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Reduction of Intussusception Under General Anesthesia by Hydrostatic

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Reduction of Intussusception Under General Anesthesia by Hydrostatic Chand et al. Annals of Pediatric Surgery (2021) 17:9 Annals of Pediatric Surgery https://doi.org/10.1186/s43159-021-00076-w ORIGINAL RESEARCH Open Access Reduction of intussusception under general anesthesia by hydrostatic technique: the RIGHT technique Karunesh Chand1, Ravi Patcharu1* , Badal Parikh2 and Arun Kumar Yadav3 Abstract Background: Intussusception is the one of the commonest causes of intestinal obstruction requiring urgent attention in early childhood. There is no gold standard of non-operative reduction. We report our 6 years’ experience in non-operative reduction using our “RIGHT” (Reduction of Intussusception under General anesthesia using Hydrostatic Technique) technique, emphasizing the need to perform the procedure in the operating room (OR) under general anesthesia. This prospective observational study covering the period from July 2014 till May 2020 included patients diagnosed with intussusception. Hydrostatic reduction was performed in the OR under general anesthesia by infusing a saline enema and the reduction was confirmed by ultrasound. Results: Forty-eight patients underwent reduction using the RIGHT technique. Successful reduction was achieved in 44 (91.6%) patients. Four (8.3%) patients needed surgery, three (6.2%) due to failed reduction and one (2.0%) due to perforation. One (2.2%) patient developed a recurrence. Conclusions: The “RIGHT” technique is a combination of the best available techniques of reduction of intussusception. It ensures patient safety by being performed in the OR, being pain free, avoiding radiation, avoiding the risk of aspiration associated with sedation, and also being able to immediately address a failure of reduction or a complication by surgical exploration. Keywords: Hydrostatic reduction, Saline enema, Non-operative reduction, Ultrasound guided, Operating room, RIGHT technique Background available are a permutation and combination of either of Intussusception is the one of the commonest cause of operative, hydrostatic, or pneumatic reduction, under intestinal obstruction requiring urgent attention in neo- fluoroscopy or ultrasound (USG) guidance, or laparo- natal and early childhood. Ileocolic intussusception in scopic guidance or manipulation. A combination of which the ileum telescopes into the colon is the com- these modalities gives us 8–10 treatment options which monest variety. If left undiagnosed or misdiagnosed and are practiced by different surgeons based on their choice, untreated, it may turn fatal due to gangrene and slough- comfort, and available resources. ing off of ileum leading to perforation peritonitis. Vari- The presence of multiple treatment options for a par- ous methods of reduction have been tried for the last ticular entity reveals that there is no gold standard of 300 years depending on available knowledge and re- treatment. Surprisingly, all these methods have been sources of the era. Presently, the treatment options proven to be equally efficacious, hence defining the best treatment option is still elusive. Our experience is that * Correspondence: [email protected] non-operative reduction attempted in the radiology suite 1Department of Pediatric Surgery, Army Hospital (Research & Referral), New is quite unsafe and uncomfortable for the patient and Delhi 110010, India the parents, messy for the operators, and has a Full list of author information is available at the end of the article © The Author(s). 2021 Open Access This article is licensed under a Creative Commons Attribution 4.0 International License, which permits use, sharing, adaptation, distribution and reproduction in any medium or format, as long as you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons licence, and indicate if changes were made. The images or other third party material in this article are included in the article's Creative Commons licence, unless indicated otherwise in a credit line to the material. If material is not included in the article's Creative Commons licence and your intended use is not permitted by statutory regulation or exceeds the permitted use, you will need to obtain permission directly from the copyright holder. To view a copy of this licence, visit http://creativecommons.org/licenses/by/4.0/. Chand et al. Annals of Pediatric Surgery (2021) 17:9 Page 2 of 7 significant delay in immediate surgical management in time taken for reduction and the volume of fluid infused case of failure or complication. were recorded. The aim of the present study is to find an ideal envir- The objective USG criteria for reduction were chosen onment which is very safe for the patient, comfortable for reducing measurement bias which were: for the operators and flexible enough to promptly deal with any complication. 