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| ORIGINAL ARTICLE |
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| Year : 2017 | Volume
: 5
| Issue : 1 | Page : 21-25 |
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Pneumatic reduction of intussusception in children
Aditya Pratap Singh, Ramesh Tanger, Vinay Mathur, Arun Kumar Gupta
Department of Pediatric Surgery, SMS Medical College, Jaipur, Rajasthan, India
| Date of Web Publication | 12-Apr-2017 |
Correspondence Address:
Aditya Pratap Singh
Near the Mali Hostel, Main Bali Road, Falna, Dist-Pali, Rajasthan
India
 Source of Support: None, Conflict of Interest: None  | Check |
DOI: 10.4103/ssj.ssj_64_16
Context and Aims: Pneumatic reduction has a higher success rate and lower incidence of complications compared to barium enema and hydrostatic reductions. What is deterrent to its common use is the cumbersome technique. Our technique is simple that can be used in any hospital with locally available facilities.
Settings and Design: This was a prospective study.
Subjects and Methods: A total of 25 children were enrolled in the study between September 2015 and June 2016 at our institute. Patients were given air enema under US guidance using locally assembled equipment. The intraluminal pressure was monitored with a pressure gauge and was not permitted to go above 100 mmHg. A total of three attempts of 3 min each were allowed.
Statistical Analysis Used: We just used simple statistic to calculate average.
Results: There were 17 males and 8 females. The average age of the patients was 8.5 months. Twenty-two (88%) of the cases were reduced successfully while 3 (12%) failed to reduce. A majority of those that did not reduced had symptoms for at least 4 days. No bowel perforation occurred in our study. All cases of the intussusception have length <5 cm were reduced with pneumatic reduction in our study.
Conclusions: The technique described is easy to assemble, safe, and effective. We recommend it for regular use in pneumatic reduction of intussusception, especially in the center have limited resources. Keywords: Intussusception, lead point, pneumatic reduction
How to cite this article:
Singh AP, Tanger R, Mathur V, Gupta AK. Pneumatic reduction of intussusception in children. Saudi Surg J 2017;5:21-5 |
| Introduction | |  |
Pneumatic reduction of intussusception is a well-established technique, with a higher reduction rate and lower complication rate compared to barium enema and hydrostatic reductions.[1],[2] This is usually done with the help of sophisticated and costly equipment, which monitors the pressure and stops insufflation at the set pressure. Our technique is a simple, cheap, and reliable that can be used in most hospitals, especially at the center with limited resources. Intussusception is the invagination of one portion of intestine (intussusceptum) into the contiguous distal segment (intussuscipiens), the most common being ileocolic intussusception. It is the most common cause of bowel obstruction in the infant-toddler age group. Pneumatic reduction of intussusception has been practiced since 1950. It involved per rectal insufflations of air at a pressure of between 80 and 100 mmHg.
| Subjects and Methods | | |
A total of 25 children were enrolled in this initial study. These were children who had clinical features of intussusception and had been diagnosed using an abdominal ultrasound scan. The parents/guardians of all children were informed about the options that were available at the time, i.e., surgery as well as ultrasonography (US)-guided pneumatic reduction which was explicitly explained to them. Children who had significant abdominal distension, signs of peritonitis, and children whose parents did not agree to the procedure were excluded from this initial study.
The 17 male and 8 female children were symptomatic from between a few hours to 5 days with gastrointestinal symptoms such as vomiting, abdominal pain, diarrhea, and blood-stained mucoid stools.
Patients were resuscitated adequately using intravenous fluids and antibiotics. Relevant laboratory investigations were done which included the complete blood count, blood urea electrolytes, and serum creatinine. A nasogastric tube was also passed to decompress the bowel. When the patient was adequately resuscitated, he/she was taken to the operation theater for the reduction to be done. An initial abdominal ultrasound was done to confirm the presence of the intussusception. The equipment used for the reduction was custom-made/locally prepared, consisting of the part of the aneroid sphygmomanometer containing the hand bulb, release valves, and aneroid gauge, which was connected to a short tube, which in turn was also connected to a Foley's catheter [Figure 1].
Criteria for complete reduction were as follow:
- Disappearance of the intussusception
- Ultrasound confirmation of complete reduction after the procedure.
A total of three attempts of 3 min each were permitted. When the intussusception reduced, the child was sent back to the ward and monitored.
