Success rate of pneumatic reduction of intussusception with and without sedation

Application of Delayed Repeated Enema With Sedation in Pediatric Intussusception: A Single Center Retrospective Study

OBJECTIVE

This study aimed to evaluate the clinical application of delayed repeated air enema (DRE) with sedation in pediatric intussusception.

METHOD

We retrospectively assessed cases of idiopathic intussusception treated with air enema reduction at the emergency department of Beijing Children's Hospital affiliated to Capital Medical University from January 2016 to August 2019. The included cases were assigned to the success or failure groups based on the outcomes of DRE with sedation. General patient information, clinical manifestations, test results, and surgical conditions were collected for comparative analysis.

RESULTS

A total of 3052 cases were initially diagnosed with intussusception and underwent air enema reduction. Ultimately, 211 cases were included, with 162 in the success group and 49 in the failure group. The success rate of DRE with sedation was 76.8% (162/211), with an overall reduction success rate of 97.8% (2984/3052). Univariate logistic regression analysis showed that patients in the failure group had a significantly higher proportion of patients with age ≤1 year, bloody stools, and left-sided intussusception before DRE compared to the success group (OR = 2.3, 95%CI: 1.1∼4.6, P = 0.023; OR = 3.4, 95%CI: 1.6∼7.2, P = 0.002 and OR = 12.6, 95%CI: 4.6∼34.6, P < 0.001). Multiple logistic regression analysis based on these three factors revealed that the risk of DRE failure was 10.1 times higher in cases with the left-sided intussusception before DRE.

CONCLUSIONS

DRE with sedation can improve the overall enema reduction success rate for intussusception and has good feasibility and safety profiles. Left-sided intussusception before DRE is an independent risk factor for enema failure.

Intussusception reduction methods in daily practice-a survey by the European Society of Paediatric Radiology Abdominal Imaging Taskforce

BACKGROUND

Image-guided intussusception reduction has been practised internationally for many decades. The use of different modalities, delayed repeat attempts, and sedation/anaesthesia are unknown.

OBJECTIVE

To survey the practice of image-guided intussusception reduction.

MATERIALS AND METHODS

A 20-point questionnaire created by the European Society of Paediatric Radiology (ESPR) Abdominal Imaging Taskforce was distributed via the ESPR members' mailing list and shared on social media between 28 March and 1 May 2023.

RESULTS

There were 69 responses from 65 worldwide institutions, with a mean of 18 intussusception reductions performed per year: 55/69 (80%) from 52 European institutions and 14/69 (20%) from 13 institutions outside of Europe. European centres reported using 19/52 (37%) fluoroscopy, 18/52 (35%) ultrasound, and 15/52 (28%) a mixture of both, with 30/52 (58%) offering a delayed repeat at 15 min to 24 h. Non-European centres reported using 5/13 (39%) fluoroscopy, 6/13 ultrasound (46%), and 2/13 (15%) a mixture of both, with 9/13 (69%) offering a delayed repeat attempt. Sedation or analgesia was used in 35/52 (67%) of European and 2/13 (15%) non-European institutions.

CONCLUSION

There is wide variation in how image-guided intussusception reduction is performed, and in the use of sedation/anaesthesia.

Liberal surgical laparoscopy reduction for acute intussusception: experience from a tertiary pediatric institute

