 (51.5%), a rectal mass in 61 (59.2%), and a gangrenous bowel condition in 30 (29.1%). In terms of the diagnostic method, 64 (62.1%) of the patients were diagnosed clinically, and 39 (37.9%) were diagnosed by ultrasound. Most patients [60 (58.3%)] had a >3-day history of symptoms at presentation. The key clinical manifestations and findings are shown in detail in Table 1.

Table 1.

Clinical presentations and findings according to the patterns of clinical presentations and management outcomes of pediatric intussusception at Wolaita Sodo University Comprehensive Specialized Hospital (n = 103).

Variables	Categories	n	%
Means of visit to the hospital	Referred from health institution	76	73.8
	Self-referred	27	26.2
Abdominal pain	Yes	75	72.8
	No	28	27.2
Bloody stool	Yes	53	51.5
	No	50	48.5
Vomiting	Yes	83	80.6
	No	20	19.4
Abdominal distension	Yes	18	17.5
	No	85	82.5
Duration of symptoms	≤24 hours	10	9.7
	25–48 hours	16	15.5
	48–72 hours	17	16.5
	>72 hours	60	58.3
Tachycardia	Yes	93	90.3
	No	10	9.7
Fever	Yes	19	18.4
	No	84	81.6
Tachypnea	Yes	20	19.4
	No	83	80.6
Delayed capillary refill time	Yes	26	25.2
	No	77	74.8
Eager to drink	Yes	24	23.3
	No	79	76.7
Irritable	Yes	36	35.0
	No	67	65.0
Lethargy	Yes	16	15.5
	No	87	84.5
Sunken eyes	Yes	51	49.5
	No	52	50.5
Rectal mass	Yes	61	59.2
	No	42	40.8
Abdominal tenderness	Yes	36	35.0
	No	67	65.0
Diagnosis	Clinical	64	62.1
	Imaging (ultrasonography)	39	37.9
Blood transfusion	Yes	13	12.6
	No	90	87.4
Bowel condition	Viable	62	60.2
	Gangrenous	30	29.1
	Perforated	4	3.9
	Gangrenous and perforated	7	6.8

Intraoperative findings and management outcomes

Table 2 presents the intraoperative findings and management outcomes. A pathological lead point was found in 16 (15.5%) patients. Among these 16 patients, the lead points were a lymph node in 7 (43.75%), Meckel’s diverticulum in 2 (12.5%), duplication cyst in 3 (18.75%), and other sites in 4 (25.0%) (Figure 1).

Table 2.

Intraoperative findings and management outcomes according to patterns of clinical presentations and management outcomes of pediatric intussusception at Wolaita Sodo University Comprehensive Specialized Hospital (n = 103).

Variables	Categories	n	%
Pathological lead point	Yes	16	15.5
	No	87	84.5
Operative procedure performed	Manual reduction	56	54.4
	Resection and anastomosis	47	45.6
Patient transferred to	PACU	72	69.9
	ICU	31	30.1
Patient condition at discharge	Discharged improved	84	81.6
	Left against medical advice	6	5.8
	Died	13	12.6
Surgical site infection	Yes	13	12.6
	No	90	87.4
Wound dehiscence	Yes	6	5.8
	No	97	94.2
Postoperative complication	Yes	5	4.9
	No	98	95.1
Hospital-acquired infection	Yes	15	14.6
	No	88	85.4
Length of hospital stay	≤4 days	26	25.2
	4.1–6 days	20	19.4
	6.1–11 days	31	30.1
	>11 days	26	25.2

PACU, post-anesthesia care unit; ICU, intensive care unit

Figure 1.

Exploration of the type of lead point among patients according to the patterns of clinical presentations and management outcomes of pediatric intussusception.

The most common operative procedure was manual reduction, which was performed in 54.4% of the patients. Resection and anastomosis were also common, performed in 47 (45.6%) patients. Resection and anastomosis were performed because of gangrenous bowel attributable to delayed presentation in most cases, and bowel perforation occurred during manual reduction in some patients. Many patients [31 (30.1%)] were transferred to the intensive care unit (ICU) either at Wolaita Sodo Teaching and Referral Hospital or at the study site. The length of hospital stay was >11 days in 25% of patients, ranging from 1 to 25 days (mean, 8.01 ± 5.39 days). Surgical site infection occurred in 13 (12.6%) patients, and hospital-acquired infection occurred in 15 (14.6%). Upon discharge, 84 (81.6%) patients showed improvement, 6 (5.8%) left against medical advice, and 13 (12.6%) died. The cause of death in most of these patients was sepsis related to gangrenous bowel, bowel perforation, and late presentation.

