Air intussusception reduction: "the winds of change"

Effects of sedatives on radiologic enema reduction in children with ileocolic intussusception: A systematic review and meta-analysis

BACKGROUND

In children with ileocolic intussusception, sedatives such as midazolam, ketamine and propofol may facilitate radiologic enema reduction, but studies on their separate and joint effects remain controversial.

OBJECTIVES

We aimed to systematically analyze studies for the effects of sedatives on the radiologic reduction of ileocolic intussusception in children.

METHODS

We searched PubMed, EMBASE, CINAHL, Scopus and Web of Science from database inception through March 2023 for articles that enrolled children with ileocolic intussusception who underwent non-operative pneumatic or hydrostatic enema reduction under ultrasound or fluoroscopic guidance with or without the use of sedatives. The primary and secondary outcomes were success rate in radiologic reduction of ileocolic intussusception and risk of perforation, respectively. Effect estimates from the individual studies were extracted and combined using the Hartung-Knapp-Sidik-Jonkman log-odds random-effects model. Heterogeneity between studies was checked using Cochran's Q test and the I2 statistic.

RESULTS

A total of 17 studies with 2094 participants were included in the final review, of which 15 were included in the meta-analysis. Nine studies reported on the success rate of radiologic reduction performed under sedation in all participants, while six studies compared the success rate in two patient groups undergoing the procedure with or without sedation. The pooled success rate of non-operative reduction under sedation was 87 % (95 % CI: 80-95 %), P = 0.000 with considerable heterogeneity (I2 = 85 %). A higher success rate of 94 % (95 % CI: 88-99 %) and homogeneity (I2 = 12 %) were found in studies with pneumatic enema reduction. Among comparative studies, the odds of success of non-operative reduction were increased when the procedure was performed under sedation, with a pooled odds ratio of 2.41 (95 % CI: 1.27-4.57), P = 0.010 and moderate heterogeneity (I2 = 60 %). In a sensitivity analysis, homogeneity was found between analyzed studies when two outliers were excluded (I2 = 0.73 %). The risk of perforation was not significantly different (OR 1.52, 95 % CI: 0.09-23.34), P = 0.764 indicating small study effects. No publication, bias was detected on visual inspection of the funnel plots or the Begg's and Egger's bias tests. Most studies were categorized as having a low risk of bias using Joanna Briggs Institute checklists.

CONCLUSIONS

In selected patient groups, sedation can increase the success rate of radiologic enema reduction in children with ileocolic intussusception without evidence of increased risk of perforation. Systematic review protocol registration: PROSPERO CRD42023404887.

Ultrasound-guided pneumatic reduction of intussusception in children: 15-year experience in a tertiary children's hospital

BACKGROUND

International practice regarding the method used to nonoperatively reduce pediatric intussusception is variable.

OBJECTIVE

To provide an overview of ultrasound-guided pneumatic intussusception reduction and assess its safety and effectiveness.

MATERIALS AND METHODS

A single-center prospective study was conducted in a tertiary referral pediatric hospital during the 15-year period between January 2008 and February 2023. All patients with ileocolic intussusception underwent abdominal sonographic examination for diagnosis. An ultrasound-guided pneumatic reduction of intussusception was then attempted. Children who were hemodynamically unstable, with signs of peritonitis or bowel perforation and those with sonographically detected pathologic lead points were excluded.

RESULTS

A total of 131 children (age range 2 months to 6 years) were enrolled in this study. Pneumatic intussusception reduction was successful in 128 patients (overall success rate 97.7%). In 117 patients, the intussusception was reduced on the first attempt and in the remaining on the second. In three cases, after three consecutive attempts, the intussusception was only partially reduced. As subsequently surgically proven, two of them were idiopathic and the third was secondary to an ileal polyp. No bowel perforation occurred during the reduction attempts. There was recurrence of intussusception in three patients within 24 h after initial reduction which were again reduced by the same method.

CONCLUSION

Ultrasound-guided pneumatic intussusception reduction is a well-tolerated, simple, safe and effective technique with a high success rate, no complications and no ionizing radiation exposure. It may be adopted as the first-line nonsurgical treatment of pediatric intussusception.

Nonavailability of Ultrasound: Try Stethoscope in Pneumatic Reduction

Aim and Objective

This study aimed to finding alternative ways for centers with nonavailability of ultrasonography or fluoroscopy for nonoperative pneumatic reduction of intussusceptions.

Materials and Methods

A total of 48 cases of intussusceptions were included in the study in-between October 2016 and March 2018. We tried stethoscope-guided pneumatic reduction using locally assembled equipment. The intraluminal pressure was monitored and maintained below 100 mmHg. A total of two attempts of 3 min each were allowed. We compared our results with the control group who have been performing laparotomy for every case of intussusception.

Results

There were 35 males and 13 females in our study. The average age of the patients was 7.5 months. Intussusceptions were reduced in 38 (80%) patients but could not be reduced in 10 (20%) patients. Majority of the intussusceptions had symptoms of at least 2 days. There were no complications such as perforation in our study.

