Journal of Indian Association of Pediatric Surgeons
Journal of Indian Association of Pediatric Surgeons
                                                   Official journal of the Indian Association of Pediatric Surgeons                           
Year : 2022  |  Volume : 27  |  Issue : 3  |  Page : 329--332

The syringe technique for ultrasound-guided hydrostatic intussusception reduction


Sandeep Rai1, Aureen Ruby DCunha1, RM ShreeRaghu2, Neevan DSouza3,  
1 Department of Paediatric Surgery, K.S. Hegde Medical Academy, NITTE University, Mangaluru, Karnataka, India
2 Department of General Surgery, K.S. Hegde Medical Academy, NITTE University, Mangaluru, Karnataka, India
3 Department of Biostatistics, K.S. Hegde Medical Academy, NITTE University, Mangaluru, Karnataka, India

Correspondence Address:
Dr. Aureen Ruby DCunha
Department of Paediatric Surgery, K.S. Hegde Medical Academy, Mangaluru, Karnataka
India

Abstract

Background: Ultrasound-guided hydrostatic reduction (UGHR) is a well accepted and widely used method of paediatric intussusception reduction, with the saline drip technique being the most commonly employed. Aims and Objectives: In this study we aimed to assess the outcomes of a novel technique of UGHR. Materials and Methods: Data was obtained from a 15 year retrospective chart review of paediatric intussusceptions. Following resuscitation, UGHR was performed for uncomplicated intussusceptions using a 50cc syringe to infuse saline into the colon. It was performed in the ultrasound suite without sedation and time taken was monitored. A maximum of 3 attempts were done to achieve reduction. Results: UGHR was attempted in 66 of 93 intussusceptions. The commonest type of intussusception was ileo-colic(91%) and the commonest symptom was vomiting(70%). Surgery was performed only when there was shock, peritonitis or repeated failed reductions. The median time taken for reduction was 4.9 minutes. The overall success rate was 83% with 89% of these requiring only a single attempt. There were no deaths or procedure related complications. Conclusions: The syringe technique for intussusception reduction is a safe, effective, and time-saving technique. Additionally, it offers the advantages of simplicity and rapidity of reduction and in experienced hands may not require pressure monitoring



How to cite this article:
Rai S, DCunha AR, ShreeRaghu R M, DSouza N. The syringe technique for ultrasound-guided hydrostatic intussusception reduction.J Indian Assoc Pediatr Surg 2022;27:329-332


How to cite this URL:
Rai S, DCunha AR, ShreeRaghu R M, DSouza N. The syringe technique for ultrasound-guided hydrostatic intussusception reduction. J Indian Assoc Pediatr Surg [serial online] 2022 [cited 2022 Jun 26 ];27:329-332
Available from: https://www.jiaps.com/text.asp?2022/27/3/329/345133


Full Text



 Introduction



Nonoperative management of intussusception in children is now a universally established practice and has dramatically and favorably evolved over the years. From the initial usage of barium enema to air, oxygen, and ionic contrast agents, ultrasound-guided hydrostatic reduction (UGHR) currently is the standard of care at several centers for the management of uncomplicated intussusceptions. In the conventionally described method of UGHR, saline is infused into the colon with a drip set, with the reservoir placed at a height of three to four feet to generate a pressure of about 100–130 mmHg.[1] When higher pressures are mandated, the column height is increased accordingly. In this study, we aimed to assess the outcomes of a novel technique of UGHR, using a 50cc catheter-tipped syringe.

 Materials and Methods



An In-patient chart analysis was conducted to review pediatric intussusceptions in a tertiary care hospital over a 15-year period (2005–2020). Being a retrospective study, no ethical clearance was required from the institutional review and ethical board.