The most common types of intussusception based on the intraoperative findings were ileocolocolic in 40 (38.83%) patients, ileocolic in 27 (26.26%), ileoileal in 26 (25.24%), and colocolic in 10 (9.71%). These findings are diagrammatically depicted in Figure 2.

Figure 2.

Anatomic classification of intussusception according to the patterns of clinical presentations and management outcomes of pediatric intussusception at Wolaita Sodo University Comprehensive Specialized Hospital.

Predictors of pediatric intussusception management outcomes

To conduct an appropriate logistic regression analysis, the outcome variable was dichotomized into two groups: patients discharged with improvement (positive outcome), constituting 81.6% of all patients, and patients who left against medical advice or died (merged and categorized as patients with an unfavorable outcome) (negative outcome), constituting 18.4% of all patients. This indicates that most of the patients were discharged with favorable outcomes following management of pediatric intussusception at WSUCSH. However, a substantial number of patients were discharged with negative outcomes.

Of the variables included in the final model, the following were identified as predictors of the outcome after controlling for likely confounders: patient age, type of intussusception, and operative procedure. Patients aged <1 year were 96% less likely to have positive outcomes than those aged >4 years [adjusted AOR (AOR), 0.04; 95% CI, 0.03–0.57]. The type of intussusception was also a predictor, and the ileocolic type was associated with a nine-times higher likelihood of having favorable outcomes (AOR, 9.16; 95% CI, 2.39–21.2). Compared with other operative procedures, manual reduction was associated with a three-times higher likelihood of a positive outcome (AOR, 3.08; 95% CI, 3.05–5.48) (Table 3).

Table 3.

Factors associated with management outcomes of pediatric intussusception at Wolaita Sodo University Comprehensive Specialized Hospital.

Variables	Categories	Outcome		COR (95% CI)	AOR (95% CI)
Variables	Categories	Positive	Negative	COR (95% CI)	AOR (95% CI)
Length of hospital stay	≤4 days	17 (20.2%)	9 (47.4%)	1.26 (0.88–3.42)	0.16 (0.08–2.12)
	4.1–6 days	17 (20.2%)	3 (15.8%)	4.21 (0.99–8.98)	3.2 (0.19–7.68)
	6.1–11 days	28 (33.3%)	3 (15.8%)	4.22 (0.89–5.77)	3.72 (0.39–8.56)
	>11 days	22 (26.2%)	4 (21.1%)	1	1
Age	≤1 year	31 (36.9%)	12 (63.2%)	0.34 (0.13–0.79)	0.04 (0.03–0.57) *
	1–4 years	18 (21.4%)	3 (15.8%)	0.46 (0.043–6.42)	0.56 (0.03–8.22)
	≥4 years	35 (41.7%)	4 (21.1%)	1	1
Sex	Male	54 (64.3%)	14 (73.7%)	0.19 (0.18–2.22)	0.11 (0.08–1.32)
	Female	30 (35.7%)	5 (26.3%)	1	1
Residence	Rural	74 (88.1%)	18 (94.7%)	0.50 (0.12–6.01)	0.41 (0.02–9.02)
	Urban	10 (11.9%)	1 (5.3%)	1	1
Abdominal distension	Yes	62 (73.8%)	13 (68.4%)	0.33 (0.11–11.21)	1.93 (0.29–13.41)
	No	22 (26.2%)	6 (31.6%)	1	1
Eager to drink	Yes	22 (26.2%)	2 (10.5%)	3.09 (1.66–6.11)	3.14 (1.76–8.51)
	No	62 (73.8%)	17 (89.5%)	1	1
Type of intussusception	Ileoileal	23 (27.4%)	3 (15.8%)	2.12 (1.22–9.07)	3.91 (1.11–11.17)
	Ileocolic	26 (31.0%)	1 (5.3%)	8.26 (1.19–11.01)	9.16 (2.39–21.2) *
	Colocolic	8 (9.5%)	2 (10.5%)	5.12 (0.14–11.22)	4.72 (0.54–10.18)
	Ileocolocolic	27 (32.1%)	13 (68.4%)	1	1
Sunken eyes	Yes	37 (44.0%)	14 (73.7%)	1.17 (0.51–2.19)	0.07 (0.05–1.15)
	No	47 (56.0%)	5 (26.3%)	1	1
Operative procedure	Manual reduction	54 (64.3%)	2 (10.5%)	2.11 (1.09–5.98)	3.08 (3.05–5.48) *
	Resection and anastomosis	30 (35.7%)	17 (89.5%)	1	1

COR, crude odds ratio; AOR, adjusted odds ratio; CI, confidence interval.

Statistically significant association.