Conclusion

Stethoscope-guided pneumatic reduction seems to be a feasible and alternative effective method for the treatment of intussusceptions in children where availability of ultrasonography and skilled radiologist with overburden of work is a great issue.

Utility of hospital admission for pediatric intussusceptions

PURPOSE

The standard practice in pediatric patients diagnosed with intussusception has been reduction via enema and admission for a period of nil per os and observation. Little data exists to support this practice. The objective of this study was to examine whether post-reduction admission to hospital is required.

METHODS

A retrospective chart review was performed on all patients aged 0-18 years old with intussusception over a span of 20 years. Study included children treated for intussusception on first encounter with enema and subsequently admitted for observation. Study excluded those readmitted for recurrence after 48 h, patients whose intussusception did not reduce on first try, those lost to follow-up, and those who went to the operating room. Early recurrence was defined as recurrence within 48 h post-reduction.

RESULTS

Out of 171 patients admitted, only one experienced an early recurrence (0.6 %). Median length of stay for all patients was 2 days. Average cost incurred per day for intussusception admission was $404.

CONCLUSION

Intussusception in a child that is successfully reduced via enema has a low recurrence rate and is usually followed by prompt resolution of symptoms. An abbreviated period of observation in the emergency department post-reduction may result in healthcare savings.

Intussusception:

Intussusception, the invagination of one portion of the intestine into another, is considered a true emergency, which most commonly affects pediatric patients. It occurs when bowel (small or large) telescopes within itself, creating an obstructive mass. Peristalsis exacerbates the more proximal bowel into the lesion, causing the intussusception to have a “sleeve”-like shape. The lesion propagates distally, with obstructive ischemia and possible necrosis occurring over time. With the improvement of technology in diagnostic imaging, sonography has become the initial imaging modality of choice. The authors present a case study and current review of the literature regarding intussusception from a sonographer's viewpoint.

Adding a custom made pressure release valve during air enema for intussusception: A new technique

BACKGROUND

Non-surgical reduction remains the first line treatment of choice for intussusception. The major complication of air enema reduction is bowel perforation. The authors developed a custom made pressure release valve to be added to portable insufflation devices, delivering air at pressures accepted as safe for effective reduction of intussusception in children under fluoroscopic guidance. The aim of this study was to develop a custom made pressure release valve that is suitable for the insufflation devices used for air enema reduction of intussusception and to put this valve into regular clinical practice.

MATERIALS AND METHODS

An adjustable, custom made pressure release valve was assembled by the authors using readily available components. The valve was coupled to a simple air enema insufflation device. The device was used for the trial of reduction of intussusception in a prospective study that included 132 patients.

RESULTS

The success rate for air enema reduction with the new device was 88.2%. The mean pressure required to achieve complete reduction was 100 mmHg. The insufflation pressure never exceeded the preset value (120 mmHg). Of the successful cases, 58.3% were reduced from the first attempt while 36.1% required a second insufflation. Only 5.55% required a third insufflation to complete the reduction. In cases with unsuccessful pneumatic reduction attempt (18.1%), surgical treatment was required. Surgery ranged from simple reduction to resection with a primary end to end anastomosis. No complications from air enema were recorded.

CONCLUSIONS

The authors recommend adding pressure release valves to ensure safety by avoiding pressure overshoot during the procedure.

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.

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.

Pneumatic reduction of intussusception: factors affecting outcome in Thailand

Background: Pneumatic reduction has become a therapeutic method for intussusception instead of surgery. It is more successful than barium reduction, but it depends on how much the operator is familiar with the method and equipment.

Objective: Determine success rate and recurrent rate of intussusception and factors affecting outcome of pneumatic reduction in Thailand.

Materials and methods: Fifty-eight children with 73 numbers of intussusception who underwent pneumatic reduction at Songklanagarind Hospital, Thailand between January 2002 and March 2007 were retrospectively reviewed. Age, sex, clinical parameters, physical examination, imaging findings, and reduction technique were evaluated.

Results: Overall success rate was 54 out of the 73 episodes and recurrent rate was 10 out of 58 patients with intussusception. Long duration of symptom, rectal bleeding, dehydration, and leukocytosis significantly affected poor outcome. Radiographic findings of gut obstruction and ascites as well as sonographic findings of thickened colonic wall, trapped fluid between intussusceptum and intussuscipien, and small bowel obstruction could also predict the poor outcome.

Conclusion: Many factors from clinical presentation, plain radiographic, and sonographic findings affect poor outcome of pneumatic reduction. However, it can be performed unless peritonitis and sepsis/shock are present.