Equipment
The device used was assembled using equipment readily available in the hospital. A handheld pump attached to a pressure gauge, 2-way Foley's balloon catheter (F), was used to insufflate the air through the rectum. After the catheter had been introduced per rectum, the balloon was inflated with between 20 and 40 cc of air through the balloon inlet.
The caliber of the catheter used ranged from 18FG to 22FG depending on the patient's age. Before the start of each procedure, air was pumped with Foley's catheter. With an airtight device, the pressure gauge maintained a fixed pressure.
Technique
Clinical diagnosis of intussusception was confirmed by ultrasound. Before attempting the pneumatic reduction, it was ensured that the patient was well hydrated and did not have any clinical evidence of peritonitis.
Foley's catheter was introduced per rectum, and the balloon was inflated with between 20 and 40 cc of air. It completely occluded the rectum but was not overinflated. The patients' gluteal folds were strapped together to further ensure no air leakage during the procedure. Air was insufflated using the hand pump to a pressure of between 80 and 100 mmHg. The pressure was maintained for 3 min. After 1 min, the insufflation was repeated. A total of three insufflations were performed for the duration of 3 min each. Reduction of the intussusception was observed during intermittent US of the abdomen. The patient's vital signs were monitored throughout the procedure with pulse oximeter. The pneumatic reduction was considered a failure when the intussusception did not reduce after the 3rd attempt and the patient proceed to surgery.
| Results | | |
A total of 25 children were enrolled in the study out of which 17 (68%) were male and 8 (32%) were females, giving a female to male ratio of 2:1. The average age of the patients was 8.5 months. The most common type of the intussusception at the time of diagnosis was ileocolic. The intussusception reduced successfully in 22 (88%) patients but not in the other three cases (12%). Of the three cases that failed to reduce, the process was abandoned after three attempts without any evidence of major complications. In the three cases that were abandoned after three attempts, one had evidence of bowel ischemia at surgery, and two had Non-Hodgkin's lymphoma and Meckel's diverticulum acting as a lead point. None of the cases that were reduced recurred. The average duration of the reduction process was 7 min with the duration ranging between 3 and 10 min. The average pressure needed to reduce the intussusception was about 70 mmHg (range 60–100 mmHg). Most of the children (9) who had successful reduction were discharged after 2 days.
| Discussion | | |
Intussusception is a common abdominal emergency in children. It necessitates prompt diagnosis and management. Nonsurgical reduction of intussusception dates back to the time of Hippocrates, and various reduction procedures have been used since then.[3],[4],[5]
Nonsurgical management of intussusception in children is not new. It has gained acceptance in many parts of the world in the last five decades.[6],[7],[8] Different centers have chosen particular types of nonsurgical method of reduction based on their successful experiences. Although barium enema is the standard of care for the diagnosis and therapeutic reduction of intussusception, it has been challenged by alternative procedures. Among them, pneumatic reduction with fluoroscopic guidance is claimed to be quick, safe, and clean, and it has been reported to have a high success rate.[6],[7],[9],[10] However, fluoroscopy uses ionizing radiation, and it may not depict lead points and residual ileoileal intussusception.[11] Recently, ultrasonography (US)-guided hydrostatic reduction has been recommended because there is no radiation exposure, and it can be used to accurately confirm a diagnosis and subsequent reduction.[8],[12],[13],[14],[15] US-guided hydrostatic reduction can depict lead points and residual ileoileal intussusception more readily than fluoroscopy-guided pneumatic reduction.
There seems to be no consensus on the best procedure for use in the nonsurgical reduction of intussusception.[2],[4],[5],[16],[17] After we weighed the advantages and disadvantages of various reduction procedures, we decided to combine US guidance and pneumatic reduction to apply the advantages of both types of procedures. With pneumatic reduction, there is a high success rate, while with US guidance, there is no radiation exposure. The purpose of this prospective study was to assess the feasibility and effectiveness of US-guided pneumatic reduction of childhood intussusception.
Pneumatic reduction of intussusception in children is a quick method of the management of intussusception. This was shown in our study to take an average of 7 min (range 3–10 min for the whole procedure) for the reduction to take place, i.e., from the start of gas inflation to complete reduction. The short reduction time has also been reported in studies in many centers.[7],[10],[11],[16] This means that it takes a much shorter time to complete one pneumatic reduction than for the patient to be ready for manual reduction by the surgeon in theater.
