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ORIGINAL ARTICLE
Year : 2020  |  Volume : 25  |  Issue : 2  |  Page : 76-79
 

Nonavailability of ultrasound: Try stethoscope in pneumatic reduction


Department of Pediatric Surgery, SMS Medical College, Jaipur, Rajasthan, India

Date of Submission13-Jun-2018
Date of Decision03-Aug-2018
Date of Acceptance26-Oct-2019
Date of Web Publication28-Jan-2020

Correspondence Address:
Dr. Aditya Pratap Singh
Near the Mail Hostel, Main Bali Road, Falna, Pali - 306 116, Rajasthan
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/jiaps.JIAPS_129_18

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   Abstract 


Aim and Objective: This study aimed to finding alternative ways for centers with nonavailability of ultrasonography or fluoroscopy for nonoperative pneumatic reduction of intussusceptions.
Materials and Methods: A total of 48 cases of intussusceptions were included in the study in-between October 2016 and March 2018. We tried stethoscope-guided pneumatic reduction using locally assembled equipment. The intraluminal pressure was monitored and maintained below 100 mmHg. A total of two attempts of 3 min each were allowed. We compared our results with the control group who have been performing laparotomy for every case of intussusception.
Results: There were 35 males and 13 females in our study. The average age of the patients was 7.5 months. Intussusceptions were reduced in 38 (80%) patients but could not be reduced in 10 (20%) patients. Majority of the intussusceptions had symptoms of at least 2 days. There were no complications such as perforation in our study.
Conclusion: Stethoscope-guided pneumatic reduction seems to be a feasible and alternative effective method for the treatment of intussusceptions in children where availability of ultrasonography and skilled radiologist with overburden of work is a great issue.


Keywords: Intussusception, pneumatic, reduction, stethoscope


How to cite this article:
Tanger R, Singh AP, Gupta AK, Barolia DK, Shukla AK. Nonavailability of ultrasound: Try stethoscope in pneumatic reduction. J Indian Assoc Pediatr Surg 2020;25:76-9

How to cite this URL:
Tanger R, Singh AP, Gupta AK, Barolia DK, Shukla AK. Nonavailability of ultrasound: Try stethoscope in pneumatic reduction. J Indian Assoc Pediatr Surg [serial online] 2020 [cited 2020 Apr 10];25:76-9. Available from: http://www.jiaps.com/text.asp?2020/25/2/76/276933





   Introduction Top


Intussusception is the invagination of one portion of the intestine (intussusceptum) into the contiguous distal segment (intussuscipiens), with the most common being ileocolic intussusception. It is the most common cause of bowel obstruction in the infant-toddler age group. Pneumatic reduction of intussusception is nowadays a well-established technique which has excellent success rate and minimum complication rate compared to barium enema and hydrostatic reductions.[1],[2] This is usually done under ultrasound guidance.[3] Availability of ultrasound machines and skilled radiologists is a significant issue in many centers. Our center has overburden of patients with unavailability of radiologist most of the time for this procedure. We have been performing stethoscope-guided pneumatic reduction. When intussusception reduces by pneumatic reduction, it produces whistling sound due to the escape of air in the proximal bowel, which is audible by the stethoscope. Our technique is simple and reliable that can be used in most hospitals, especially at centers with limited resources and nonavailability of skilled radiologist.


   Materials and Methods Top


A total of 48 cases of intussusceptions were included in our study. This prospective study was conducted from October 2016 to March 2018. The cases of intussusception were diagnosed by abdominal ultrasound scan. The parents/guardians of all children were informed about the options available at that time, that is, surgery as well as pneumatic reduction. We excluded the cases of intussusception who had significant abdominal distension, signs of peritonitis, length of intussusception >6 cm, and history of >4 days and children whose parents did not agree to the procedure. The children were symptomatic from few hours to 4 days with gastrointestinal symptoms such as vomiting, abdominal pain, diarrhea, and blood-stained mucoid stools. We compared our results with that of the control unit who have been performing laparotomy for every case of intussusception. Fifty-three patients of intussusceptions were admitted in the control surgical unit. Exploratory laparotomy was performed for every case. The intussusceptions were reduced manually in 42 cases, and resection anastomosis was performed in 11 cases either because of gangrenous changes, or severe serosal tear.