The optimal treatment for acute intussusception has not yet been defined. In this study, we explored whether employing a liberal laparoscopic intervention for intussusception could lead to favorable outcomes. We performed a historical control analysis to evaluate the outcomes associated with this liberal surgical management protocol. This liberal surgical management protocol were revised to incorporate a new protocol centered around the laparoscopic approach. In some cases of acute intussusception, liberal laparoscopic exploration and intervention were undertaken without initial hydrostatic or pneumatic reduction. During the study interval, a retrospective review was conducted on a total of 3086 patients. These were categorized into two groups: 1338 cases before May 2019 (pre-protocol group) and 1748 cases after May 2019 (post-protocol group). Surgical intervention rates in the pre-protoco and post-protocol period were 10.2% and 27.4% respectively (odds ratio [OR] = 0.30 [95% CI 0.25-0.37]; p < 0.001). No significant differences were observed in baseline clinical characteristics or demographic features between the two groups. The duration from admission to operation was longer for the pre-protocol group (p = 0.008) than for the post-protocol group. The post-protocol group demonstrated decreases in both intestinal resection (OR = 1.50 [95% CI 0.96-2.35]; p = 0.048) and total recurrent events (OR = 1.27 [95% CI 1.04-1.55]; p = 0.012) compared to the pre-protocol group. Liberal laparoscopic intervention for intussusception may effectively reduce the risk of intestinal resection and total recurrent events, thereby exhibiting promising outcomes for patients with intussusception.

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.

Intussusception Management in Children: A 15-Year Experience in a Referral Center

OBJECTIVE

To report a 15-y, single-center experience in the management and outcomes of ileocolic intussusception (ICI) episodes.

METHODS

A retrospective study was performed in patients with ICI episodes, who were treated at a single quaternary referral center from 2005 to 2019. Data evaluated included patient demographics, clinical presentation, treatment modalities, hospital stay, complications, and outcomes.

RESULTS

A total of 546 ICI episodes (66.1% males) were included, with a median age at diagnosis of 15 mo. Enema reduction was performed in 478 patients (87.6%), with an overall success rate of 85.8%. Hydrostatic saline enema was the most effective method (89.3%) when compared to pneumatic (80.6%) or barium enema (79.8%), this difference being statistically significant (p = 0.031). No associated complications were observed during nonoperative reduction. Surgical treatment was performed in 101 patients, in whom 36 bowel resections were performed. Postoperative complications were reported in 6 patients (5.9%). Hospital stay was significantly longer in patients with operative management (median 5 d vs. 1 d; p < 0.001).

CONCLUSIONS

Nonoperative management has a high overall success rate and low complication and recurrence rates. Saline enema reduction presents the highest effectiveness, and should be considered the first-line treatment.

Ultrasound guided hydrostatic enema reduction of ileocolic intussusception: a safe and effective technique

BACKGROUND

Currently, the primary management of ileocolic intussusception in children is usually by non-operative image-guided enema reduction. In most centres around the world especially in Australasia the predominant technique is the pneumatic reduction under fluoroscopic guidance. At our institution, we have been performing ultrasound-guided hydrostatic reduction since 2012.This is an audit to determine the efficacy and safety of ultrasound-guided hydrostatic reduction for intussusception.

METHODS

Following ethics approval, a retrospective review of all patients presenting to our institution with intussusception and subsequently undergoing hydrostatic reduction over a period of 9 years (2012 to-2020) was performed. The parameters studied included (i) successful reduction, (ii) recurrence, (iii) need for surgery and (iv) lead point at surgery.

RESULTS

The mean age at presentation was 12 months. One hundred and eight children were diagnosed to have ileocolic intussusception. One hundred and six underwent ultrasound-guided hydrostatic reduction with successful reduction in 96 (90.5%) patients. Reduction was unsuccessful in 10 patients (9.5%). Of these eight were noted to have a pathological lead point (four-Meckel's diverticulum and four-Lymphoma) at the time of the surgery. The intussusception recurred in six patients (6.25%) within 24 h. No reduction related perforation occurred during the study period.

CONCLUSION

Ultrasound-guided hydrostatic reduction is a safe and effective technique for managing intussusception as it allows continuous monitoring of the reduction of the intussusception without exposing the children to ionizing radiation.

A comparison of the success rate of pneumatic reduction in intussusception between general anesthesia and deep sedation: a randomized controlled trial

PURPOSE

This study was aimed to compare the success rate between patients who underwent general anesthesia and deep sedation.

METHODS

Patients who were diagnosed with intussusception and had no contraindications would receive non-operative treatment first by undergoing pneumatic reduction. The patients were then split in to two groups: one group underwent general anesthesia (GA group), while the other underwent deep sedation (SD group). This study was a randomized controlled trial which compared success rate between two groups.

