John Caffey Award. Colonic perforation by air and liquid enemas: comparison study in young pigs

Practice variation in the management of pediatric intussusception: a narrative review

Ileocolic intussusception, a major cause of acute intestinal obstruction in young children, necessitates rapid diagnosis and a multidisciplinary treatment approach. A recent large study identified variations in pain management, sedation, and non-operative reduction methods in these patients. We aimed to explore variability within the diagnostic and treatment pathways of ileocolic intussusception. A narrative review of the literature was conducted for peer-reviewed articles published in English between 2004 and 2024. We searched the electronic databases Ovid, Embase, Scopus, PubMed, and the Cochrane Database. Google Scholar was searched using the search terms "intussusception," "triage," "diagnosis," emergency department," "radiology," "ultrasound," "POCUS," "reduction," "air-enema," "fluid-enema," "pneumatic," "hydrostatic," "pain," "sedation," "operating-room," "laparoscopy," and "surgery" to identify articles published in electronic journals, books, and scientific websites. Data were analyzed by a multidisciplinary team of specialists in pediatric emergency medicine, pediatric radiology, and pediatric surgery. Fifty-six papers were included in this review. Six areas of practice variation were found: pain management in triage, the use of point-of-care ultrasound in the emergency department, the use of pneumatic versus hydrostatic technique for the reduction procedure, performing the reduction procedure under sedation, patient observation after an uncomplicated reduction, and the use of open surgery or laparoscopy for patients who underwent unsuccessful reduction.

CONCLUSION

This review has identified practice variations in several key areas of ileocolic intussusception management. The findings underscore the need for further research in these areas and the establishment of uniform standards aimed at improving the care of children with ileocolic intussusception.

WHAT IS KNOWN

• Ileocolic intussusception necessitates rapid diagnosis and a collaborative treatment approach involving emergency medicine, radiology, surgery, and often anesthesia. • A previous study reported variations in the practice of pain management and sedation among these patients.

WHAT IS NEW

• This narrative review identified practice variations in several key areas within the diagnostic and treatment pathways of ileocolic intussusception.

Ketamine sedation during air enema reduction of pediatric intussusception: Assessing safety and intraluminal pressure

BACKGROUND

Recent reports have demonstrated promising results regarding the use of ketamine sedation for reducing pediatric intussusception without an associated elevated risk of bowel perforation. However, data on direct intraluminal pressure are still lacking. This study aimed to investigate sedation safety, primarily by comparing intraluminal pressure.

METHODS

This retrospective study included patients aged 10 years or younger, diagnosed with intussusception at a university-affiliated pediatric emergency department (ED) between July 2021 and February 2023. These patients were categorized into two groups: sedation and non-sedation. During regular working hours (from 9:00 a.m. to 5:00 p.m. on weekdays), patients were administered 1 mg/kg of intravenous ketamine for sedation during air enema reduction. Patients within non-working hours did not receive sedative interventions.

RESULTS

In a study of 114 patients with intussusception (median age: 25 months), 29 (25.4%) received sedatives, and 85 (74.6%) did not. Maximum intraluminal pressure during the procedure showed no significant difference between the groups (sedation: 64 mmHg, non-sedation: 83 mmHg, p = 0.091). Bowel perforation was not observed in the overall cohort. No difference was observed in the failure rate or recurrence rate within 24 h between the two groups. Sedation with a median dose of 1 mg/kg ketamine did not cause delays in the ED process and demonstrated no adverse events while maintaining appropriate sedation depth with sequential dosing.

CONCLUSIONS

The utilization of ketamine sedation during fluoroscopy-guided air enema reduction for pediatric intussusception was not associated with increased intraluminal pressure, increased rate of reduction failure, or bowel perforation.

Sedation and Analgesia for Reduction of Pediatric Ileocolic Intussusception

Importance

Ileocolic intussusception is an important cause of intestinal obstruction in children. Reduction of ileocolic intussusception using air or fluid enema is the standard of care. This likely distressing procedure is usually performed without sedation or analgesia, but practice variation exists.

Objective

To characterize the prevalence of opioid analgesia and sedation and assess their association with intestinal perforation and failed reduction.

Design, Setting, and Participants

This cross-sectional study reviewed medical records of children aged 4 to 48 months with attempted reduction of ileocolic intussusception at 86 pediatric tertiary care institutions in 14 countries from January 2017 to December 2019. Of 3555 eligible medical records, 352 were excluded, and 3203 medical records were eligible. Data were analyzed in August 2022.

Exposures

Reduction of ileocolic intussusception.

Main outcomes and measures

The primary outcomes were opioid analgesia within 120 minutes of reduction based on the therapeutic window of IV morphine and sedation immediately before reduction of intussusception.

Results

We included 3203 patients (median [IQR] age, 17 [9-27] months; 2054 of 3203 [64.1%] males). Opioid use was documented in 395 of 3134 patients (12.6%), sedation 334 of 3161 patients (10.6%), and opioids plus sedation in 178 of 3134 patients (5.7%). Perforation was uncommon and occurred in 13 of 3203 patients (0.4%). In the unadjusted analysis, opioids plus sedation (odds ratio [OR], 5.92; 95% CI, 1.28-27.42; P = .02) and a greater number of reduction attempts (OR, 1.48; 95% CI, 1.03-2.11; P = .03) were significantly associated with perforation. In the adjusted analysis, neither of these covariates remained significant. Reductions were successful in 2700 of 3184 attempts (84.8%). In the unadjusted analysis, younger age, no pain assessment at triage, opioids, longer duration of symptoms, hydrostatic enema, and gastrointestinal anomaly were significantly associated with failed reduction. In the adjusted analysis, only younger age (OR, 1.05 per month; 95% CI, 1.03-1.06 per month; P < .001), shorter duration of symptoms (OR, 0.96 per hour; 95% CI, 0.94-0.99 per hour; P = .002), and gastrointestinal anomaly (OR, 6.50; 95% CI, 2.04-20.64; P = .002) remained significant.

Conclusions and Relevance

This cross-sectional study of pediatric ileocolic intussusception found that more than two-thirds of patients received neither analgesia nor sedation. Neither was associated with intestinal perforation or failed reduction, challenging the widespread practice of withholding analgesia and sedation for reduction of ileocolic intussusception in children.

