Ultrasound-Guided Pneumatic Reduction Of Intussusception In Children

with complaints of severe abdominal pain. In 43.8% of the patients, the duration of symptoms was less than 24 hours. The mean length of intussusception was 3.64 cm. A total of 94 (96%) children had successful reduction of intussusceptions with recurrence found in only two of cases. Conclusion


Introduction
segment of the bowel into an immediately adjacent segment.The intussusceptum is the proximal segment that invaginates into the distal segment known as the intussuscipiens. 1,24][5] It is most commonly seen in the ages of 6 months to 3 years, with a male predominance of around 1.5:1 to 3:1. 6,7he classical triad of intussusception has been described as abdominal pain, red currant jelly stool, and a palpable abdominal mass, however, this triad is only present in 25-50% of cases. 8,9%. 10 Ultrasonography is the most reliable method for the diagnosis of intussusception at the current time. 9,11e treatment modalities for intussusception include both operative and non-operative procedures.Nonoperative procedures have preferential status in the current treatment of intussusception in children. 8,12Non-operative procedures are indicated in states of hemodynamic stability and without contraindications such as perforation or peritonitis. 13Operative procedures are indicated when there is a failure of non-operative measures or there is a contraindication to non-operative methods. 14The nonoperative methods include ultrasound-guided hydrostatic reduction, ultrasound-guided pneumatic reduction, 5,8,9   Pneumatic reduction of intussusception has been regarded as superior to barium and hydrostatic reduction.It is a cheaper, easier, and quicker procedure to perform with higher success rates, and reduces the chance of radiation associated with barium procedures. 5,8,9,12nd well-timed reduction of intussusception prevents the occurrence of infarction and necrosis of the bowel, perforation, peritonitis, shock, and even death.1,2,9 guided pneumatic reduction in treating pediatric intussusception at our institute and identify and evaluate the recurrence of the condition.

Methodology
This is a prospective descriptive cross-sectional study conducted in the Department of pediatric surgery at Ishan Children & Women's Hospital, Kathmandu, Nepal.All the patients who went for pneumatic reduction from November 2019 to November 2022 were included in the study.
Inclusion criteria: All pediatric patients with a clinical ultrasonography.

Exclusion criteria:
The patients with red currant stool, fever, features of obstruction and peritonitis, and hemodynamic instability were excluded.reduction even after three attempts of pneumatic reduction at a pressure range of 80-120 mm of Hg for 3 to 5 minutes.
Informed consent was taken from the parents, and ethical clearance was taken from the Hospital Ethical Committee.The procedure involved using a catheter and sphygmomanometer to reduce intussusception in children.The catheter was locally assembled and appropriately sized (18 -26 Fr) as shown in Figure 1 Necessary blood tests were done, and the patients were booked for emergency laparotomy if the procedure failed.Under intravenous anesthesia in the operating room, the patient was positioned in a supine or left lateral position, and the two-way Foley's catheter lubricated with lignocaine with 30 to 50 ml of normal saline and gluteal fold held together to prevent leakage of air as shown in Figure 2. Air bulb, while the pressure was maintained between 80-120 mmHg for 3-5 minutes.
The success of the procedure was determined using an ultrasound scan after procedure with no evidence of telescoping of bowel into bowel.Three attempts were allowed at the interval of 5 minutes.Patients who failed the procedure underwent emergency laparotomy, while successful cases were monitored in the ward before being discharged.Patients who experienced a recurrence after successful reduction were allowed a maximum of three repeat procedures.

Figure 1. Assembled equipments
The variables that were analyzed to predict outcome are: age, gender, type of intussusceptions, presenting complaint, duration of symptoms before presentation, length of intussusception, and duration of pneumatic reduction.The data was calculated using SPSS 26th edition.

