- Email: [email protected]
Results of air pressure enema reduction of intussusception: 6,396 cases in 13 years
Results of Air Pressure Enema Reduction of Intussusception: 6,396 Cases in 13 Years By Jing-zhen
Guo, Xiao-yi
Ma, and Qi-hong
Shanghai, 6 lntussusception is the most common surgical emergency of childhood in China. Over the past 10 years, the incidence of intussusception has steadily increased worldwide, as well as in China. For example, 279 cases were treated in the Shanghai Children’s Hospital in 1974, while 615 were treated in 1984. Twelve cases were treated in a course of a single night during 1985. Over the past 13 years, for which we have good records, 6,396 cases of intussusception were treated at the Shanghai Children’s Hospital. Males outnumber females by a ratio of 2 to 1. In 3,872 cases seen over the past 6 years, 35.1% were under 6 months of age, 65.9%
MATERIALS
AND
METHODS
Air pressure enema reduction under radiographic control has been our treatment of choice since its introduction 23 years ago. In most of the 6,396 patients treated over the past 13 years, air enema has been used for both diagnosis and treatment (Table 1). The device we are using now is a SWY-A Electra-Therapeutic Apparatus for Intestinal Intussusception, made in Jiangsu, China (Fig 1). It has a miniature air pump, a system of pressure selection, and an indication with a visual alarm. A balloon catheter connected to the air pump is inserted into the rectum of the young patient. As the control button is pressed, the pump operates for 4-second intervals with an inflation volume of 220 mL and the intracolon pressure rises steadily until the preset value is reached, a maximum of 110 mmHg for children and 80 mmHg for young infants. Inflation is never undertaken without fluoroscopic control. Most of these procedures are carried out in the emergency room. The patients routinely receive sodium luminal or 10% chloral hydrate for sedation and atropine as an antispasmodic. Intravenous fluids may be administered depending on the state of hydration. A glycerine enema is given to evacuate feces and facilitate inflation of the colon. If the initial attempt at reduction is unsuccessful and the patient remains in good general condition, the patient is hospitalized, intravenous fluids are administered, and air enema reduction is attempted, repeated 2 to 3 hours later. In our series, almost 50% required such a second effort for successsful reduction. Sometimes bimanual manipulation through the abdominal wall may aid reduction. If repeated efforts at air reduction are unsuccessful, the patient is taken to the operating rmm where the patient is examined before
and after induction of general anesthesia. If no mass can be palpated, fluoroscopy is repeated, with another effort at air enema reduction if the intussusception is still present. If fluoroscopic examination confirms air reduction at that time, the patient is spared a laparotomy. Technically important points with respect to the air pressure reduction technique are as follows: maximum safe air pressure is 110 mmHg for older infants and children and 80 mmHg for young infants; all catheter manipulations and introductions of air must be under fluoroscopic control; before repetition of attempts at air enema reduction, the already insutilated air must be evacuated through the catheter; the catheter should be moved about to assure even distribution of the air pressure; air pressure enema should be continued as long as there is any progress, however slow, and the patient’s general condition permits; and roentgenogram exposure should be fractional and intermittent. In general, air reduction enema is attempted in a child with the following positive features: the general condition is good; dehydration is absent or slight; the onset of symptoms is within 60 hours; the stools are mild or moderate in currant jelly content; and there is absence of diarrhea in a young infant with symptoms and signs of intussusception. Conversely, air pressure enema reduction is abandoned in favor of surgical operation in the following situations: in newborn infants; where the time of onset is uncertain but probably more than 60 hours; where massive bloody or mucous stools are present; in the presence of severe abdominal distention; in infants under 3 months of age with severe diarrhea; where severe dehydration is present; in the presence of evidence of toxic shock; when abdominal examination suggests peritonitis; when air pressure reduction cannot be confirmed fluoroscopically, or when massive bleeding or perforation occurs during the course of attempts at air pressure reduction.