RESULTS

A total of 49 episodes diagnosed with intussusception were random into 25 episodes in GA group and 24 episodes in SD group. There was no significant difference in baseline characteristic between the two groups. The success rates of GA group and SD group were equally 88.0% (p = 1.00). Sub-analysis of the success rate was lower in the patients with high-risk score for failed reduction. (Chiang Mai University Intussusception (CMUI) failed score in success VS failed = 6.9 ± 3.2 vs. 10.3 ± 3.0 p = 0.017).

CONCLUSION

General anesthesia and deep sedation offered similar success rates. In cases of high risk of failure, general anesthesia should be considered to accommodate the switch to surgical management in the same setting if the non-operative approach fails. The appropriate treatment and sedative protocol also increase the success of reduction.

Midazolam premedication in ileocolic intussusception: a retrospective multicenter study

Ileocolic intussusception is a common cause of bowel obstruction. When spontaneous reduction does not occur, non-operative management through enema reduction is necessary. Despite the evidence indicating that sedatives favor success in the reduction, their use is still not a common practice. To determine if midazolam (MDZ) before enema improves the rate of procedure success, we retrospectively reviewed charts of patients admitted to two Italian pediatric emergency departments. Outcome measures were the success rate of the enema, recurrence, and need for surgery. Patients were grouped according to the use of MDZ or not, before hydrostatic reduction attempt. We included 69 and 37 patients in the MDZ and non-MDZ groups, respectively. The two groups did not differ in demographics, clinical characteristics, and ultrasound findings. Intussusception reduction after the first enema attempt occurred in 75% (MDZ group) and 32.4% (non-MDZ group) of patients (P < .001); 27.9% (MDZ group) and 77.8% (non-MDZ group) of patients underwent surgery (P < .001). Among them, spontaneous reduction of intussusception during the induction of general anesthesia occurred in 31.6% and 42.9% of patients, respectively (P .43). Multivariate logistic regression analysis showed that only MDZ had a positive effect on the result of the enema (OR 7.602, 95%CI 2.669-21.652, P < .001).

CONCLUSION

Procedural sedation with MDZ for enema reduction of intussusception can increase the success rate and lead to a better management of patients.

WHAT IS KNOWN

• Despite the evidence of the usefulness of sedatives in the reduction of intussusception, their use is still not a common practice.

WHAT IS NEW

• Midazolam during enema reduction of intussusception can increase the success rate and consequently lead to better management of patients.

Temporal Validation of Chiang Mai University Intussusception Failed Reduction Score (CMUI)

This study aimed to validate the “Chiang Mai University Intussusception Failed Score (CMUI)” for intussusception non-operative reduction. Both a 2-year retrospective and a 5-year prospective consecutive review of patients with intussusception were conducted. Data were collected from January 2013 to December 2020. Related retrospective data of a developmental set from two centers from January 2006 to December 2012 were used. Ten prespecified prognostic factors for failed reduction were collected and from these a predictive score was calculated. The actual results of non-operative reduction were collected and set as a reference standard. Altogether, 195 episodes of intussusception were found. Twenty-two patients were excluded due to contraindications; therefore, a total of 173 episodes were included in the validation dataset. The development data set comprised 170 episodes. We found that no statistical significance was found from comparing the areas under the ROC of two datasets (p-value = 0.31), while specificity of the validation set was 93.8% (88.1–97.3). This temporal validation showed a high specificity and a high affinity for prediction of failed reduction as the development dataset despite being in an era of a higher successful reduction rate. The intensive reduction protocols might be introduced among patients with high-risk scores.

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.

Factors Associated with a Failed Nonoperative Reduction of Intussusception in Children

Aims:

The aim of this study was to evaluate the factors associated with the failure of nonoperative reduction of intussusception in children.

Methods:

A retrospective study was conducted in a tertiary care pediatric surgery hospital. The children admitted to the department of pediatric surgery between November 2013 and February 2020 with the diagnosis of Intussusception were included.