All reductions were performed under ultrasound guidance using normal saline as the infusate. A 50cc catheter-tipped syringe was used to fill the colon through a 16-French Foley's catheter with the bulb inflated with 20–30cc of water. The reduction team comprised three personnel: a pediatric surgeon to perform the reduction, an assistant to position the child and monitor time, and a radiologist to follow the reduction in real time [Figure 1].{Figure 1}

The operating theater was kept on standby in the event of a procedure-related complication arising requiring immediate surgery. The patients were adequately resuscitated and written informed consent was obtained from the parents/guardians prior to commencing the procedure. Sedation was not used as the duration of the procedure was short and also because it would interfere with the child's response to a successful reduction. If an intussusception was detected on scan, the reduction was performed immediately in the ultrasound suite to avoid delay. The equipment used is demonstrated in [Figure 2].{Figure 2}

Children who presented in shock or with peritonitis were taken up for upfront surgery. The presence of minimal free fluid or red currant jelly stool did not preclude reduction if the patient was otherwise haemodynamically stable.

A successful reduction was confirmed by sonological disappearance of the intussusception and entry of fluid into the ileum. If complete reduction did not occur at the first attempt, the fluid was left in situ for about 5–10 minutes with the aim of maintaining pressures within the system. If the reduction was unsuccessful even after this, the fluid was allowed to egress and the procedure was repeated (for a maximum of three attempts) after a period of bowel rest, before resorting to surgical intervention.

Post reduction, the child was kept nil by mouth for 24 hours, following which a scan was repeated to ensure that there was no residual or recurrent intussusception before commencing enteral feeds. Once oral feeds were established, the child was discharged on oral antibiotics and the parents were advised to maintain a semisolid diet for about 4 days thereafter, to minimize the risk of an early recurrence.

 Results



There were a total of 93 intussusceptions during the aforementioned period. Of these, UGHR was attempted in 66. Among the 27 which were excluded, 25 were transient intussusceptions (18 – ileoileal, 4 – ileocolic, 2 – jejunojejunal, and 1 – colocolic), and two required immediate surgery.

Of the 66, 43 intussusceptions occurred in boys and 23 in girls, with a median age of 12 months (interquartile range [IQR]: 7, 24). The median symptom duration was 2 days (IQR: 1, 3), and the median duration of hospital stay was 3 days (IQR: 2, 4). Symptomatology varied between age groups, and most children had a combination of two or more symptoms. Vomiting was the predominant symptom (70%), followed by intermittent irritable cry (56%) in younger children and colicky abdominal pain (35%) in older children. Eighteen (27%), 13 (20%), and 12 (18%) children, respectively, had blood in stools, fever, and diarrhea. Rare symptoms included constipation, abdominal distension, weight loss, and encephalopathy.

Where imaging measurements were documented, the median length of the intussusception was 3.9 cm (range: 2–6.5 cm). Sixty of the 66 intussusceptions were ileocolic, two ileo-ileocolic, and two colocolic. Significant mesenteric lymphadenopathy was present in 78% (36/46) and free fluid in 36% (17/47) on the initial scan. The time taken for the first reduction (from the start of saline insufflation till confirmed reduction) ranged from 4 to 7 minutes, with a median of 4.9 minutes.

Fifty-five intussusceptions were successfully reduced yielding an overall success rate of 83%. Eighty-nine percent of these reduced on the first attempt. 5.5% each required a second and third reduction, respectively. Among the 11 children who underwent surgery, 4 had no definitive pathology, 2 were found to have lymphoma of the resected specimens, and 1 each had a polyp, a Meckel's diverticulum, and roundworms. One had bowel gangrene and one was not documented. Two children had delayed recurrences at 5 and 6 months, respectively, from the first episode. Both underwent UGHR the second time as well, but one child ultimately required surgery. There were no immediate or delayed procedure-related complications encountered with this technique. There were no mortalities.