From the Department of Surgery, Shanghai Children’s Hospital, Shanghai, The Peoples Republic of China. Presented before the 17th Annual Meeting of the American Pediatric Surgical Association, Toronto. Ontario, May 14-I 7, 1986. Address reprint requests to Jing-zhen Guo, MD, 380 Kang Ding Rd. Shanghai, Peoples Republic of China. o 1986 by Grune & Stratton, Inc. 0022-3468/86/2112-0039$03.00/O
Table 1. Age Incidence in 3,872 Year
11 Year
70
150
170
128
46
153
164
89
52
661
65
187
234
111
64
4891340
829
69
245
284
176
55
436/ 195
631
67
168
178
163
61
162
204
144
1,192
871
448
1980
3991197
596
1981
313/191
504
1982
44612 15
1983 1984 1985
399/252
Total
2.482/1,390
Percent l
64136
*Percent <6 months of age, 35.1%;
~3 Months
Cases of Intussusception ~6 Months
Male/Female
Total
Zhou
China
651
28
3.872
345
100 < 1 year of age, 64.9%;
113 1,016
8.9
26.2
30.8
a2 Years
22.5
>2 Years 72
11.6
~2 years of age, 88.4%.
Journal of Pediatric Surgery, Vol 2 1, No 12 (December), 1986: pp 120 1- 1203
1201
GUO, MA, AND ZHOU
Table 2. Clinical Criteria Scoring System for lntussusception ClinicalSignsand Symptoms
ScOre
Duration of onset <24 hr
1
24-46 hr
2
46-60 hr
3
~60 hr
4
Age >l yr 6-12 mo 3-6
mo
~3 mo
1 2 3 4
Interval between the onset of symptoms and the appearance of bloody stools No bloody stools >24 Fig 1. SWY-A Intussusception.
Electra-Therapeutic Apparatus for Intestinal
hr
6-24 3-6
hr hr
~3 hr
0 1 2 3 4
Nature and color of stools
RESULTS
Although accurate records are not available when barium enema was used in the 1960s reduction of intussusception was successful in over 80% of cases. With air pressure reduction in the 197Os, reduction was achieved in 94%. The rate of reduction is currently running at 95.25%. Of our 6,396 cases, 383 cases received surgical treatment (6%). Colonic perforation occurred nine times in 6,396 cases (0.14%) with two deaths (.03%). A scoring system based on clinical criteria is currently being evaluated as a tool to predict if air reduction is likely to be successful and safe, and thus to identify those patients for whom operative management rather than air pressure reduction is the treatment of choice (Table 2). Points have been assigned to the various favorable and unfavorable indicators referred to above. Thus, clinical signs considered favorable, such as short duration of symptoms, older age of patient, and absence of diarrhea, abdominal distention, and dehydration are. all assigned low scores. Criteria considered to be less favorable to a nonoperative approach such as longer duration of symptoms, younger age, shorter interval between onset of symptoms, and appearance of bloody stools, pure bloody, or mucous stools, and presence of severe diarrhea, abdominal distention, or severe dehydration are assigned higher scores. The higher the score, the lower the successful rate of air reduction. It appears to be impossible to safely reduce an intussusception by air
Dark currant-jelly stools
1
Bright currant-jelly stools
2
Pure bloody
3
Mucus stools
4
Coexistence with diarrhea None
0
~3 times a day
1
>3 times a day
2
Frequent diarrhea
3
Abdominal distention No abdominal distention
0
Mild
1
Moderate
2
Severe
3
Dehydration No dehydration
0
Mild
1
Moderate
2
Severe
3
Total score
enema in a patient with a score of 15 or more. This scoring system has been examined retrospectively in 200 cases, and it holds promise of being a practical and reliable guide in the determination of initial treatment. The scoring system has been applied to all cases seen since October 1985 and, although the overall rate of air reduction has remained approximately the same, no perforations have thus far occurred. The value of the scoring system will be the subject of a future communication following its evaluation in a larger series of patients.