Making intussusception reductions easier: use of medical air in lieu of manual pump

BACKGROUND

Pneumatic reduction of ileocolic intussusception is commonly performed with manual insufflators. The challenge of operating a handheld device while controlling the fluoroscope and monitoring the reduction could be obviated if the manual insufflation could be eliminated.

OBJECTIVE

The aim in this retrospective study was to describe and evaluate the use of medical wall air in intussusception reduction.

MATERIALS AND METHODS

We retrospectively reviewed all intussusception reductions over a period of years: from 2015 to 2018 using the manual insufflator and from 2018 to 2021 using medical air. We compared success rates, complication rates and time to reduction as documented on fluoroscopic image time stamps. Demographic data were obtained from the medical record. Attending radiologists and fluoroscopic technologists indicated their preference between methods, ease of use, perceived duration of reduction and perceived difference in success rates through an anonymous internal survey.

RESULTS

There were 179 first reduction attempts in 167 patients (93 attempts during the period using the manual insufflator and 86 after converting to wall air). There was no difference in reduction duration (8:23 min for insufflation, 8:22 min for wall air, P=0.99) and no statistically significant difference in success rate (66.8% for insufflation and 79.1% for wall air, P=0.165). All survey respondents preferred the wall air method. The vast majority (93%) perceived that the wall air method was faster.

CONCLUSION

Hospital wall air can be used to successfully reduce intussusceptions without incurring time burden or loss of effectiveness. The method leads to a perception of increased efficiency.

Current diagnosis and image-guided reduction for intussusception in children

Intussusception involves an invagination of the proximal bowel into the distal bowel, with ileocolic intussusception being the most common type. However, a diagnostic delay can lead to intestinal ischemia, bowel infarction, or even death; therefore, its early diagnosis and management are important. The primary role of abdominal radiography is to detect pneumoperitoneum or high-grade bowel obstruction in cases of suspected intussusception, and ultrasonography is the modality of choice for its diagnosis. Nonoperative enema reduction, the treatment of choice for childhood intussusception in cases without signs of perforation or peritonitis, can be safely performed with a success rate of 82%. Enema reduction can be performed in various ways according to image guidance method (fluoroscopy or ultrasonography) and reduction medium (liquid or air). Successful enema reduction is less likely to be achieved in children with a longer symptom duration, younger age, lethargy, fever, bloody diarrhea, unfavorable radiologic findings (small bowel obstruction, trapped fluid, ascites, absence of flow in the intussusception, intussusception in the left-sided colon), and pathological lead points. This review highlights the current concepts of intussusception diagnosis, nonsurgical enema reduction, success rates, predictors of failed enema reduction, complications, and recurrence to guide general pediatricians in the management of childhood intussusception.

Reduction of ileocolic intussusception under sedation or anaesthesia: a systematic review of complications

BACKGROUND

Despite the increased use of sedation in children undergoing stressful procedures, reduction of ileocolic intussusception (RII) is usually performed on awake children without any form of sedation.

OBJECTIVE

To evaluate the incidence of severe complications of RII under sedation or anaesthesia.

DESIGN

A systematic review including English language original articles of any date.

PATIENTS

Children undergoing RII (pneumatic or hydrostatic) under sedation or anaesthesia.

DATA SOURCES

Ovid Embase, Scopus, PubMed, the Cochrane Database of Systematic Reviews and the internet search engine Google Scholar.

DATA EXTRACTION

Three authors independently reviewed each article for eligibility. The Newcastle-Ottawa Scale was used to assess the quality of included studies.

MAIN OUTCOME MEASURES

The primary outcome was the incidence of intestinal perforation during RII. The secondary outcomes were the incidence of sentinel adverse events defined as death, cardiopulmonary resuscitation, permanent neurological deficit and pulmonary aspiration syndrome.

RESULTS

The search yielded 368 articles. Nine studies with 1391 cases were included in the analysis. Of the nine studies, six had a score of ≤6 stars in the Newcastle-Ottawa Scale assessment, indicating low-to-moderate quality. Propofol-based sedation was used in 849 (59.2%) cases; 5 (0.6%) had intestinal perforation. Intestinal perforation was not reported in patients who were sedated with other sedatives. One patient had pulmonary aspiration syndrome.

CONCLUSIONS

Although caution remains warranted, current data suggest that the incidence of severe complications due to RII under sedation or anaesthesia is low. Due to the lack of prospective data, it is difficult to ascertain the exact incidence of severe complications.

Periprocedural analgesia and sedation in air enema reduction for intussusception: A retrospective Australian cohort study

AIM

Periprocedural analgesia or sedation for air enema reduction (AER) of intussusception is a matter of debate. We set out to review Australian periprocedural pain management in AER.

METHODS

Retrospective electronic medical record review of emergency department presentations of intussusception at an Australian children's hospital over 2 years for periprocedural analgesia and sedation and short-term outcomes.

RESULTS

A total of 73 patients (mean age 23 months) had ultrasound-confirmed intussusception. Prior to AER, analgesia was administered to 61 of 73 (83.5%) patients. Opioids were administered in 48 of 73 (65.8%) and 8 of 73 (11.0%) received sedation. Thirteen of 73 (17.8%, 95% confidence interval 9.0-26.6) had spontaneously reduced; 60/73 that underwent primary AER had successful reduction in 54 (90.0%, 95% confidence interval 82.4-97.6). A total of seven patients required surgery. No AER attempts were complicated by bowel perforation.

CONCLUSION

The use of periprocedural analgesia for AER in this Australian series was common, whilst sedation use was infrequent. No perforations occurred.

Practical Imaging Strategies for Intussusception in Children

OBJECTIVE. Intussusception is the most common cause of intestinal obstruction in young children. Radiology has a key role in its diagnosis and treatment. This systematic review summarizes the currently available evidence for best practices in radiologic management of pediatric intussusception. CONCLUSION. High diagnostic accuracy and lack of ionizing radiation make ultrasound (US) the preferred imaging modality for diagnosing intussusception. For intussusception reduction, fluoroscopy-guided pneumatic enema and US-guided hydrostatic enema are equally dependable and safe techniques. The areas that warrant further research in this field include the efficacy and safety of the US-guided pneumatic enema, potential benefits of sedation and general anesthesia for the reduction procedure, and the optimal management of intussusceptions potentially involving pathologic lead points.