Results:

A total of 106 (67%) children underwent pneumatic reduction. Eighty-nine (84%) children had a successful reduction. A higher rate of failed reduction was found in children who presented at or after 48 h of the onset of symptoms (P = 0.03) and abdominal distension at presentation (P < 0.002). On multiple logistic regression analysis, the children presenting at or after 48 h of the onset of symptoms (odds ratio [OR] = 11.3; P = 0.039) and abdominal distension at presentation (OR = 4.46; P = 0.021) were found to be associated with increased risk of failure of nonoperative reduction. The variables age <1 year, weight <10 kg, pain abdomen, vomiting, bilious vomiting, fever, bleeding per rectum, and palpable mass were not associated with the failed nonoperative reduction. The variables, presentation at or after 48 h of the onset of symptoms (OR = 2.812; P = 0.045) and abdominal distension at presentation (OR = 8.758; P = 0.000) were found to be associated with an increased need for surgery.

Conclusion:

The risk factors for failed nonoperative reduction of intussusception include a presentation at or after 48 h of the onset of symptoms and the presence of abdominal distension at presentation. The delayed presentation was associated with the increased need for surgery and increased chances of intestinal nonviability.

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.

Clinical Characteristics of Intussusception with Surgical Reduction: a Single-Center Experience with 568 Cases

BACKGROUND

Intussusception is among the most common acute abdominal emergencies in infancy, but only some cases need surgical reduction. This study assessed the clinical characteristics of patients undergoing surgical reduction of intussusception.

METHODS

This retrospective study reviewed 568 pediatric patients who failed air-enema reduction and underwent surgical reduction for intussusception in our department between 2008 and 2017.

RESULTS

The series comprised 376 boys and 192 girls (2.0:1, male:female ratio) and most of the intussusceptions were primary, which is typical before the age of 1 year. The success rate of air-enema reduction in our hospital was 94.2%. Patients over 3 years old had the highest rate of surgical reduction (ca. 11.8%). The probabilities of primary and secondary intussusception were equal above 2 years old. Intussusception caused by intestinal malignant lymphoma was diagnosed above 2 years of age with atypical symptoms. Gender was irrelevant regarding the presence of bloody stools (P = 0.594), but the younger patients and children with complex/compound intussusception had a higher proportion of bloody stools (n = 148, 40.0%, P = 0.000) and intestinal necrosis (n = 44, 42.3%, P = 0.024). The occurrence time of bloody stools (OTBS) in complex/compound intussusception was shorter than for other types.

CONCLUSIONS

This retrospective study analyzed the clinical features of patients undergoing surgical reduction for intussusception and summarized the characteristics and management of complex/compound intussusception.

Validation and modification of the ‘Chiang Mai University Intussusception scoring system’ used to predict failure of non-surgical treatment in infantile intussusception

Background

This study aimed to validate and modify the recently released Chiang Mai University Intussusception (CMUI) scoring system in predicting failure of non-surgical management of infantile intussusception.

Methods

A retrospective review was conducted in 151 cases of infantile intussusception who were primarily treated with pneumatic reduction in our institute during 2008–2018. The analysis focused on the validation of the CMUI scoring system. Following this analysis, the scoring system was modified to be more suitable for our clinical practice, in which we perform pneumatic reduction in all cases.

Results

Pneumatic reduction was successfully performed in 120/151 cases (79.5%). A high CMUI score was significantly associated with increased likelihood of failure at the positive likelihood ratio of 1.49 (sensitivity 25.8 and specificity 82.7). The area under the receiver operating characteristic curve (AUC) was 0.73. We modified the CMUI System in two ways, first by removing the item ‘method of reduction’ and replacing it with ‘hyponatremia’, and by changing the definition of low body weight to less than 9 kg. The modified CMUI had an AUC of 0.76. A high score (>9 points) on the modified version gave a positive likelihood ratio of 4.77 (sensitivity 53.0 and specificity 80.9).

Conclusion

In infantile intussusception primarily treated with pneumatic reduction, the modified CMUI scoring system gave a better prediction reliability than the original.

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.