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Introduction
The current standard of treatment for intussusception is image-guided non-operative reduction in a child who is clinically fit for the procedure (1-3). The 3 most often used techniques for the non-operative reduction are hydrostatic reduction using barium or saline, and pneumatic reduction. A literature search yields numerous recent articles discussing the success and complication rates of individual techniques or comparisons between any 2 techniques (1,3-5). Hence, we aimed to compare all 3 techniques with regards to the rates of success, recurrence, and complications, and to ascertain an association of successful reduction with patients’ age or symptom duration.
Methods
This was a retrospective 3-center study done from January 2017 through December 2019. Routine practices for non-operative reduction of intussusception varied in the 3 tertiary care centers in India. At Seth GSMC and KEM Hospital, it was ultrasonography (US)-guided saline reduction (USR); at Indira Gandhi Institute of Child Health, fluoroscopy-guided pneumatic reduction (FPR); and at Manipal Hospitals, fluoroscopy-guided barium reduction (FBR). This study was approved by the institutional ethics committees of the 3 centers with a waiver for informed consent (IRB no. EC/OA 183/2020). All children with intussusception who underwent an attempt at one of the techniques during the period were included, while those with intussusception who directly underwent surgery were excluded. Consistently in all 3 centers, candidates for the reductions were younger than 14 years. They were confirmed to have intussusception on US and had to be hemodynamically stable with no abdominal signs of peritonitis, such as a distended abdomen on presentation. In contrast, children who presented with signs of peritonitis or an obvious lead point on US were directly operated upon without an attempt at the non-operative reduction.
The patients were grouped as per the 3 techniques (see details in Appendix 1 [https://doi.org/10.22470/pemj.2024.01081]). Reduction of intussusception was declared successful when there was free flow of saline, air, or barium into the small bowel. Time to reduction was calculated from the beginning of instillation of the fluid or air to its free egress into the small bowel. In the case of failed reduction, we tried to further reduce up to maximum of 3 times. If intussusception was still not reduced or in case of complications (e.g., perforation), the patient was taken for surgery. Recurrence was defined as a US-proven intussusception in a child who had been successfully reduced. Decision for management for a recurrent intussusception was the same as the initial presentation. Any child who had 3 or more recurrences would undergo evaluation for a lead point or surgery.
According to the abovementioned group designations, we compared the variables including age, sex, successful reduction, time to reduction, recurrence, and perforation. In order to study an association of the patients’age with the successful reduction, the patients were further divided into the age groups: younger than 12 months, 12-36 months, and older than 36 months. For an association of the duration of symptoms before presentation with the successful reduction, they were categorized as follows: symptoms lasting less than 24 hours, 24-48 hours, and longer than 48 hours.
Quantitative data were analyzed with descriptive statistics and expressed as means and standard deviations. Qualitative data were analyzed using Fisher’s exact tests. A P value of less than 0.05 was considered significant. Data were tabulated and analyzed with IBM SPSS ver. 21 (IBM Corp.).
Results
In the 3-year study period, a total of 255 patients underwent one of the 3 techniques of intussusception reduction, of whom 11 were excluded from the study owing to the direct operations (Seth GSMC and KEM Hospital, 2: Indira Gandhi Institute of Child Health, 4; and Manipal Hospitals, 5).
Baseline characteristics are detailed in Table 1. Reduction was successful in 90.3%, 85.1%, and 87.7% in the USR, FPR, and FBR groups, respectively (P = 0.961). Time to reduction was shorter in the FPR group, compared with the USR and FBR groups (P < 0.001). Perforation occurred in 1 patient in the FPR group who was subsequently managed with immediate needle decompression, followed by laparotomy and reduction of intussusception with closure of perforation. There were no complications noted in the other groups. There was no in-hospital mortality.
There were no significant differences in the rates of successful reduction among the 3 techniques with respect to the patients’age or symptom duration (Table 2). The children who had failed reduction underwent laparotomy and their intraoperative findings are tabulated in Appendix 2 (https://doi.org/10.22470/pemj.2024.01081). Recurrence rates were 11.8%, 20.3%, and 15.8% in the USR, FPR, and FBR groups, respectively (P = 0.522). The number of patients with recurrence who were successfully managed with reduction has been tabulated in Appendix 2. One patient in the USR group, 3 in the FPR group, and 4 in the FBR group reported second recurrences.