Sedated ultrasound guided saline reduction (SUR) of ileocolic intussusception: 20 year experience

BACKGROUND

Ileocolic intussusception is a common abdominal emergency in children, diagnosed routinely with ultrasound and treated most frequently with fluoroscopic pneumatic reduction without sedation. Alternatively, ultrasound can also be used to obviate ionizing radiation and sedation can be used to avoid discomfort from the procedure. The purpose of this study was to present our experience with sedation using saline enema under ultrasound guided control to reduce ileocolic intussusception.

MATERIALS AND METHODS

This is a retrospective study of patients with ileocolic intussusception presenting to a tertiary care hospital between 1998 and 2018. We excluded the data of patients that underwent either fluoroscopic guided reduction with barium enema or primary surgery. All patients received sedation with propofol and subsequently underwent our sedated ultrasound guided saline reduction (SUR) protocol until reduction was confirmed.

RESULTS

414 total reductions were performed in the 338 children who underwent our SUR protocol, of which 86.0% were successful. Zero perforations occurred during attempted reduction. 58 patients required surgery after a failed reduction (14.0%). There were 76 recurrent episodes that underwent our SUR protocol, of which 93.4% had a successful reduction.

CONCLUSION

The success rate of reduction was high and compared similarly to techniques that either use pneumatic reduction under radiation or refrain from administering a sedative prior to enema.

LEVEL OF EVIDENCE

Treatment study level III.

Commentary regarding sedated ultrasound guided saline reduction (SUR) of ileocolic intussusception; 20 year experience

This is a commentary on the manuscript by Sacks R, Anconina R, Farkas E, et al, titled "Sedated Ultrasound Guided Saline Reduction (SUR) of Ileocolic Intussusception: 20 Year Experience".

A new enema for treatment of intussusception with hydrostatic reduction: Olive oil

OBJECTIVES

Intussusception is routinely treated using ultrasound-guided hydrostatic reduction (USGHR) with normal saline in our paediatric surgery department. With this study, olive oil was added to normal saline in ultrasound-guided reduction of intussusception.

MATERIALS AND METHODS

Forty patients who were diagnosed and treated for intussusception in Van Yuzuncu Yıl University Faculty of Medicine Pediatric Surgery Department from March 2017 to May 2017 were included in the study. During this retrospective study, randomly chosen 20 patients that treated with USGHR using normal saline were marked as Group 1. Moreover, 20 patients that treated with USGHR using a mixture of olive oil and saline (10% olive oil 90% normal saline) were marked as Group 2. Patients' age, gender, symptoms, treatment techniques, complications and hospitalisation periods were retrospectively noted.

RESULTS

Forty patients were included in the study. In Group 1, 14 patients were treated in the first session, 4 patients were treated in the second session and 2 patients required laparotomy. Mean reduction time in this group was 15 min mean fluid volume used in each reduction was 80 ml/kg and mean hospitalisation period was 38 h. In Group 2, 19 patients were treated in the first session, and only 1 patient required a second session. Mean reduction time was 12 min, used fluid volume was 58 ml/kg for each reduction and hospitalisation period was 24 h.

CONCLUSION

The average volume of fluid used for reduction, average reduction time, numbers of recurrent reductions and hospitalisation were less when a mixture of olive oil and normal saline were used in comparison with when normal saline was used alone to reduction the intussusception under ultrasound guidance. Using olive oil mixed with normal saline as a new enema fluid is likely to increase the success rate of ultrasound-guided reduction of intussusception.

Emergency Physician-Administered Sedation for Pneumatic Reduction of Ileocolic Intussusception in Children: A Case Series

BACKGROUND

Ileocolic intussusception is a major cause for intestinal obstruction in early childhood. Reduction of intussusception, in the vast majority of institutions, is performed on awake children, without sedation.

OBJECTIVE

The aim of this study was to report the course of the first patients who were sedated by emergency physicians for pneumatic reduction of intussusception (PRI).

METHODS

We conducted a case series analysis of prospectively collected data on patients undergoing PRI, using a sedation recording tool. This tool uses standardized definitions from the Quebec guidelines for terminology and reporting adverse events in emergency medicine. Recording of time interval measurements and adverse events was performed by the emergency physician and nurse.

RESULTS

Between February 2016 and March 2018, 11 males and 3 females, with a median age of 11 months (interquartile range [IQR] 6-20 months), underwent sedation for PRI by five attending pediatric emergency physicians. All of the reductions were successful and without complications. Eight patients received ketamine and propofol, 5 received ketamine, and 1 received ketamine and midazolam. Median times for the presedation phase, procedure, sedation, physiologic recovery and emergency department recovery were: 131 min (IQR 79-104 min), 10.5 min (IQR, 9-12 min), 21 min (IQR, 20-30 min), 25 min (IQR, 23-30 min), and 108 min (IQR, 82-161 min), respectively. Four respiratory adverse events that required intervention were recorded. All were effectively treated with airway repositioning, suctioning, oxygen administration, or bag-mask ventilation.

CONCLUSIONS

The first series of patients sedated for PRI by emergency physicians is reported. Our initial findings suggest the feasibility of emergency physician-administered sedation for PRI.

Comparative safety and efficacy of balloon use in air enema reduction for pediatric intussusception

BACKGROUND

Intussusception, a common cause of bowel obstruction in young children, is primarily treated with air enema reduction. There is little literature comparing the safety and efficacy of air reduction without or with a rectal balloon.

OBJECTIVE

To determine the safety and efficacy of a rectal balloon seal in air enema reduction.

MATERIALS AND METHODS

We retrospectively reviewed the records of children who underwent air reduction for ileocolic or ileo-ileocolic intussusception over an 8-year period. We sorted data from 566 children according to whether a rectal balloon was used in the reduction, and further sorted them by type and experience level of the practitioner. Using logistic regression analyses, we identified risk factors for iatrogenic bowel perforation or failed reduction.

RESULTS

Significant associations with bowel perforation included balloon use (P=0.038), age <1 year (P<0.0001), and attending physician's level of experience <5 years (P=0.043). Younger age was associated with both perforation (P<0.0001) and procedural failure (P=0.001). The risk-adjusted predicted probability of perforation decreased with age, approaching zero by 10 months regardless of balloon use. For cases without bowel resection, the risk-adjusted predicted probability of failure decreased toward zero by 30 months with balloon use, while remaining constant at 3-12% regardless of age when not using a balloon.