An interactive teaching device simulating intussusception reduction

Intussusception is relatively uncommon, occurring in 0.5 to 2.3 cases per 1,000 live births in the USA. Radiology residents, therefore, have few opportunities to participate in intussusception reduction during training, and practicing radiologists encounter it infrequently. Training is essential, as successful reduction avoids surgery. The judgment involved in reducing an intussusception is best gained with experience. We developed a training device that simulates fluoroscopic intussusception reduction with air. The device consists of a doll that contains a cylinder with similar stress and strain characteristics to the human colon. The trainee pumps air into the cylinder through a rectal tube using a standard hand-held air reduction pump. A sensor measures the pressure within the chamber and transmits readings to a computer, which displays images from actual intussusception reductions based on the pressure maintained within the device. A random component in the software gives the user a new experience each time and models uncertainties in the actual reduction process, including perforation. This intussusception reduction simulator can enhance resident education, giving residents the opportunity to practice this technique before employing it on a real patient. The simulator can also help practicing radiologists become more comfortable with intussusception air reduction.

Air enema for intussusception: is predicting the outcome important?

Air enema is the treatment of choice for childhood intussusceptions. Although peritonitis is the established contraindication, studies have attempted to identify factors that affect the outcome of air enema. In our series we studied the impact of such factors on the clinical scenario to determine if it was important to predict the outcome of air enema. We retrospectively reviewed the records of 179 children who underwent air enema for intussusception at our institution over a 5-year period. Abdominal colic was present in 144 children, vomiting in 139 and rectal bleeding in 108 children. The duration of symptoms was less than 24 h in 131 children. An abdominal mass was present in 121 children, rectal prolapse of intussusception in 14, dehydration in 31 and small bowel obstruction in 27 children. The success rate of air enema was calculated. All clinical features were analyzed for impact on outcome using univariate and multivariate analysis. The extent of this impact on the clinical scenario was examined. Air enema was successful in 157 cases (89%). One child developed a perforation during the procedure (0.6%). The recurrence rate was 8%. Using chi2 test, success of air enema was reduced in the presence of rectal bleeding, rectal prolapse of intussusception, dehydration, and small bowel obstruction. This reduction was statistically significant (P < 0.05). Using logistic regression analysis, the success of air enema was significantly reduced (P < 0.05) only in the presence of prolapsing rectal intussusception (57%) and small bowel obstruction (52%). Small bowel obstruction and prolapsing rectal intussusceptions merely reduce the success of air enema and do not increase the complications. Since the success of air enema is very high, it must be attempted in all children with the exception of peritonitis. Predicting the outcome is not crucial because of the high success rate and low complication rate.

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.

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.

Effective dose at pneumatic reduction of paediatric intussusception

AIM

The purpose of this study was to assess screening times and resulting dose implication at pneumatic reduction of intussusception in the paediatric age group and to examine the relationship with the outcome of the procedure.

MATERIALS AND METHODS

We retrospectively reviewed the case notes and departmental records of 143 children who had undergone a total of 153 pneumatic reductions in our department over a 4-year period. Success rates, screening times and available dose-area products (DAP) were recorded. The DAPs were converted to effective dose (ED) for 77 procedures.

RESULTS

A 76.5% (117/153) success rate was achieved with a recurrence rate of 6.5% and only one complication: a perforation. Screening times were recorded in 137 reductions and ranged from 15 s to 22.6 min. Although the longest screening time was associated with an unsuccessful outcome, the second longest time of 21 min was successful. This gave a DAP of 1278 cGy cm(2)and an ED of 12.73 mSv, which is equivalent to approximately 400 abdominal films for a 1-year-old. A lifetime risk of fatal cancer of one in 1000 was achieved, assuming the worst case, after a screening time of 30 min on our conventional fluoroscopy unit.

CONCLUSION

Our success rate compares well with other centres. Our institution is a tertiary referral centre and the occasional long screening time may reflect the delay and complex nature of the patients referred. Persistence at air reduction may be successful and the success rate increases with delayed attempts but the risks of the increasing radiation burden must be weighed against the risks of emergency surgery and anaesthesia.Heenan, S. D. (2000). Clinical Radiology 55, 811-816.

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: the accuracy of ultrasound-guided saline enema and the usefulness of a delayed attempt at reduction

BACKGROUND/PURPOSE

The aim of this study was to evaluate the therapeutic value of ultrasound (US)-guided saline enema for intussusception and the usefulness of a delayed attempt after at least 30 minutes when reduction has not been complete.

METHODS

One hundred ninety-five cases of intussusception were diagnosed with ultrasonography. US-guided saline hydrostatic reduction was performed in 194 with an additional attempt after at least 30 minutes in those cases in which only partial resolution had been achieved. The method was changed (the volume of the reservoir bag and the caliber of the catheter were increased) so we analyze two different periods; 85 cases are included in the first period and 110 in the second.

RESULTS

The global rate of successful reduction was 81.9% (159 of 194 cases), and it raised to 88.2% (97 of 110 cases) in the second period. In 15.5% cases (30 of 194) reduction was achieved in a delayed attempt at least 30 minutes after the initial partial resolution. The rate of recurrence was 9.7%. No perforation was seen.

CONCLUSIONS

The accuracy of US-guided saline enema in achieving intussusception reduction is high, similar to other methods, avoiding radiation exposure. A delayed attempt after a period of rest increases the rate of reductions.

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.