Discussion R.M. Filler (Toronto): I would like to say a few words about this paper because working in our Radiology Department, we have a Chinese radiologist also from Shanghai but not from the same hospital. She
also has had a tremendous experience with air reduction enema, and she has convinced our radiologists that this method is worthy of a trial for several reasons. Less radiation is needed with the reduction since air is
AIR PRESSURE ENEMA REDUCTION OF INTUSSUSCEPTION
much easier to see than barium. Intraluminal pressures can be controlled very accurately with the air pump, and there is a feeling that air is somewhat more effective than barium in achieving reduction. Intraluminal pressure control is better, and it appears that the head of the intussusception can be reduced a little more quickly. Finally, if there is a leak, it is better to have air in the peritoneum than contrast material. Whether this all turns out to be true or not is difficult to know at present since only 15 patients have been treated. However, the radiologists have been reasonably happy with the method. Undoubtedly many of you will be hearing about this technique in your hospitals since our group has been presenting this information to other pediatric radiology groups and I am told that there are a significant number of radiologists interested in purchasing this method. J. R. Wesley (Ann Arbor, MI): There were 11% in this large group of intussusception that were older children, and might well have been expected to have a pathologic leading point. Are the authors able to identify a pathologic leading point, if one exists, with the air contrast technique? I noticed that the presence of pathologic leading point was not included among the indications for surgery. 1s this problem addressed by the authors, and how do they handle this group of children? D. W. Hight (Hartford, CT): How is the barium enema used as a diagnostic measure? I wonder if these diagnoses are made purely on clinical grounds and then
1203
they proceed with the enema. How do they confirm that in every case these are in fact intussusceptions? D.M. Hays (Los Angeles): Do they quote a recurrence rate? We think barium enema reduction has about a 10% recurrence rate roughly. T.V. Santulli (New York): You said that 6% of the patients were operated on because this technique was unsuccessful. You did not tell us how many patients actually went directly to operation without this treatment in that same period. A. Shaw (closing): Unfortunately, some of the data that was requested by the discussants is not available in the manuscript. For instance, I cannot tell you what proportion of those operated on for intussusception represented failure of air pressure enema reduction and what proportion had their operation without attempt at air pressure reduction because of the presence of unfavorable clinical criteria. The operative findings are not discussed and no mention is made of lead points in children requiring surgical exploration. As Dr Abrams commented, the diagnostic accuracy of fluoroscopy using air insufflation is equal to that seen in this country using barium. I am sure that Drs Guo, Ma, and Zhou would very much appreciate the comments made here this morning. Certainly, when I was born in Shanghai I could never have anticipated standing before a group like this presenting this remarkable clinical paper some 50 odd years later. It is a joy and a privilege to do so.
Guo, Xiao-yi
Ma, and Qi-hong
Shanghai, 6 lntussusception is the most common surgical emergency of childhood in China. Over the past 10 years, the incidence of intussusception has steadily increased worldwide, as well as in China. For example, 279 cases were treated in the Shanghai Children’s Hospital in 1974, while 615 were treated in 1984. Twelve cases were treated in a course of a single night during 1985. Over the past 13 years, for which we have good records, 6,396 cases of intussusception were treated at the Shanghai Children’s Hospital. Males outnumber females by a ratio of 2 to 1. In 3,872 cases seen over the past 6 years, 35.1% were under 6 months of age, 65.9%
MATERIALS
AND
METHODS
Air pressure enema reduction under radiographic control has been our treatment of choice since its introduction 23 years ago. In most of the 6,396 patients treated over the past 13 years, air enema has been used for both diagnosis and treatment (Table 1). The device we are using now is a SWY-A Electra-Therapeutic Apparatus for Intestinal Intussusception, made in Jiangsu, China (Fig 1). It has a miniature air pump, a system of pressure selection, and an indication with a visual alarm. A balloon catheter connected to the air pump is inserted into the rectum of the young patient. As the control button is pressed, the pump operates for 4-second intervals with an inflation volume of 220 mL and the intracolon pressure rises steadily until the preset value is reached, a maximum of 110 mmHg for children and 80 mmHg for young infants. Inflation is never undertaken without fluoroscopic control. Most of these procedures are carried out in the emergency room. The patients routinely receive sodium luminal or 10% chloral hydrate for sedation and atropine as an antispasmodic. Intravenous fluids may be administered depending on the state of hydration. A glycerine enema is given to evacuate feces and facilitate inflation of the colon. If the initial attempt at reduction is unsuccessful and the patient remains in good general condition, the patient is hospitalized, intravenous fluids are administered, and air enema reduction is attempted, repeated 2 to 3 hours later. In our series, almost 50% required such a second effort for successsful reduction. Sometimes bimanual manipulation through the abdominal wall may aid reduction. If repeated efforts at air reduction are unsuccessful, the patient is taken to the operating rmm where the patient is examined before