CONCLUSION

The likelihood of a successful air reduction might be safely increased by using an inflated rectal balloon in children older than 9 months. Use of a balloon in younger infants is associated with a higher risk of iatrogenic bowel injury.

Intussusception reduction: Effect of air vs. liquid enema on radiation dose

BACKGROUND

Both air and radiopaque liquid contrast are used to reduce ileocolic intussusception under fluoroscopy. Some suggest air lowers radiation dose due to shorter procedure times. However, air enema likely lowers radiation dose regardless of fluoroscopy time due to less density over the automatic exposure control cells.

OBJECTIVES

We test the hypothesis that air enema reduction of ileocolic intussusception results in lower radiation dose than liquid contrast enema independent of fluoroscopy time. We describe a role for automatic exposure control in this dose difference.

MATERIALS AND METHODS

We retrospectively evaluated air and liquid intussusception reductions performed on a single digital fluoroscopic unit during a 26-month period. We compared patient age, weight, gender, exam time of day and year, performing radiologist(s), radiographic image acquisitions, grid and magnification use, fluoroscopy time and dose area product. We compared categorical and continuous variables statistically using chi-square and Mann-Whitney U tests, respectively.

RESULTS

The mean dose area product was 2.7-fold lower for air enema, 1.3 ± 0.9 dGy·cm², than for liquid, 3.5 ± 2.5 dGy·cm² (P<0.005). The mean fluoroscopy time was similar between techniques. The mean dose area product/min was 2.3-fold lower for air, 0.6 ± 0.2 dGy·cm²/min, than for liquid, 1.4 ± 0.5 dGy·cm²/min (P<0.001). No group differences were identified in other measured dose parameters.

CONCLUSION

Fluoroscopic intussusception reduction using air enema uses less than half the radiation dose of liquid contrast enema. Dose savings are independent of fluoroscopy time and are likely due to automatic exposure control interaction.

Intussusception: past, present and future

Intussusception is a common etiology of acute abdominal pain in children. Over the last 70 years, there have been significant changes in how we diagnose and treat intussusception, with a more recent focus on the role of ultrasound. In this article we discuss historical and current approaches to intussusception, with an emphasis on ultrasound as a diagnostic and therapeutic modality.

Comparative Effectiveness of Imaging Modalities for the Diagnosis and Treatment of Intussusception: A Critically Appraised Topic

RATIONALE AND OBJECTIVES

The purpose of this study was to critically appraise and compare the diagnostic performance of imaging modalities that are used for the diagnosis of intussusception and methods used in the treatment of ileocolic intussusception.

METHODS

A focused clinical question was constructed and the literature was searched using the patient, intervention, comparison, outcome (PICO) method comparing radiography, ultrasound, and computed tomography in the detection of intussusception. The same methods were used to compare pneumatic (gas) reduction and hydrostatic (liquid) reduction using saline, water-soluble contrast, and barium. Retrieved articles were appraised and assigned a level of evidence based on the Oxford University Centre for Evidence-Based Medicine hierarchy of validity for diagnostic studies.

RESULTS

The retrieved sensitivity for the diagnosis of intussusception using plain radiography is 48% (95% confidence interval [CI], 44%-52%), with a specificity of 21% (95% CI, 18%-24%). The retrieved sensitivity for the diagnosis of intussusception using ultrasound is 97.9% (95% CI, 95%-100%), with a specificity of 97.8% (95% CI, 97%-99%). Based on a good quality meta-analysis, the combined success rate of gas enema reduction was shown to be 82.7% (95% CI, 79.9%-85.6%) compared to a combined success rate of 69.6% (95% CI, 65.0%-74.1%) for liquid enema reduction.

CONCLUSIONS

The best available evidence recommends ultrasound as the diagnostic modality of choice for the diagnosis of ileocolic intussusception in children. In stable children without signs of peritonism, nonoperative reduction is the treatment of choice. Pneumatic (gas) reduction enema has been shown to be superior to hydrostatic (liquid) enema reduction.

Success rate of pneumatic reduction of intussusception with and without sedation

BACKGROUND

Pneumatic reduction of ileocolic intussusception is often performed without sedation. The aim of this study was to evaluate the success rate of pneumatic reduction of intussusception with and without sedation.

METHODS

We conducted a retrospective cohort study in Israel in two tertiary care centers using a similar protocol for pneumatic reduction of intussusception. In one center, patients had pneumatic reduction of intussusception under propofol-based sedation, while in the other, patients had pneumatic reduction of intussusception without any sedation. Children aged 3 months to 8 years who were diagnosed with ileocolic intussusception between January 1, 2008 and July 31, 2015 were included in the study. Multivariable regression was used to adjust for the possible confounders of age, gender, number of cases of intussusception prior to the study period, time period from the beginning of symptoms to emergency department admission (<12 h, >12 h), and time period from emergency department admission to the beginning of pneumatic reduction of intussusception. Secondary outcomes of the study included the proportion of bowel perforations during the procedure, and the proportion of early (within 48 h) recurrence of intussusception.

RESULTS

The sedation and nonsedation cohorts included 124 and 90 patients, respectively. The cohorts were comparable with regard to demographic characteristics, hemodynamic vital signs on admission to the emergency department, blood gases tests during emergency department stay, and time variables prior to reduction of intussusception. Multivariable regression revealed reduction of intussusception success rates of 89.5% and 83.3% for the sedation group and nonsedation group, respectively, with an adjusted odds ratio of 1.2, 95% CI 1.1-5.3. Three sedated patients and 0 nonsedated patients developed bowel perforations during the procedure. Rates of early recurrence of intussusception of sedated patients and nonsedated patients were 5.1% (6/117) and 1.3% (1/79), respectively (P = 0.15, RR = 3.9, 95% CI: 0.47 to 31.81).

CONCLUSION

The findings suggest that the pneumatic reduction of intussusception under propofol-based sedation had a slightly higher success rate than the pneumatic reduction of intussusception without sedation; however, the safety of this practice is yet to be determined.

Simple and Safe Device for Pneumatic Reduction of Intussusception

An apparatus for gas enema technique at intussusception in children has been constructed.

Meta-analysis of Air Versus Liquid Enema for Intussusception Reduction in Children

OBJECTIVE

The purpose of this study was to assess the effectiveness and safety of air versus liquid enema reduction in the treatment of intussusception in children.