Results
Over three years, 98 children were treated with ultrasoundguided pneumatic reduction for intussusception and included in this study.The mean length of intussusception was 3.64±0.72cm.There were four cases of failed pneumatic reduction.Among those cases, 3 were of ileocolic type while 1 case was of ileoileal type of intussusception.The common factor among the cases of failed pneumatic reduction was presentation after more than 72 hours of the onset of symptoms to our institute, and rectal bleeding/red currant stool.Exploratory laparotomy with manual reduction was done for all these failed cases.Lead points were observed in two cases undergoing exploratory laparotomy.The surgical reduction cases were discharged on the 5th postoperative day.The cases of pneumatic reduction were discharged on 2nd post-procedure day.
Recurrence of intussusception occurred in two cases.The second patient experienced recurrence after six months of the initial pneumatic reduction.For both cases, the pneumatic reduction of intussusception was repeated and the symptoms were alleviated.The intussusception in both cases was of ileocolic type.There was no incidence of perforation during the procedure.

Discussion
Air enema reduction or pneumatic reduction of intussusception has gained widespread popularity, particularly among the pediatric population. 5,6,15ltrasound-guided pneumatic reduction of intussusception has shown better outcome compared to other methods of reduction of intussusception. 8,9,15A study by Khorana et al showed that pneumatic reduction is around 1.48 times be used according to the availability of resources at the institute and the experience of the doctor performing the reduction. 14 16 he risk of perforation was found similar between pneumatic or hydrostatic reduction.8][19][20] In our study, we achieved a success rate of 95.91% with an ultrasound-guided pneumatic reduction of intussusception, which is comparable to the success rate achieved by Wang et al and Todani et al. 17,18 A similar study from Nepal by Adhikari also achieved a 92% success rate which is similar to our study. 2cording to Kumar et al, age less than three months or more than two years is associated with an increased likelihood of pathological lead points and failure of pneumatic reduction. 7Our study did not demonstrate age to studies by Mensah et al, Tang et al, and Dung et al. 5,9,21 of symptoms of obstruction.We observed that the longer the duration of symptoms before reduction, the more the chance of failure was seen.We observed four cases among 98 total cases with duration of symptoms of more than 72 hours, which observed failure of pneumatic reduction and thus had to undergo exploratory laparotomy.Duration being the predictor of outcome has been reported by various other authors as well including Tang et al, Stein et al, and Katz et al. [20][21][22] in our study was rectal bleeding or the occurrence of red currant stool.Rectal bleeding occurred in only 38 (38.7%) cases of 98 total cases; however rectal bleeding and duration of symptoms for more than 72 hours were seen in all four cases of reduction failure.Hematochezia is most likely due to mucosal ulceration associated with bowel wall ischemia. 21A study by Reijnen et al found that patients with symptom duration of more than 48 hours and rectal bleeding were associated with a 92% risk of failure of pneumatic reduction. 23ang et al which is similar to the observation of our study. 21e mean length of intussusception was 3.64 ± 0.72 cm.The study by Adhikari had the mean length of intussusception intussusception of 4cm. 2,246][7] In our study, we found the M:F ratio to be 1.33:1, similar to the study by Kumar et al, Hazra et al, and Dung et al. 7,9,25 In our study, we observed that sex was not associated with an increased risk of failure of reduction of intussusception by pneumatic study by Tang et al. 21.Various studies have given perforation rates ranging from 0.5-1%. 21,26,27Our study did not experience any perforation during the pneumatic reduction of intussusception.In case of perforation, rapid hemodynamic and respiratory deterioration can occur, even leading to death. 27Immediate measures to decompress the high abdominal pressure should be kept ready to deal with such complications and constant vigilance should be kept by the surgeon or the radiologist performing the procedure.by hydrostatic methods. 5,21,28In our study, the patients with failed reduction were taken directly for exploratory laparotomy, where 2(2.04%) cases were found to have lead points.Another disadvantage of pneumatic reduction is pseudo-reduction wherein gas enters the small bowel without the intussusception being reduced. 4,20In our study, we did not observe any pseudo-reduction.
There are some limitations in our study.The study is done at a single institute with a small sample size.Fecal matter in the colon obstructs the air-entry while inappropriate

Conclusion
Pneumatic reduction of intussusception is a cheap, safe, associated with reduced morbidity and mortality and reduced risk of exploratory laparotomy.The main predictor for the outcome was the duration of symptoms before presentation to the institute, thus early use of pneumatic reduction is advisable.Red currant stool or rectal bleeding should also be considered as a bad predictor.Ultrasoundguided pneumatic reduction is thus, a safe and recommended procedure for the treatment of intussusception in the pediatric population.

Figure 2 .
Figure 2. Position of the patient