Discussion

Pediatric abdominal surgery emergencies occur worldwide, necessitating prompt diagnosis and treatment.² Acute intussusception is considered more prevalent in children aged <2 years, particularly in infants aged 4 to 9 months.^21–23 Nevertheless, 43 (41.7%) patients in our study were infants aged <1 year, 39 (37.9%) were >4 years old, and 21 (20.4%) were 1 to 4 years old. This suggests that attention should also be paid to the occurrence of intussusception in older children. The highest incidence among infants in our study is in agreement with many studies both worldwide and in Africa.^24–28 Shiyi and Ganapathy²⁹ found that approximately 10% of intussusceptions occur in children aged >5 years, 3% to 4% occur in children aged >10 years, and 1% occur in infants aged <3 months. In one case series,³⁰ children aged >3 and >5 years accounted for 36.1% and 9.5% of the patients with intussusception, respectively, supporting our findings of a higher incidence among children aged >4 years. Male patients were more commonly affected than female patients in this study, with a male:female ratio of 1.94:1.00; this is also comparable to the results reported by other researchers.^3,25,26,31 However, the specific cause of these age and sex variances remain unknown. In our study, more than 89% of the patients came from rural areas located a considerable distance from the study area, which is consistent with other studies.^3,27,32

Intussusception manifests as paroxysmal stomach pain/crying, an abdominal sausage-shaped mass, and bloody stool. In the present study, the clinical presentations included bloody stool in 53 (51.5%) patients, abdominal pain in 75 (72.8%), vomiting in 83 (80.6%), and a rectal mass in 61 (59.2%). This is consistent with research conducted in South Africa showing that >90% of patients presented with vomiting and bloody stool, 60% with a palpable mass, and >30% with a mass palpable on rectal examination or presenting at the anus.^33,34 Notably, the incidence of bloody stool was lower in our study than in these studies from South Africa.^33,34 Justice et al.³⁵ reported that 78% of the children in their study presented with abdominal pain, lethargy, and vomiting, which is in agreement with our study. However, other studies have suggested that the patterns of symptoms may vary depending on the age and sex of the child³⁶ and the duration of signs upon presentation to the hospital. A significant number of children with intussusception present for definitive treatment late in the clinical course, and this seems to be the norm in many developing countries.¹⁸ Our study showed that most of the patients [60 (58.3%)] had a >3-day history of symptoms at presentation, which is consistent with the literature from developing countries.^2,9,10 The reason for late presentation may be the need to travel long distances, potentially from rural areas. Ninety-two (89.3%) of our patients were from a rural area, and most such patients seeking public health care have limited access to transport. The presentation of intussusception is similar to many common abdominal and respiratory tract infections in children. Intussusception is clinically or surgically diagnosed in most patients in developing countries, which is consistent with the higher percentage of clinical diagnoses [64 (62.1%)] than ultrasound-based diagnoses [39 (37.9%)] in our study.

The suggested treatment modality for acute intussusception is surgery or nonsurgical therapies such as hydrostatic and pneumatic reduction under fluoroscopy or ultrasound guidance.⁴ The most common operative procedure in our study was manual reduction, performed in 54.4% of the patients; resection and anastomosis were also commonly performed [47 (45.6%) patients]. This finding suggests a growing diagnostic and interventional shift in intussusception management from surgical to nonsurgical reduction.³³ Non-operative reduction using hydrostatic or pneumatic pressure by enema is the treatment of choice for an infant or child who is clinically stable and has no evidence of bowel perforation or shock when appropriate radiologic facilities are available. Because of the increased availability of diagnostic modalities among many institutions and the advancements in medical specialties, non-operative reduction currently predominates globally. This is also augmented by increased health-seeking behavior and early presentation to health facilities, which reduces the complications associated with resection and anastomosis. Our findings are consistent with this explanation because most of our patients were managed by surgical means.

It should be noted that the current findings contradict data from Tikur Anbesa Specialized Hospital in Ethiopia,^37,38 Jimma University Medical Centre in Ethiopia,¹⁹ and Tanzania,³ where surgery is used for management of most patients. These differences may be due to patients’ early health-seeking behavior, considerable immediate and late surgical complications, and higher proportion of viable bowel [62 (60.2%) patients in the present study]. Surgical intervention is indicated when there is evidence of bowel necrosis, bowel perforation, or peritonitis; when safe facilities to perform an enema reduction are unavailable; or when repeated relapse occurs despite appropriate management. Most studies have shown that late presentation in developing countries is closely associated with surgical treatment and complications.^33,39,40

Intraoperative findings revealed pathological lead points in 16 (15.5%) patients in our study. The lead points were a lymph node in 7 (6.8%) patients, Meckel’s diverticulum in 2 (1.9%), a duplication cyst in 3 (2.9%), and other sites in 4 (3.9%). This incidence of 15.5% is higher than in a study from South Africa, which showed a 2% incidence of lead points,⁴ as well as another study showing lead points in 1.5% to 12.0% of cases.⁴¹ Open surgery was performed in our study, and 47 (45.6%) patients underwent resection and anastomosis procedures. This proportion of patients is less than that in a Tanzanian study, in which 55% of patients underwent intestinal resection,⁴² but higher than the proportions of 33% and 39% reported in Kenya and Tanzania,⁴³ respectively. The higher rate of bowel resection in our study is attributed to the patients’ late presentation, which reflects the low level of health awareness in our community; infrastructural problems associated with the high proportion of patients in rural areas; and similarity of symptoms with other common pediatric conditions.