MATERIALS AND METHODS

Literature searches of the PubMed, Embase, and Cochrane Library databases were conducted from January 1, 1966, through May 31, 2013. Articles on the use of air or liquid enema in children with a confirmed diagnosis of intussusception and reporting either a success rate for enema reduction of intussusception or a perforation rate were selected. Enema reduction success rate, perforation rate, and recurrence rate were the main outcomes and were calculated by random effects modeling.

RESULTS

One hundred two articles (101 reporting success rate, 71 reporting perforation rate) were included that presented results for 32,451 children (age range, 1 day-22 years; boys, 66%; girls, 34%). In 44 studies (16,187 children), the combined estimate for success rate of air enema was 82.7% (95% CI, 79.9-85.6%; inconsistency index [I(2)] = 97%), and in 52 studies (13,081 children) of liquid enema, it was 69.6% (95% CI, 65.0-74.1%; I(2) = 98%). In 38 studies (15,752 children), the combined estimate of perforation rate for air enema was 0.39% (95% CI, 0.23- 0.55%; I(2) = 40%), and in 30 studies (9429 children) of liquid enema, it was 0.43% (95% CI, 0.24- 0.62%; I(2) = 9%). Among 10,494 children (26 studies) undergoing air enema reduction, the rate of first intussusception recurrence was 6% (95% CI, 4.5-7.5%; I(2) = 89%), similar to the 7.3% (95% CI, 5.8-8.8%; I(2) = 71%) found for 4004 children (24 studies) undergoing liquid enema reduction.

CONCLUSION

Air enema was superior to liquid enema for intussusception reduction. The success rate was higher without a difference in perforation rate. Limitations included heterogeneity and publication bias.

Pneumatic colon injury following high pressure blow gun dust cleaner spray to the perineum

•

Accident related pneumatic colon perforation is difficult to diagnose in children preoperatively as they are anxious to tell the history of trauma.

•

The presence of pneumoperitoneum always leads to exploratory laparotomy.

•

The sudden onset of tension pneumoperitoneum, intraoperative of multiple site colon injury with or without perforation in normal children should suspect the presence of trauma.

•

Creation of ostomy at the site of normal looking colon preferable to colon resection.

Introduction

A pneumatic tool or air tool such as blow gun dust cleaner is a tool driven by compressed air and spraying of the perineum can insufflate the colon due to its high pressure and high flow rate.

Presentation of case

We present a case of 4 year old boy who developed sudden onset of tense abdominal distention and developed peritonitis. Patient’s family initially denied a history of trauma. Radiologic examination showed pneumoperitoneum and colon dilatation. Exploratory laparotomy revealed a tension pneumoperitoneum, bloody ascitic fluid, multiple site of ecchymosis and serosal tear of the colon and a minute perforation of transverse colon. Postoperative reinvestigation revealed that the patient’s perineum was sprayed, using blow gun dust cleaner.

Discussion

Air from pneumatic tools produces column of air at pressure of 3.5–8.8 kg/cm² and pressure greater than the resting anal pressure of 0.109 kg/cm² force air to enter the colon when the perineum is sprayed. Different degree of colon injury results when airflow is greater than 1.46 L/m, and/or intraluminal pressure greater than 0.109 kg/cm². In most children, initial anxiety to tell the truth result in difficulty to obtain good history.

Conclusion

Spraying of the perianal with excessive pneumatic force of greater than the resting anal pressure and high air flow rate causes multiple site colon injury and tension pneumoperitoneum due to colon perforation. Parent should be caution in children playing with high pressure pneumatic tool, and the importance of history is emphases for early correct diagnosis.

Japanese guidelines for the management of intussusception in children, 2011

BACKGROUND

The Japanese Society of Emergency Pediatrics has formulated evidence-based guidelines for the management of intussusception in children in order to diagnose intussusceptions promptly, to initiate appropriate treatment as early as possible, and to protect intussuscepted children from death.

METHODS

Literature was collected systematically via the Internet using the key words "intussusception" and "children." The evidence level of each paper was rated in accordance with the levels of evidence of the Oxford Center for Evidence-based Medicine. The guidelines consisted of 50 clinical questions and the answers. Grades of recommendation were added to the procedures recommended on the basis of the strength of evidence levels.

RESULTS

Three criteria of "diagnostic criteria,""severity assessment criteria," and "criteria for patient transfer" were proposed aiming at an early diagnosis, selection of appropriate treatment, and patient transfer for referral to a tertiary hospital in severe cases. Barium is no longer recommended for enema reduction (recommendation D) because the patient becomes severely ill once perforation occurs. Use of other contrast media, such as water-soluble iodinated contrast, normal saline, or air, is recommended under either fluoroscopic or sonographic guidance. Delayed repeat enema improves reduction success rate, and is recommended if the initial enema partially reduced the intussusception and if the patient condition is stable.

CONCLUSIONS

The guidelines offer standards of management, but it is not necessarily the purpose of the guidelines to regulate clinical practices. One should judge each individual clinical situation in accordance with experiences, available devices, and the patient's condition.

External manual reduction of paediatric idiopathic ileocolic intussusception with US assistance: a new, standardised, effective and safe manoeuvre

BACKGROUND

The ultimate goal in the management of paediatric ileocolic intussusception is to achieve non-operative reduction and therefore patient cure. The standard non-surgical treatment consists of enema (air or liquid media).

OBJECTIVE

The purpose of this study is to present external manual reduction for paediatric ileocolic intussusception. We present a new manoeuvre that is standardised, simple, safe and effective for the radiologist in the non-surgical management of this pathology.

MATERIALS AND METHODS

External manual reduction is performed under sedation. Execution of the manoeuvre is detailed and illustrated. The procedure was carried out 15 times in 13 paediatric patients with idiopathic ileocolic intussusception.

RESULTS

Complete reduction exclusively by external manual reduction was accomplished on 12 occasions (80%). In the remaining three procedures, partial reduction to the cecum was obtained. Subsequent enema achieved complete reduction in two. Overall non-surgical reduction rate was 93%.

CONCLUSION

External manual reduction is a radiation-free, safe and effective procedure. In case of incomplete reduction, it facilitates enema performance. External manual reduction incorporates and additional initial step in the non-surgical reduction of intussusception and should be considered a first-line procedure.