The patients were resuscitated using intravenous (IV) fluids and antibiotics. All routine blood investigations were performed including complete blood counts, blood urea, serum creatinine, and electrolytes. A nasogastric tube was also passed to decompress the bowel. When the patient was adequately resuscitated, he/she was taken for the procedure. The equipment used for the reduction included an aneroid sphygmomanometer pressure gauge with an insufflator, a hand bulb, release valves, a Foley's catheter, and a stethoscope fixed on the abdominal wall in the right iliac fossa with the help of a micropore tape [Figure 1].
Figure 1: (a) Instruments in the procedure, (b) photographs showing the procedure

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Criteria for complete reduction were as follows:

  • Whistling sound audible by the stethoscope
  • Central fullness of the abdomen
  • Fall of pressure in the pressure gauge
  • Disappearance of the palpable lump.


Technique

The clinical diagnosis of intussusception was confirmed by ultrasound. Before attempting pneumatic reduction, it was ensured that the patient was well hydrated. The stethoscope was fixed on the abdominal wall in the right iliac fossa with the help of the micropore tape. The Foley's catheter (18 Fr) was introduced per rectum, and the balloon was inflated by 20–30 cc of saline. It completely occluded the rectum but was not overinflated. The patient's gluteal folds were strapped together to further ensure no air leakage during the procedure. Air was insufflated using the hand pump to a pressure of between 80 and 100 mmHg. The pressure was maintained for 3 min. The reduction of intussusceptions was assessed by listening to whistling sound by the stethoscope along with the other criteria. The procedure was repeated after 1 min if unsuccessful. A total of two insufflations were performed for 3 min each. Reduction of the intussusception was observed by the stethoscope. The patients' vital signs were monitored throughout the procedure with a pulse oximeter. The pneumatic reduction was considered a failure if no whistling sound was audible by the stethoscope, without a fall in pressure in the gauze and central abdominal fullness. After the second attempt for reduction, surgery was proceeded. Two attempts of 3 min each time were permitted. When the intussusception reduced, the patients were shifted to the ward and monitored. Follow-up ultrasound was performed on the same day.


   Results Top


A total of sixty cases of intussusceptions were admitted in our unit. After meeting the exclusion criteria, 48 cases were enrolled in the study, out of which, 35 (68%) were male and 13 (32%) were female, with a female-to-male ratio of 2:1. The average age of the patients was 7.5 months. The most common type of intussusception at the time of diagnosis was ileocolic. The intussusceptions were reduced successfully in 38 (80%) patients and were unsuccessful in the other 10 (20%) cases. The process was abandoned after two attempts without any evidence of major complications in the ten cases. There were four cases of bowel ischemia intended for surgery; two had non-Hodgkin's lymphoma and Meckel's diverticulum acting as a lead point, and in the four cases, preoperative reduction was performed. There was no recurrence seen in our study. The average duration of the reduction process was 10 min, with the duration ranging between 8 and 15 min. The average pressure needed to reduce the intussusception was about 70 mmHg (range: 60–100 mmHg). Most of the children who had successful reduction were discharged on the 1st or 2nd postoperative day. Fifty-three patients with intussusceptions were admitted in the control surgical unit. Exploratory laparotomy was performed in all cases. The intussusceptions were reduced manually in 42 cases, and resection anastomosis was done in 11 cases either because of gangrenous changes, or severe serosal tear [Table 1]. we also compared the procedure outcome with duration of symptoms and criteria for the pneumatic reduction as shown in [Table 2].
Table 1: Comparison of the test and control groups

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Table 2: Procedural outcome with duration of symptoms and with criteria for pneumatic reduction

