An ideal treatment for intussusception can be defined as one that is efficacious, safest, and painless for the patient, comfortably performed by the user, replicable, and avoids delay in treatment of possible complications. Intussusception was first described by Paul Barbette in 1674 and was further characterized by John Hunter in 1793 [1]. Various methods of reduction both operative and non-operative have been tried over the last 300 years [2]. In 1952, Ravitch and Mc Cune published a landmark series in which they used barium sulfate enema to diagnose as well as reduce intussusception, calling this “hydrostatic reduction.” They reported 73.6% success rate, no deaths, and 5.55% recurrence rate [3], after which attention shifted to non-operative reduction. The successful reduction of intussusception by saline enema under real-time sonography guidance was first described in 1982 by Kim et al. [4].
The various methods of non-operative reduction are pneumatic or hydrostatic, under fluoroscopy, or USG guidance done in the radiology suite either by surgeons themselves or assisted by a radiologist. In the radiology suite, this procedure is generally performed on an awake child or with minimal sedation used on an ad hoc basis [4]. All these procedures have variable success rates with no defined gold standard of treatment. Treatment is in accordance with the operator’s comfort and availability of resources. Surgical exploration remains a fallback procedure in case of failure or complication.
We consider the treatment of intussusception to be constituted of three arms. First is the “counterforce” (fluid, air or manual). The second is an “observer” who is the radiologist (USG/fluoroscopy), and the third arm is a “fallback team” comprising of the pediatric surgeon and anesthesiologist who are to be ready in the OR for immediate surgical intervention, if needed. In almost all described techniques of non-operative reduction, only two of these three arms have been used, comprising of a surgeon and a radiologist and performed in the radiology suite. But before starting the procedure, the third arm consisting of the anesthetist and OR is always notified and in as many as 10–20% of cases where failure or complications arise may be pressed into action. We do not consider this to be the best possible treatment scenario. Trying to reduce an intussusception in the radiology suite with a child who is in pain and in the presence of anxious parents leads to added stress to the patient and the parents. The surgeon performing the procedure in the radiology suite is concerned of the possibility of failure of reduction, of causing perforation, and whether the OR would be readily available without any delay, if needed. The apprehensions of the surgeon and the parents can be allayed by performing the procedure in the OR under GA with the surgical team ready for any eventuality. The contention of risk of GA and need for anesthesiologist is unsubstantiated as sedation in radiology suite with limited resources and the risk of aspiration itself warrants for the procedure to be done under the care of an anesthesiologist preferably in the OR. Sedatives usually given during such procedures are benzodiazepines and anti-cholinergics combined with ketamine or fentanyl, doses of which may have to be increased many folds if the procedure is prolonged. The disadvantages of sedation in children can be due to undersedation like causing anxiety to the patient, leading to an uncooperative child, causing difficulty in hydrostatic reduction, and also leaving a psychological impact as complete amnesia is not achieved. Oversedation can cause serious adverse events like respiratory insufficiency and cardiovascular depression besides the risk of aspiration [5]. As per the 2016 update of American Academy of Pediatrics guidelines on monitoring pediatric patients under sedation [6], sedation is known to cause serious adverse events especially in children less than 6 years old. Because the intended level of sedation may be exceeded, the person monitoring needs to be well trained in managing pediatric apnea, laryngospasm, and airway obstruction. Hence also the role of a pediatric anesthesiologist is highlighted. With advancement in pediatric anesthesia, administration of GA to a child has become extremely safe. GA even without muscle relaxants owing to its inherent analgesic and muscle relaxant property relaxes the abdominal muscle tone and voluntary pressure exerted by a crying child. In case of an unsuccessful reduction or complication, precious time is saved as the patient is already in the OR. Thus, in addition to a higher rate of success, GA is safer than sedation [7].
The “RIGHT” technique we describe here, involves three elements: general anesthesia, hydrostatic reduction, and USG guidance, which entails an anesthesiologist, pediatric surgeon, and radiologist working in tandem. Reduction of intussusception under GA has been reported in a few studies, but has not been used as a protocol in management. Chatterejee et al. described a technique of hydrostatic reduction assisted manually after performing a laparotomy which can be used by surgeons in resource challenged situations where USG or fluoroscopy is unavailable [8]. Purenne et al. [7] showed that the success rate of reduction by air enema increased when the procedure was done under GA when compared to sedation. However, they performed the procedure in the radiology suite and in cases where surgery was required, the anesthesia was maintained, and the patient was shifted to the OR. Collins et al. [9] in their study achieved successful reduction under GA in those cases which had one failed attempt under sedation. They proposed that GA reduces abdominal wall muscle tone and relaxes a struggling child with abdominal pain, allowing for better conditions for hydrostatic reduction. They also proposed that anesthetic-induced reductions in splanchnic blood flow may result in less edema of the bowel wall, which could prevent obstruction and further compromise. Chandrashekharam et al. [2] in their technique done under GA monitored the reduction of intussusception under direct vision after introducing a laparoscope. Digant et al. [10] evaluated the role of USG guidance for hydrostatic reduction using normal saline and concluded that it was an optimal and safe procedure.
In our study, the success rate of 44 out of 48 (91.6%) is closer to the success rate with hydrostatic reduction under ultrasound guidance of 95.5% as reported by Bai et al. [11] and Wang and Liu [12]. In all the four patients who underwent surgical exploration, there was no time lag as surgical team was scrubbed and ready and the child was already under GA. There was only one recurrence, which was also reduced by the “RIGHT” technique. Thus, our success rate in idiopathic (without lead point) intussusception was 97.7%. The biggest advantage of the “RIGHT” technique is that in the eventuality of a complication, which is life threatening, precious time can be saved in conversion to surgical exploration.
Since this technique requires the simultaneous involvement of the pediatric surgeon, radiologist, and the anesthesiologist and is to be performed in the OR, the technique may not be feasible at a primary or secondary level hospital where availability of the OR and the presence of all three specialists at the same time in an emergency may be difficult. The study has been carried out in a single center. A multi-centric study is recommended to confirm the findings and increase generalizability of the “RIGHT” technique.