Colorectal perforation by self-induced hydrostatic pressure: a report of two cases

BACKGROUND

Most iatrogenic colorectal perforations occur as a result of endoscopic or fluoroscopic studies. Accidents associated with hydrostatic pressure-induced perforation are rarely reported, and self-induced hydrostatic pressure is an extremely rare cause of perforation because the anal sphincter complex may provide a protective barrier against perianal hydrostatic pressure. We present two cases of rectosigmoid colon perforation secondary to self-induced hydrostatic pressure.

CASE REPORTS

A 61-year-old man and a 45-year-old man presented with abdominal pain after forceful entry of tap water into the rectum, during rinsing of the anus after defecation in the first case, and during self-administered enema in the second case. Emergency operations were performed with the suspicion of hydrostatic pressure-induced rectal injury, and showed rectosigmoid mesenteric perforation in both cases. Resection of the diseased segment and end colostomy (Hartmann's procedure) was performed in the first case, and primary resection and anastomosis in the second case. The pathologic results showed abrupt loss of the colonic wall in the mesenteric border, without evidence of other inflammatory disease; these findings were consistent with acute mechanical colon injury. The postoperative course in both cases was uneventful.

CONCLUSION

These cases put forth an unusual type of colorectal injury, caused specifically by hydrostatic pressure, thus adding to the available literature on hydrostatic pressure-induced injury.

Deep sedation during pneumatic reduction of intussusception

BACKGROUND

Pneumatic reduction of intussusception under fluoroscopic guidance is a routine procedure. The unsedated child may resist the procedure, which may lengthen its duration and increase the radiation dose. We use deep sedation during the procedure to overcome these difficulties.

OBJECTIVE

The purpose of this study was to summarize our experience with deep sedation during fluoroscopic reduction of intussusception and assess the added value and complication rate of deep sedation.

MATERIALS AND METHODS

All children with intussusception who underwent pneumatic reduction in our hospital between January 2004 and June 2011 were included in this retrospective study. Anesthetists sedated the children using propofol. The fluoroscopic studies, ultrasound (US) studies and the childrens' charts were reviewed.

RESULTS

One hundred thirty-one attempted reductions were performed in 119 children, of which 121 (92%) were successful and 10 (8%) failed. Two perforations (1.5%) occurred during attempted reduction. Average fluoroscopic time was 1.5 minutes. No complication to sedation was recorded.

CONCLUSIONS

Deep sedation with propofol did not add any complication to the pneumatic reduction. The fluoroscopic time was short. The success rate of reduction was high,raising the possibility that sedation is beneficial, possibly by smooth muscle relaxation.

Pediatric radiology fellows' experience with intussusception reduction

BACKGROUND

Intussusception reduction allows young children to avoid surgery. However, graduating residents have had relatively little training in intussusception reduction and, for the most part, consider themselves ill-prepared to perform this procedure.

OBJECTIVE

The goal of this study was to assess the extent of training in intussusception reduction during one year of a pediatric radiology fellowship and to determine whether graduating fellows consider themselves adequately trained in this technique.

MATERIALS AND METHODS

Pediatric radiology fellows were surveyed during June 2010 and asked to characterize their fellowship, to indicate the number of intussusception reductions performed (both the total number and those performed with faculty oversight but without active faculty involvement), and to assess the adequacy of their training.

RESULTS

There were 31 responses, representing almost 1/3 of current fellows. Pediatric radiology fellows perform on average 6.9 reductions, 3.8 of which are with faculty oversight but without active faculty involvement. Ninety percent consider themselves well-trained in the technique, whereas 10% are uncertain (none consider their training inadequate).

CONCLUSION

Almost all pediatric radiology fellows consider their training in intussusception reduction to be adequate.

Functional evaluation of the endotics system, a new disposable self-propelled robotic colonoscope: in vitro tests and clinical trial

OBJECTIVE

Currently, the best method for CRC screening is colonoscopy, which ideally (where possible) is performed under partial or deep sedation. This study aims to evaluate the efficacy of the Endotics System, a new robotic device composed of a workstation and a disposable probe, in performing accurate and well-tolerated colonoscopies. This new system could also be considered a precursor of other innovating vectors for atraumatic locomotion through natural orifices such as the bowel. The flexible probe adapts its shape to the complex contours of the colon, thereby exerting low strenuous forces during its movement. These novel characteristics allow for a painless and safe colonoscopy, thus eliminating all major associated risks such as infection, cardiopulmonary complications and colon perforation.

METHODS

An experimental study was devised to investigate stress pattern differences between traditional and robotic colonoscopy, in which 40 enrolled patients underwent both robotic and standard colonoscopy within the same day.

RESULTS

The stress pattern related to robotic colonoscopy was 90% lower than that of standard colonoscopy. Additionally, the robotic colonoscopy demonstrated a higher diagnostic accuracy, since, due to the lower insufflation rate, it was able to visualize small polyps and angiodysplasias not seen during the standard colonoscopy. All patients rated the robotic colonoscopy as virtually painless compared to the standard colonoscopy, ranking pain and discomfort as 0.9 and 1.1 respectively, on a scale of O to 10, versus 6.9 and 6.8 respectively for the standard device.

CONCLUSIONS

The new Endotics System demonstrates efficacy in the diagnosis of colonic pathologies using a procedure nearly completely devoid of pain. Therefore, this system can also be looked upon as the first step toward developing and implementing colonoscopy with atraumatic locomotion through the bowel while maintaining a high level of diagnostic accuracy;

An air insufflation device for reduction of intussusception in children

The authors have developed a portable device for insufflation of air reliably at pressures accepted as safe for effective reduction of intussusception in children under fluoroscopic guidance. The results of reduction with the device were equal to those by saline enema reduction under ultrasound guidance.

Intermittent sonographic guidance in air enemas for reduction of childhood intussusception

OBJECTIVE

The purpose of this study was to prospectively assess the value of intermittent sonographic guidance in nonsurgical air reduction of childhood intussusception.

METHODS

The study group included 86 consecutive childhood intussusceptions confirmed on sonography for which we designed an air enema. With intermittent sonographic guidance of our own method, air was gradually injected to the initial intracolonic pressure of 60 mm Hg, which we attempted for 30 seconds on the initial attempt. If the air enema reduction attempts were not successful at a given pressure setting, we repeated the technique at each pressure setting upgraded by increments of 20 mm Hg up to 120 mm Hg. Surgery was performed when even repeated reduction attempts at the maximum intracolonic pressure of 120 mm Hg were unsuccessful. We calculated the successful reduction rate for the intussusceptions at each pressure setting.