The procedure is cheap. The hospital charge for pneumatic reduction is far less than the fee for surgical management. Patients have a shorter hospital stay (2 days) with this procedure. Clearly, the cost of surgical management far outweighs that for pneumatic reduction, especially in uncomplicated cases. Another issue worth noting is that even though surgery is the only means of managing both the intussusception and its complications, it does not offer any significant protection against future recurrence in patients who do not have lead points.
The 5-year review mentioned earlier rectal bleeding (hematochezia) at presentation as a major predictor of nonreduction.[7] Most of our patients (92%) presented with rectal bleeding, thus comparing this figure to our success rate it was unlikely that rectal bleeding is a predictor of nonreduction in our environment.
A limitation of pneumatic reduction under fluoroscopic guidance is its limited ability to identify the lead points which cause intussusception during the pneumatic reduction process, and another concern is that fluoroscopic images may fail to depict residual ileoileal intussusception.[11] One study indicated the ability to identify only 2 out of 12 lead points identified at surgery.[11] Hence, under US guidance, we can solve this problem. Another limitation worth noting is pseudoreduction, where gas enters small bowel even though the intussusception has not reduced.[7],[16] We did not see pseudoreduction in our study by US.
Our study findings demonstrate that US-guided pneumatic reduction is a feasible and effective technique for nonsurgical reduction of pediatric intussusception; it has a high success rate and requires no radiation exposure to either the patient or medical personnel. In this study, the overall success rate of US-guided pneumatic reduction was 88%, with no immediate recurrence of intussusception and no radiation exposure. The almost same success rate (84.4%) was seen in the other study.[18] The entire procedure was performed in operation theater under general anesthesia with sedation.
One of the major complications related to nonsurgical reduction is perforation. In our study, there was no complication seen as perforation. US have also become a useful tool for the accurate depiction of a small amount of intraperitoneal air.[19],[20] Even a small amount of intraperitoneal free air can be easily depicted with US on the nondependent portion (i.e., epigastric subphrenic area in a supine position) as an echogenic line with a posterior ring-down artifact. It is also prudent to have an 18-gauge needle at the side of the table at all times in case respiratory distress develops.[21] Most detected perforations are thought to be perforations that occur before enema therapy.[5] The previously reported [6],[7],[9],[10] perforation rates with various techniques were 0.14%–2.80%. In our study, there was no case of perforation. The present study has some limitations that prevent us from generalizing the results. Our study design was not intended for a comparison of reduction techniques, and the number of patients in our group was relatively small. A randomized controlled study in which various reduction techniques are compared both for their success rate and incidence of complications should be performed to determine the best technique.
The reported success rate of pneumatic reduction ranged from 27% to 96%, and many authors have reported it to be more than 88%.[16] The high success rate compared to hydrostatic reduction is due to the inherent compressible effect of air that results in air dissecting between the intussusceptum and intussuscipiens. This effect facilitates and expedites the reduction.[6] Our study had a success rate of 88%. We used sedation and muscle relaxant in our study. Some author says that sedation could mask the signs of shock during the procedure [22] and straining during the reduction procedure protects against bowel perforation [22] and furthermore the increased intra-abdominal pressure caused by crying and straining resulted in rapid reduction.[22],[23] In our study, probably sedation and muscle relaxant helped in reduction. Apart from higher success rate, US-guided pneumatic reduction has other advantages. Reduction was faster and without radiation. Bowel perforation is a known complication in both air and barium reduction. If perforation occurs when barium is used, contamination of the peritoneal cavity with fecal-mixed barium is more detrimental than the pneumoperitoneum caused when air is used.[24] Various devices for the purpose of pneumatic reduction have been described.[6],[23] Some have been patented and are available commercially. However, everywhere it is not affordable and not available. For this reason, we decided to assemble our own device using equipment readily available in the hospital. Our series has proven that pneumatic reduction with this device is effective and safe and can be easily performed at any hospital where facility for US machine is available.
| Conclusions | | |
US-guided pneumatic reduction seems to be a feasible and effective method for the treatment of intussusceptions in children because of its radiation-sparing effect and high success rate.
This simple system for pneumatic reduction is easy to assemble and use. It is cheap since no barium or saline is used and the apparatus can be reused. The only part that needs to be changed is Foley's catheter since it comes into contact with the patient. The rest of the system can be cleaned and reused.
Acknowledgment
The authors would like to thank Dr. Annu Bhandari, M. D. Radiodiagnosis
Financial support and sponsorship
Nil.
Conflicts of interest
There are no conflicts of interest.
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[Figure 1]
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