General anaesthesia may improve the success rate of hydrostatic reductions of 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.

Effect of general anesthesia on delayed repeat enema in pediatric intussusception

BACKGROUND

The study aimed to assess the efficacy and safety of delayed repeated enema (DRE) and to evaluate the effect of general anesthesia (GA) on DRE.

METHODS

A retrospective analysis was conducted of all children below 3 years with primary intussusception who were offered DRE in our tertiary center, from 2014 until 2019. Following a standardized pneumatic enema protocol, those who showed a partially successful result were offered DRE 2 h later, either awake (Group A) or under GA (Group B). DRE under GA was our preferred procedure unless there were no pediatric anesthetists available at that time. Data collected for each group included age, sex, duration of symptoms, success rate of the DRE, and any complications noted.

RESULTS

The study included 57 children (32 males and 25 females). The median age in Group A (31 patients) was 10 months while in Group B (26 patients) it was 11 months. The number of patients with duration of symptoms < 24 h vs > 24 h was 12:19 and 9:17 in Group A and B patients respectively. DRE was successful in 14/31 (45.2%) of Group A patients with one complication and in 9/26 (34.6%) of Group B patients with no complications. There was no statistically significant difference between both groups' success rate and complication rate. Both groups were similar in age, sex, and duration of symptoms.

CONCLUSIONS

DRE can effectively increase the overall success rate of pneumatic enema in selected patients with pediatric intussusception. However, the current evidence does not justify the routine use of GA during attempts DRE attempts.

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.

The Effect of Midazolam on Decreasing the Duration of Intussusception Hydrostatic Reduction in Children

BACKGROUND AND OBJECTIVE

The use of sedative medications may be effective in the success and facilitation of the intussusception non-surgical treatment. Therefore, the purpose of this study was to examine the effect of midazolam on decreasing the duration of intussusception hydrostatic reduction in children.

MATERIALS AND METHODS

In a double-blind clinical trial, 32 children were diagnosed with ileocolic intussusception based on sonographic findings, were studied and randomly divided into two groups. After obtaining written informed consent from the parents, 5 minutes before reduction, an intravenous Midazolam at the concentration of 1.0 mg/kg (up to 3 mg) was infused, and then barium reduction was performed under fluoroscopy guideline. In the control group, sterile water was injected as placebo and the remaining reduction steps were performed compared with the experiment group.

RESULTS

Of 16 patients that received Midazolam, 15 patients demonstrated successful reduction; and of 16 patients that received distilled water, only 11 patients showed successful reduction (P=0.07). The mean duration of a successful reduction in the Midazolam group and placebo was 34.8±11.35 and 32.73±19.2 min, respectively (P=0.733).

CONCLUSIONS

The use of Midazolam as a benzodiazepine with known sedative and muscle relaxant effects can increase the success rate of enema reduction in intussusception.

General anesthesia for intussusception reduction by enema

OBJECTIVES

Intussusception is the most frequent cause of bowel obstruction in children. Although enema is usually used as the initial treatment, surgery may be required in more than 50% of patients. General anesthesia (GA) has been suggested to increase the rate of enema success. The purpose of this study was to evaluate whether GA increases the success rate of reduction by air enema.

METHODS

In this retrospective single-center study from 1989 to the end of June 2008, patients receiving air enema for intussusception reduction were studied. Multivariable analysis using propensity score was performed to compare the success rate between patients receiving sedation or GA.

RESULTS

The success rate of air enema increased from 72% in 1989 to the current rate of 90%. When time elapsed between first symptoms and enema was >12 h, the success rate decreased significantly (Odds Ratio 0.67 [0.56-0.81], P < 0.0001). When patients were matched by propensity score, GA significantly increased the likelihood of success (OR 5.66 [2.85-12.89], P = 0.013).

CONCLUSIONS

Air enema performed under GA allows intussusception reduction in more than 90% of patients.

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.

Rescue by pneumoenema under general anaesthesia of apparently non-reducible intestinal intussusception

When an enema in the radiology unit is unsuccessful in treating intussusception, patients must undergo surgery. A further attempt at reduction under general anaesthesia in the operating room prior to laparotomy could avoid surgical intervention. A prospective study was carried out from 2002 to 2010 on paediatric patients with intestinal intussusception who underwent a deinvagination procedure in radiology with no anaesthesia. Unresolved cases were included in either group 3a (direct surgery) or group 3b (pneumoenema under general anaesthesia in the operating room), depending if the paediatric surgeon on duty wanted or not to participate in the study. Ninety-eight patients were included in the study. Six patients (group 1) were immediately operated after diagnosis because peritonitis was clinically suspected. Sixty-seven patients were successfully treated with an anaesthesia-free procedure in the radiology department (group 2). Of the 25 cases with initial treatment failure (group 3), 11 were assigned to group 3a (immediate laparotomy) and 14 to group 3b (pneumoenema with general anaesthesia). All patients in the 3b group were successfully treated by this procedure. There were no differences between the groups in terms of age, sex or evolution time. The average length of hospital stay and the number of repeated hospitalizations were significantly higher for group 3a.

CONCLUSION

We consider that general anaesthesia increases effective reduction pressures and could avoid many surgeries in apparently non-reducible intestinal intussusceptions.