RESULTS

The overall success rate of sonographically guided air enema reductions was 95% (82/86). The success rates of air enema reductions at 60, 80, 100, and 120 mm Hg showed progressive increases of 53% (42/86), 67% (58/86), 78% (67/86), and 95% (82/86), respectively, with no immediate recurrence and no gross perforation.

CONCLUSIONS

The use of intermittent sonographic guidance in air enemas is thought to help safely increase successful reductions of childhood intussusception even with sufficient air enema attempts.

Retrograde hydrostatic irrigation enema-induced perforation of the sigmoid colon in a chronic renal failure patient before colonoscopy

We present a rare case of colon perforation caused by hydrostatic irrigation enema in a patient with chronic renal failure. A 76-year-old woman was admitted to our hospital because of an exacerbation of lumbar pain and increased difficulty in walking. She had a medical history of traumatic neck pain and chronic lower back pain, which had been treated with non-steroidal anti-inflammatory drugs (NSAIDs) for 8 years. On admission, the C-reactive protein level was 6.8 mg/dl, so we planned to do a colonoscopy to determine the cause of inflammation. The patient developed abdominal pain approximately 3.5 h after a pre-procedural enema was administered. An emergency operation was performed and a small perforation was found in the sigmoid colon. We conclude that the cause of the colon perforation was a combination of the use of a hydrostatic retrograde irrigation enema in a patient with chronic renal failure who had been treated with long-term NSAIDs.

Clinically Suspected Intussusception in Children: Evidence-Based Review and Self-Assessment Module

OBJECTIVE

This article uses case examples to review the current evidence for the management of children with clinically suspected intussusception.

CONCLUSION

In this educational module, we review the evidence for diagnostic and management strategies in children with clinically suspected intussusception.

Life threatening tension pneumoperitoneum from intestinal perforation during air reduction of intussusception

We present a case report of a child with intussusception who underwent air reduction which was complicated by bowel perforation. Life threatening tension pneumoperitoneum developed rapidly and immediate needle decompression was life saving in this case. The pathophysiology of hyperacute abdominal compartment syndrome is discussed.

Intussusception in children: US-guided pneumatic reduction--initial experience

PURPOSE

To assess the feasibility and effectiveness of ultrasonography (US)-guided pneumatic reduction of intussusception in children.

MATERIALS AND METHODS

The study group consisted of 49 consecutive patients (aged 2 months to 7 years; 36 boys, 13 girls) who underwent 52 reductions of intussusception during 9 months. Intussusception was diagnosed in all patients with the known US criteria, and all patients underwent a US-guided pneumatic reduction attempt wholly within the US examination room. A pressure of 60 mm Hg was maintained for 30 seconds, with US guidance. The procedure was considered to be successful when US showed the disappearance of the intussusceptum and the edematous terminal ileum with an abrupt transition into the normal proximal ileum. When the intussusception was not reduced, the procedure was repeated, with pressure increased to 120 mm Hg.

RESULTS

The overall success rate of US-guided pneumatic reduction was 92% (48 of 52 reductions), with no immediate recurrence. Of the two patients who had intussusceptions that were irreducible, one had residual ileoileal intussusception at surgery, and the other had an ileal polyp as a lead point. Perforation occurred in two (4%) of 52 cases; one patient underwent right hemicolectomy due to bowel necrosis and had a pinpoint perforation in the normal proximal transverse colon, and the other underwent manual reduction of ileoileocolic intussusception, with microperforation in the proximal transverse colon.

CONCLUSION

US-guided pneumatic reduction seems to be a feasible and effective method for the treatment of intussusception in children because of its radiation-sparing effect and high success rate.

A reply

Dr McHugh, K. and Dr Rosenfeld, K. (1999). Clinical Radiology54, 452-458. Copyright 2000 The Royal College of Radiologists.

Enema-induced perforation of the rectum in chronically constipated patients

INTRODUCTION

The use of retrograde irrigation enemas is common in the treatment of chronic constipation, especially in the elderly. Perforation of the rectum and sigmoid colon caused by cleansing enemas, used by chronically constipated patients, has not been previously described.

METHODS

We reviewed all patients with colorectal perforations caused by irrigation enemas admitted to our service in the three-year period between January 1995 and December 1997.

RESULTS

Thirteen patients were treated by our surgical service because of perforations of the rectum and sigmoid colon related to a previous retrograde irrigation enema. Ten of these patients came from nursing homes, and the other three lived at home. The relevant information relating the enema administration to the patient's condition was given in only two of the ten patients referred to the emergency room by the institution's nursing or medical staff. In the other eight the information was vague and sometimes misleading. The diagnosis of colorectal perforation was made by history, plain abdominal x-rays, and CT scan with or without meglumine diatrizoate enemas. Ten patients survived, regardless of age, previous diseases, or operative findings. In all of them, diagnosis was made within 36 hours from the perforation. The three deaths occurred in patients in whom the diagnosis was made late.

CONCLUSIONS

Awareness of the possible injury from enemas administered to chronically constipated patients should be stressed. A high degree of suspicion by the attending physician is extremely important, because prompt diagnosis and early surgical treatment carries a relatively good prognosis.

Survey of intussusception reduction in England, Scotland and Wales: how and why we could do better

AIM

The aim of our study was to assess the variation in technique among hospitals in England, Wales and Scotland. In addition, local in hospital variation among paediatric radiologists at our own institution was assessed.

METHOD

Postal questionnaires were distributed to the radiology departments of 301 hospitals.

RESULTS

183 (60.8%) replies were received. 122 institutions reduced intussusceptions and 61 did not. A lack of paediatric surgical and/or anaesthetic cover, and a lack of radiological experience were the major reasons cited by the departments which did not attempt intussusception reduction. Sixty-five hospitals use barium for hydrostatic reduction, 43 employ pneumatic reduction, 10 use water-soluble enemas and four use ultrasound. Of the 65 centres using barium 16 (25%) reported a success rate of less than 50%, 24 (37%) had a 50-70% success rate, seven (11%) reduce greater than 70% of intussusceptions and 18 (27%) did not know. In the 43 institutions employing air reduction, one (2%) had a success rate less than 50%, 20 (47%) had a 50-70% success rate, 17 (40%) a success rate greater than 70% and five (11%) did not know. Overall, of the total number of hospitals which replied to our survey, 28 (23%) reported that they were not aware of their success rates. Within the pneumatic reduction group in particular there was marked variation in the methods and duration of attempted reduction - between different hospitals and within the same institution. In six departments the machine used for pneumatic reduction did not measure intraluminal pressure.