Discussion
1. FBR vs. FPR
Earlier reports of comparison between FBR and FPR showed no difference (4), but probably with improvement in training and technique, recent studies have shown higher success rates with FPR (5,6). While both are done under fluoroscopy, there seem to be specific advantages highlighted in each. The use of barium for reduction was found to have higher rates of visualization of lead points, compared to FBR (3). However, the biggest concern in the use of barium is the possible occurrence of chemical peritonitis in cases of perforation. Once barium enters the peritoneal cavity, it adheres to the peritoneum and omentum, and remains radiopaque for years, thereby leading to intestinal obstruction. Compared to after other techniques, perforation after FBR may increase the incidence of resection anastomosis, hospital stay, and morbidity (7). In a rat study, barium was found to cause chronic granuloma or involvement of retroperitoneal lymphatics (8). FPR has the advantages over FBR of being cleaner, and having a shorter fluoroscopy time (4). The learning curve may be slightly higher in FPR as clinicians who are familiar with positive contrast medium need to adjust to negative contrast. It may be difficult to visualize the intussusception and its reduction if there is a large amount of gas in the small bowel (7). Perforation in FPR can also be life-threatening if there is a delay in diagnosis and emergent management. Trapped gas in the abdomen can cause compartment syndrome, which leads to decreased venous return, decreased visceral perfusion, or shock (9). It requires a high index of suspicion for early diagnosis, immediate needle decompression with a wide-bore needle and aggressive resuscitation of shock, followed by laparotomy.
2. FPR vs. USR
Some reports have suggested that FPR has higher success rates compared to USR (1,3) whereas a few other reports have had better outcomes with USR (10,11). Compared to FBR or FPR, USR has the advantage of complete avoidance of radiation exposure. Even with perforation, it may lead to better outcomes than the other 2 techniques. However, given the operator-dependency of US, the disadvantage is the need for radiologists or equivalent expertise. In a developing country like India, this can raise a problem, particularly in areas where radiologists are unavailable at certain times. A Chinese study shows that among the hospitals where US is used for reduction, only 36.4% of US was performed by pediatric surgeons (12). In contrast, in Germany, pediatric surgeons routinely used US for reduction without a help of radiologists (13).
3. USR vs. FPR vs. FBR
There have been insufficient studies comparing all 3 techniques. Hadidi and El Shal (14) found that there was a higher success rate with FPR than the other 2 techniques. No perforation occurred in the FPR group whereas 3 and 2 perforations occurred in the FBR and USR groups, respectively, but the difference was not significant (14). Alehossein et al. (15) also compared all 3 techniques of reduction in a single institution and found no differences in the rates of successful reduction among the 3 groups. In this current study, we have found no difference in the rates of successful reduction, recurrence rates, and perforation. This finding indicates that all techniques have comparable outcomes, but the decision to use one over the others should be made based on the strengths and weaknesses of each technique (Table 3).
Liu et al. (10) found that a higher success rate in USR than in FPR was found in the age group of 4-24 months with no difference in the age group older than 24 months. Another study comparing all 3 techniques of reduction found that there was no difference between the age and the techniques (15). In our study as well, we found no association of age with successful reduction.
In intussusception, edema and ischemia worsen with time, decreasing the chance of non-operative reduction while increasing that of perforation. The abovementioned study by Liu et al. (10) found that USR was more effective than FPR in children presenting with symptoms lasting 12-24 hours while there was no difference in those with shorter or longer duration of symptoms. We found no association of symptom duration with successful reduction.
The time required for reduction in our study as in other studies was shorter in the FPR group than in the USR and FBR groups (4,14). This finding is more important when we compare FPR and FBR since both techniques predispose patients to radiation hazards. According to a study on the effect of FPR and FBR on radiation dose (16), FPR lowers radiation dose regardless of fluoroscopy time, due to the density of air over the automatic exposure control cells. In contrast, the use of barium increased the dose by interfering with photon absorption (16). US completely avoids radiation exposure not only to patients but also to their guardians or healthcare workers who may stay at the bedside during the procedures.
Some reports show that all 3 techniques are being done exclusively by radiologists (15,17). In contrast, a few reports suggest a combined team approach by pediatric surgeons with radiologists (18). A pediatric surgeon is always required to stand by during the reduction for a possible emergency laparotomy. In our series, all 3 techniques of reduction have been done by pediatric surgeons and pediatric surgical residents only. For USR, radiologist assistance was taken.
Non-operative reduction is the first line of treatment for intussusception. USR, FPR, and FBR have comparable outcomes, with FPR requiring a shorter time than the other 2 techniques. The reduction techniques should be decided based on the strengths and weaknesses of each technique, as well as available resources.
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