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   Discussion Top


Intussusception is a common abdominal surgical emergency in children, which needs prompt diagnosis and management. Nonsurgical reduction is widely accepted in many parts of the world in the last five decades.[4],[5],[6] Different centers have used different types of nonsurgical method of reduction based on their successful experiences. Barium enema is the standard procedure for the diagnosis and therapeutic reduction of intussusception. It has risks and complications. Pneumatic reduction under fluoroscopic guidance is claimed to be quick, safe, and clean, and it has been reported to have a high success rate.[5],[6],[7],[8] However, radiation exposure and failure to identify lead points and residual ileo-ileal intussusception are the limitations of fluoroscopy-guided reduction.[8] Ultrasonography (USG)-guided hydrostatic reduction has been recommended because there is no radiation exposure, and it can be used to accurately confirm a diagnosis and subsequent reduction.[4],[9],[10],[11],[12] USG-guided hydrostatic reduction can depict lead points and residual ileo-ileal intussusception more readily than fluoroscopy-guided pneumatic reduction.[1],[13],[14] Pneumatic reduction of intussusception has been practiced since the 1950s. The higher success rate compared to hydrostatic reduction is due to the inherent compressible effect of air that results in air dissecting between the intussusceptum and intussuscipien. This effect facilitates and expedites the reduction.[5]

Pneumatic reduction of intussusception in children is a quick method of the management of intussusception. The only limitation of pneumatic reduction of intussusception is the availability of good USG machines and skilled radiologists. In many centers, surgical reduction is the only option due to nonavailability of ultrasonography. In an overburdened center like us (more than 200 USG procedures daily), it is very difficult to do pneumatic reduction in radiology suite. Initially we performed the procedure with radiologist in operation theater, but nonavailability of the radiologist we tried stethoscope inspite of USG machine for pneumatic reduction. We performed pneumatic reduction under short general anesthesia (GA) or IV sedation. The procedure is blind and sound based. We performed the procedure under GA to create a quiet environment to listen the whistling sound by the stethoscope; otherwise, it is not needed. This was shown in our study that an average of 10 min (range: 8–15 min for the whole procedure) is needed for the reduction to take place, that is, from the start of gas inflation to complete reduction. The short reduction time has also been reported in studies in many centers.[5],[8],[11],[15] Patients have a shorter hospital stay (2 days) with this procedure. Clearly, the cost of surgical management far outweighs that of pneumatic reduction, especially in uncomplicated cases. Our study findings demonstrate that stethoscope-guided pneumatic reduction is a feasible and effective technique for nonsurgical reduction of pediatric intussusception; it has a good success rate without radiation exposure to either the patient or the medical personnel. In this study, the overall success rate of stethoscope-guided pneumatic reduction was 80%. The success rate (84.4%) was similar to that of another study.[16] The previously reported [6],[7],[15],[17] perforation rates with various techniques were in the range of 0.14%–2.80%. There were no complications seen in our study, especially bowel perforation. We used sedation/short GA in our study. Some authors suggested that sedation could mask the signs of shock during the procedure,[12] straining during the reduction procedure protects against bowel perforation,[12] and the increased intraabdominal pressure caused by crying and straining results in rapid reduction.[12],[18] In our study, sedation helped us to listen the whistling sound by the stethoscope during the procedure. Our series has proven that pneumatic reduction is safe and effective and can be easily performed at any hospital, where facility for US machine is not available. We also compared our results with that of the laparotomy cases. There were a good number of cases who had been operated with per-operative reduction. Hence, we can avoid laparotomy in such cases where USG machines and skilled radiologists are not available.


   Conclusion Top


Stethoscope-guided pneumatic reduction seems to be a feasible and effective method for the treatment of intussusceptions in children where the availability of ultrasonography and skilled radiologist is a great issue. Stethoscope-guided pneumatic reduction is a blind but audio-observed procedure with a good success rate without the help of costly USG machines and skilled radiologists. With this technique, we can avoid unnecessary laparotomy (81% as done in control surgical unit) and their lifetime complications for reducible intussusceptions in case of nonavailability of ultrasonography.