CONCLUSIONS

Ultrasound is underutilized despite being a sensitive method in diagnosis. There is almost certainly an over-reliance on plain radiographs and on the use of sedation, antibiotics and anti-spasmodics in general. We believe a 70% or greater success rate should be achievable in most institutions whether by pneumatic or hydrostatic reduction, and all departments should strive to achieve success rates in this range. Less than a quarter of centres who replied currently achieve this standard. Successful reduction rates below 50% are unacceptable in our opinion. Not surprisingly, success rates are generally highest in those centres treating more than 20 cases per annum. Twenty-eight (23%) of hospitals performing intussusception reductions did not know their success rates. Regular audits of intussesception figures should take place in all institutions. Unacceptably wide variations in intussusception reduction techniques currently exist. An accurate pressure release valve at least, and preferably intraluminal pressure monitoring should be an integral component of all pneumatic reduction devices. The British Paediatric Radiology and Imaging Group or the Royal College of Radiology should address these issues and introduce some standardization of practice.

Intussusception in children: current concepts in diagnosis and enema reduction

Intussusception cannot be reliably ruled out with clinical examination and plain radiography. However, a contrast material enema study and ultrasonography (US) allow definitive diagnosis of intussusception. The components of an intussusception produce characteristic appearances on US scans. These appearances include the multiple concentric ring sign and crescent-in-doughnut sign on axial scans and the sandwich sign and hayfork sign on longitudinal scans. Indicators of ischemia and irreducibility are trapped fluid at US and absence of blood flow at Doppler imaging. The aim of enema therapy is to reduce the greatest number of intussusceptions without producing perforation. Barium, water-soluble contrast media, water, electrolyte solutions, or air may be used with radiographic or US guidance. The differences in reduction and perforation rates between the various types of enemas are probably due more to perforations that occurred before enema therapy and the pressure exerted within the colon than to the contrast material used. The pressure within the colon is more constant with hydrostatic reduction than with air reduction; this fact may explain the lower risk of perforation with hydrostatic reduction. Radiation exposure is lower with air enema therapy than with barium enema therapy and is absent in US-guided enema therapy.

Controversies in abdominal imaging

Technologic improvement in ultrasound equipment, together with new clinical information, has altered the imaging of the abdomen in infants. Improvements in ultrasound equipment have allowed this to become the diagnostic test of choice for hypertrophic pyloric stenosis. Barium upper gastrointestinal radiography still remains the diagnostic test of choice for malrotation. New technologies for reduction of intussusception include air reduction and saline enemas with ultrasound monitoring. Controversies surrounding the different technologies and imaging strategies are discussed.

Childhood intussusception: ultrasound-guided Hartmann's solution hydrostatic reduction or barium enema reduction?

A comparison was made of the efficacy of ultrasound guided Hartmann's solution hydrostatic reduction on 23 patients (US group) with the same number of consecutive patients in whom hydrostatic reduction was done by barium enema (BE group) under fluoroscopy for childhood intussusception. The US group was diagnosed by ultrasound scan and reduction was attempted under the guidance of ultrasonography with Hartmann's solution at 100 mm Hg pressure. Excluded were patients older than 12 years, patients in shock, patients with peritonitis, bowel perforation, and gross abdominal distension as well as recurrent intussusception of more than three episodes. There were three patients excluded in this group. The diagnosis of intussusception and complete reduction were confirmed by gastrografin enema. This US group had three recurrences (3 of 26, 11.5%), one lead point (1 of 23, 4.4%), and 19 successful reductions (19 of 26, 73%). Incidentally, there were also three patients excluded in this period of barium enema reduction. There was only one recurrence (1 of 24, 4.2%), one leadpoint (1 of 23, 4.4%), and 12 successful reductions (12 of 24, 50%) in these 23 BE patients. The success rates for the ileo-colic intussusceptions with Hartmann's solution reduction and barium enema reduction were 91% (19 of 21) and 55% (12 of 22), respectively (P = .00865). There was no complication in either group, and the accuracy of diagnosing a complete reduction was 100% in both forms of reduction. Hence, ultrasound-guided hydrostatic reduction for childhood ileocolic intussusception is preferred because it is safe, accurate, has a higher success rate, and can avoid radiation exposure risk.

Perforation of the sigmoid colon by hydrostatic pressure of a public water fountain

A 39-year-old woman presented to the emergency department complaining of rectal bleeding and abdominal pain 7 h after sitting on a water display fountain. On examination, the abdomen was rigid, and the patient had a prolapsed rectum with rectal bleeding. A chest radiograph demonstrated free air. On emergent exploratory laparotomy, the patient had a perforated sigmoid colon at the rectosigmoid junction with gross abdominal soilage. The patient survived to hospital discharge. This case provides a review of the literature regarding hydrostatic injury to the colon and other self-induced colorectal perforations.

Perforation during attempted intussusception reduction in children--a comparison of perforation with barium and air

This paper compares the effects on patients of perforation with barium and with air during attempted intussusception reduction by reviewing the clinical, radiological, surgical and pathological findings and sequelae in seven children who received barium and seven who received air. In both groups perforation occurred in infants under 6 months of age (with one exception) with a long duration of symptoms. All patients with barium enema required resection of bowel whereas only four with air enema required resection. Anesthetic times were longer in those patients with barium perforation in whom the intussusception did not move and there was a large leak. The patients with perforation due to air had a shorter hospital stay with decreased morbidity compared to those with perforation due to barium. Perforation occurred through areas of transmural necrosis in a minority of patients in each group. Perforations through normal bowel and shear injury (with air enema) indicate that increased pressure during the examination is an important factor in some patients. Because perforation with air is so much easier to deal with surgically and the children do better clinically, there is a tendency for some to consider perforation with air an inconsequential situation. However, a potential rare complication with this technique is tension pneumoperitoneum. Keeping this in mind, we continue to use air as the contrast of choice because the procedure in our hands is a safe, quicker and easier technique and we have achieved a substantial improvement in reduction rates. Overall reported perforation rates with air enema compare favourably with those due to barium enema.(ABSTRACT TRUNCATED AT 250 WORDS)