Postoperative complications are associated with poor treatment results in patients with acute intussusception.⁴⁴ The most common postoperative complication is hospital-acquired infection, which occurred in 15 (14.6%) patients in our study. Hospital-acquired infection is associated with the length of hospital stay, which was >11 days in 25% of our patients (range, 1–25 days; mean, 8.01 ± 5.39 days). Surgical site infection occurred in 13 (12.6%) patients, which is a lower incidence than in studies performed in Ethiopia (21.3% and 33.9%)^45,46 and Tanzania (42.9%).³ The ICU admission rate in our study was 30.1%. Another study showed that bowel resection was also associated with ICU admission (p < 0.001) and prolonged hospitalization (p < 0.001).³ This helps to explain the reasons for the ICU admissions in our setting. Critically ill patients with conditions such as intestinal gangrene, respiratory failure requiring mechanical ventilation, and multiple organ dysfunction are more likely to be admitted to the ICU.⁴³ Our mortality rate was 12.6%, which is consistent with the mortality rate of 14.3% in the study from Tanzania.³ The mortality rate in Africa (9%) was higher than that in other regions (˂1%),^2,3,7 which is in agreement with our findings and can be explained by late presentations, open surgical procedures, postoperative complications, and poor infrastructure in the developing world, unlike more developed countries with lower mortality rates. Patients aged <1 year were 96% less likely to have positive outcomes than those aged >4 years (AOR, 0.04; 95% CI, 0.03–0.57). This is because younger patients have a higher probability of requiring bowel resection than older patients. This is consistent with other studies showing that an age of <1 year was more strongly associated with bowel resection and associated complications. An age of <1 year was shown to have a 2.7-times higher risk of bowel obstruction than older ages.⁴⁷ A study in in Nigeria showed that children aged <1 year were three times more likely than those aged >1 year to require bowel resection. This might be explained by the fact that infants are more prone to developing shock, which may further compromise the already precarious blood supply to the intussusception.⁴⁸ The type of intussusception was also a predictor, and the ileocolic type had a nine-times higher likelihood of favorable outcomes in our study (AOR, 9.16; 95% CI, 2.39–21.2). The most common form of intussusception in our study was ileocolic, which is in agreement with other studies.^45,48 The more favorable outcomes of this type are indicated by its clinical and ultrasound presentations.^49,50 Additionally, manual reduction had a three-times higher likelihood of a positive outcome than other procedures (AOR, 3.08; 95% CI, 3.05–5.48). This is also in agreement with many other studies.^23,51,52

Limitations

This study involved a retrospective record review, which has inherent limitations. The secondary data in this study might not have specifically addressed the research questions or contained the information required for analysis. Another limitation was the small sample size. Moreover, the retrospective cross-sectional study design did not allow for easy establishment of the cause–effect relationship between the study variables or other statistical inferences. The findings of this institutional study are difficult to generalize to other populations.

Conclusion

This study revealed a higher prevalence of patients with favorable than unfavorable outcomes. An ileocolic intussusception and manual reduction appear to be associated with more favorable outcomes. Although the number of pediatric surgeons in Ethiopia is gradually increasing, this country requires improved facilities, referral networks, and patient transportation to enhance outcomes. To enhance early diagnosis and attain outcomes comparable to those achieved in high-income nations, it is essential to improve population-level education and provide comprehensive training for primary healthcare workers. Additionally, optimizing referral pathways from primary healthcare settings is crucial.

Footnotes

Acknowledgement

We would like to express our gratitude to the data collectors who extracted the data from the chart review and to the study supervisors. We would also like to thank WSUCSH and Wolaita Sodo University for providing permission to use all provided documents in this research.

Author contributions

YZ: Conceived the study and drafted the manuscript. TB, AD, AW, and MM: Study design and methodology, data analysis, writing of manuscript, and critical evaluation of manuscript. All authors approved the manuscript for submission to the journal.

Data availability statement

The article contains all necessary data within the manuscript. The authors will provide the data upon request.

Declaration of conflicting interests

All the authors declare that they have no conflict of interest.

Funding

The authors received no funding for this research.

ORCID iD

Mengistu Meskele

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