1. Disappearance of the intussusceptum after passing through ileocecal valve. 2. Visualization of reflux of fluid and air bubbles Methods through the caecum and ascending colon into the This prospective observational study was conducted ileum across the ileocecal valve. from July 2014 to May 2020 at a tertiary care pediatric 3. Demonstration of fluid distended ileum. surgery center. All children suspected to have intussus- 4. Absence of intussusceptum noted during the post- ception on clinical presentation and examination and evacuation USG examination. confirmed by USG performed by a senior faculty of radi- ology were included in the study. Meticulous records Once complete reduction was achieved, the fluid was were kept so as not to miss any case presenting with in- evacuated from the colon by connecting a drainage bag tussusception to reduce bias. There were a total 48 pa- to the Foley catheter. USG was performed again on the tients during the study duration, and all were included table to rule out a residual lesion and also to look for in the present study. Data collected included patient free fluid in the pelvis and the hepatorenal pouch to rule demographics, presentation, symptoms, USG findings, out any small perforation during reduction. USG was re- procedural information, failure rate, and recurrence rate. peated after 12 h to look for recurrence, in the absence Patients with evidence of perforation or peritonitis and of which, feeds were started and the patient was dis- parents refusing to consent for the procedure were charged. Criterion for abandoning the procedure was planned to be excluded from the study. In our study, all failure to progress for 10 min on two attempts 15 min patients diagnosed with intussusception were included, apart or any complication arising during the procedure. as none of them had any exclusion criteria. The Institu- We follow this criteria as we believe that GA itself aids tional Ethics Committee approved the study. in reduction of intussusception and if two attempts have All patients diagnosed with intussusception were ad- been unsuccessful at reduction, then further attempts mitted to a single hospital. After adequate fluid resusci- are less likely to succeed and surgical intervention would tation and stabilization, consent was obtained from be ideal. parents and patient was shifted to the operating room The data was collected in paper and pencil form and (OR). The anesthetist administered general anesthesia was entered into the excel sheet. The quantitative vari- (GA). The pediatric surgery team consisted of either of ables were described as mean and SD (standard devi- two pediatric surgeons alternatively, each of whom were ation) or median and IQR (interquartile range) after practicing consultants at the tertiary care center, along checking for normality of the data. The qualitative vari- with a pediatric anesthesiologist, and the OR matron ables were described as number and percentages. Appro- was scrubbed and a laparotomy trolley was arranged and priate statistical test were used to find association or kept ready for immediate operative intervention in case correlation among variables. The data was analyzed of a complication in the form of perforation or a failure using StataCorp. 2013. Stata Statistical Software: Release of reduction. The two surgeons performed equal surger- 13. College Station, TX: StataCorp LP. The p value of ies. Both the surgeons are experienced and practicing less than 0.05 was taken as significant. surgery for more than a decade. The technique was stan- dardized as follows: the patient was placed in a supine Results position with hips partially abducted and knees partially During the study period, we enrolled 48 patients with in- flexed. A 16-Fr Foley catheter was inserted per rectum tussusception (M/F, 33/15; age mean = 16.75 months; for 7–10 cm, and the balloon was inflated with 20 ml range 6–60 months). The most common age at presenta- normal saline (NS). The radiologist localized the intus- tion was between 12 and 24 months of age. All patients susception using USG and provided intraoperative guid- presented with pain and vomiting. Twenty-one of 48 pa- ance. The Foley catheter was connected to NS infusion tients also had rectal bleeding. The duration of symp- warmed to 37 °C and set hanging 1 m above the level of toms in most patients was between 24 and 48 h. USG the OR table. NS was allowed to run at full flow, and the revealed ileocolic intussusception in all patients. The progress of the water column into the colon was moni- complete list of demographic profile, presentation, and tored by USG. Real-time monitoring of reduction of in- procedure information is shown in Table 1. Hydrostatic tussusception was done by USG by the
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