Acknowledgment

We would like to thank Dr. Neelam Dogra, Senior Professor, Department of Anaesthesia, SMS Medical College, Jaipur, Rajasthan, India.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
   References Top

1.
Lui KW, Wong HF, Cheung YC, See LC, Ng KK, Kong MS, et al. Air enema for diagnosis and reduction of intussusception in children: Clinical experience and fluoroscopy time correlation. J Pediatr Surg 2001;36:479-81.  Back to cited text no. 1
    
2.
Hadidi AT, El Shal N. Childhood intussusception: A comparative study of nonsurgical management. J Pediatr Surg 1999;34:304-7.  Back to cited text no. 2
    
3.
Singh AP, Tanger R, Mathur V, Gupta AK. Pneumaticreduction of intussusception in children. Saudi surg J 2017;5:21-5.  Back to cited text no. 3
  [Full text]  
4.
Stein M, Alton DJ, Daneman A. Pneumatic reduction of intussusception: 5-year experience. Radiology 1992;183:681-4.  Back to cited text no. 4
    
5.
Kirks DR. Air intussusception reduction: “The winds of change”. Pediatr Radiol 1995;25:89-91.  Back to cited text no. 5
    
6.
Yoon CH, Kim HS. Ultrasound guided reduction of childhood intussusception. J Korean Radiol Soc 1986;22:788-93.  Back to cited text no. 6
    
7.
del-Pozo G, Albillos JC, Tejedor D, Calero R, Rasero M, de-la-Calle U, et al. Intussusception in children: Current concepts in diagnosis and enema reduction. Radiographics 1999;19:299-319.  Back to cited text no. 7
    
8.
Miller SF, Landes AB, Dautenhahn LW, Pereira JK, Connolly BL, Babyn PS, et al. Intussusception: Ability of fluoroscopic images obtained during air enemas to depict lead points and other abnormalities. Radiology 1995;197:493-6.  Back to cited text no. 8
    
9.
Peh WC, Khong PL, Lam C, Chan KL, Cheng W, Lam WW, et al. Reduction of intussusception in children using sonographic guidance. AJR Am J Roentgenol 1999;173:985-8.  Back to cited text no. 9
    
10.
Guo JZ, Ma XY, Zhou QH. Results of air pressure enema reduction of intussusception: 6,396 cases in 13 years. J Pediatr Surg 1986;21:1201-3.  Back to cited text no. 10
    
11.
Meyer JS, Dangman BC, Buonomo C, Berlin JA. Air and liquid contrast agents in the management of intussusception: A controlled, randomized trial. Radiology 1993;188:507-11.  Back to cited text no. 11
    
12.
Rosenfeld K, McHugh K. Survey of intussusception reduction in England, Scotland and wales: How and why we could do better. Clin Radiol 1999;54:452-8.  Back to cited text no. 12
    
13.
McAlister WH. Intussusception: Even Hippocrates did not standardize his technique of enema reduction. Radiology 1998;206:595-8.  Back to cited text no. 13
    
14.
Frush DP, Zheng JY, McDermott VG, Bisset GS 3rd. Nonoperative treatment of intussusception: Historical perspective. AJR Am J Roentgenol 1995;165:1066-70.  Back to cited text no. 14
    
15.
Shiels WE 2nd, Maves CK, Hedlund GL, Kirks DR. Air enema for diagnosis and reduction of intussusception: Clinical experience and pressure correlates. Radiology 1991;181:169-72.  Back to cited text no. 15
    
16.
Hasan OB, Farres SN, Ibrahim M. Ultrasound guided pneumatic reduction of intussusception in children – A case series. Int J Recent Sci Res 2015;6:4204-7.  Back to cited text no. 16
    
17.
Wood SK, Kim JS, Suh SJ, Paik TW, Choi SO. Childhood intussusception: US-guided hydrostatic reduction. Radiology 1992;182:77-80.  Back to cited text no. 17
    
18.
Zheng JY, Frush DP, Guo JZ. Review of pneumatic reduction of intussusception: Evolution not revolution. J Pediatr Surg 1994;29:93-7.  Back to cited text no. 18
    


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    Tables

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