 Discussion



The earliest description of non-operative management of intussusception was described by Hirschsprung in 1876.[2] Although the ideal method is still debatable, we have come a long way since then, with improvisation in techniques and better results. UGHR for uncomplicated pediatric intussusceptions is now one of the most popularly used techniques since the first reduction performed by Kim et al. in 1982.[3]

Living in a fast-paced world where time and convenience take high priority, we found that the syringe technique addresses both issues aptly. We therefore decided to embark on this retrospective analysis of pediatric intussusception reductions. Our technique followed all the commonly used reduction guidelines[1],[4],[5] including those of resuscitation, number of attempts, and indications for operative management. We differed, however, in the use of a 50cc catheter-tipped syringe over the traditional saline drip.

There was a weak positive correlation between increasing age and attempts at reduction, longer duration of hospital stay, and need for surgical intervention. Likewise, it was noted that those with a longer duration of symptoms had a longer hospital stay and were also more likely to undergo surgery. None of these observations, however, were statistically significant (P > 0.05). Both colo-colic and 75% of the ileo-ileocolic intussusceptions required surgical intervention as compared to just 10% of the ileo-colics. This statistically significant (P = 0.001) result supports the understanding that ileo-ileocolic intussusceptions are harder to reduce.[6] Clinically, it translates to anticipating a more difficult reduction in the case of ileo-ileocolic and colocolic intussusceptions. If this diagnosis is made by sonography, the parents can be Counselled well in advance about the greater possibility of requiring surgical intervention.

We compared our results with other studies in which reduction times were documented. The success rates of 75%–96% were comparable with ours (83%). The time taken for reduction however, ranged between 8 and 15 minutes among the various studies.[4],[5],[7],[8] In comparison, the median time taken for complete reduction by the syringe technique was just 4.9 min. Although such a study precludes calculation of statistical significance for time taken, there is sufficient anecdotal evidence to prove that the procedural time is reduced by half to one-third of the time taken using the conventional saline drip technique.

The other advantages included a reduction of parental anxiety due to a shorter procedure time, prevention of saline reflux (and thereby loss of intracolonic pressure during straining) by the steady pressure exerted by the manually controlled syringe, and avoidance of hassles of column height adjustment when higher pressures needed to be generated.

A search of existing literature revealed only two similar studies where a syringe was used for UGHR. Ogundoyin et al. used a 100cc syringe to reduce 36 intussusceptions (8 years) with a 58.3% success rate.[9] Khong PL et al. used a 50cc syringe with pressure monitoring (100 mmHg) to reduce 64 intussusceptions (5 years), with an overall success rate of 71.1%, and 92.9% for ileocolic intussusceptions.[10] Our overall success rate of 83% was comparable or slightly better.

Of the 17% who had a failed reduction, 64% had a lead point, as mentioned in the results section. This indicates that failure of UGHR in this subset of patients was mostly due to an intrinsic bowel pathology rather than a procedure-related lapse.

The incidence of colonic perforations during hydrostatic reduction ranges anywhere from nil[6],[9] to 5%–10%.[4],[5],[11] Hence, although there were no bowel perforations encountered in our study, we cannot eliminate it as a possible procedural complication. Having a hawk's eye for increasing free fluid or abdominal distension is of utmost importance during any hydrostatic reduction procedure irrespective of the technique employed. Having encountered no complications during its use, we can say that the syringe technique is at least as safe as the traditional saline drip technique if not safer.

The study was limited by the fact that being retrospective, certain data records were incomplete, thus eliminating several patients that could have been included. In addition, since real-time pressure monitoring was not done, pressures generated by the procedure could not be documented. This study did not have a comparison arm utilizing the saline drip technique which precluded the calculation of statistical significance for the time taken.

 Conclusion



Hydrostatic reduction of intussusception using a 50cc catheter-tipped syringe is a safe, effective, and time-saving technique. While proving to be as effective as the traditional saline drip method, it offers the added advantages of simplicity and rapidity of reduction. In addition, in experienced hands, pressure monitoring may not be required.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

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