and after induction of general anesthesia. If no mass can be palpated, fluoroscopy is repeated, with another effort at air enema reduction if the intussusception is still present. If fluoroscopic examination confirms air reduction at that time, the patient is spared a laparotomy. Technically important points with respect to the air pressure reduction technique are as follows: maximum safe air pressure is 110 mmHg for older infants and children and 80 mmHg for young infants; all catheter manipulations and introductions of air must be under fluoroscopic control; before repetition of attempts at air enema reduction, the already insutilated air must be evacuated through the catheter; the catheter should be moved about to assure even distribution of the air pressure; air pressure enema should be continued as long as there is any progress, however slow, and the patient’s general condition permits; and roentgenogram exposure should be fractional and intermittent. In general, air reduction enema is attempted in a child with the following positive features: the general condition is good; dehydration is absent or slight; the onset of symptoms is within 60 hours; the stools are mild or moderate in currant jelly content; and there is absence of diarrhea in a young infant with symptoms and signs of intussusception. Conversely, air pressure enema reduction is abandoned in favor of surgical operation in the following situations: in newborn infants; where the time of onset is uncertain but probably more than 60 hours; where massive bloody or mucous stools are present; in the presence of severe abdominal distention; in infants under 3 months of age with severe diarrhea; where severe dehydration is present; in the presence of evidence of toxic shock; when abdominal examination suggests peritonitis; when air pressure reduction cannot be confirmed fluoroscopically, or when massive bleeding or perforation occurs during the course of attempts at air pressure reduction.
From the Department of Surgery, Shanghai Children’s Hospital, Shanghai, The Peoples Republic of China. Presented before the 17th Annual Meeting of the American Pediatric Surgical Association, Toronto. Ontario, May 14-I 7, 1986. Address reprint requests to Jing-zhen Guo, MD, 380 Kang Ding Rd. Shanghai, Peoples Republic of China. o 1986 by Grune & Stratton, Inc. 0022-3468/86/2112-0039$03.00/O
Table 1. Age Incidence in 3,872 Year
11 Year
70
150
170
128
46
153
164
89
52
661
65
187
234
111
64
4891340
829
69
245
284
176
55
436/ 195
631
67
168
178
163
61
162
204
144
1,192
871
448
1980
3991197
596
1981
313/191
504
1982
44612 15
1983 1984 1985
399/252
Total
2.482/1,390
Percent l
64136
*Percent <6 months of age, 35.1%;
~3 Months
Cases of Intussusception ~6 Months
Male/Female
Total
Zhou
China
651
28
3.872
345
100 < 1 year of age, 64.9%;
113 1,016
8.9
26.2
30.8
a2 Years
22.5
>2 Years 72
11.6
~2 years of age, 88.4%.
Journal of Pediatric Surgery, Vol 2 1, No 12 (December), 1986: pp 120 1- 1203
1201
GUO, MA, AND ZHOU
Table 2. Clinical Criteria Scoring System for lntussusception ClinicalSignsand Symptoms
ScOre
Duration of onset <24 hr
1
24-46 hr
2
46-60 hr
3
~60 hr
4
Age >l yr 6-12 mo 3-6
mo
~3 mo
1 2 3 4
Interval between the onset of symptoms and the appearance of bloody stools No bloody stools >24 Fig 1. SWY-A Intussusception.
Electra-Therapeutic Apparatus for Intestinal
hr
6-24 3-6
hr hr
~3 hr
0 1 2 3 4
Nature and color of stools
RESULTS
Although accurate records are not available when barium enema was used in the 1960s reduction of intussusception was successful in over 80% of cases. With air pressure reduction in the 197Os, reduction was achieved in 94%. The rate of reduction is currently running at 95.25%. Of our 6,396 cases, 383 cases received surgical treatment (6%). Colonic perforation occurred nine times in 6,396 cases (0.14%) with two deaths (.03%). A scoring system based on clinical criteria is currently being evaluated as a tool to predict if air reduction is likely to be successful and safe, and thus to identify those patients for whom operative management rather than air pressure reduction is the treatment of choice (Table 2). Points have been assigned to the various favorable and unfavorable indicators referred to above. Thus, clinical signs considered favorable, such as short duration of symptoms, older age of patient, and absence of diarrhea, abdominal distention, and dehydration are. all assigned low scores. Criteria considered to be less favorable to a nonoperative approach such as longer duration of symptoms, younger age, shorter interval between onset of symptoms, and appearance of bloody stools, pure bloody, or mucous stools, and presence of severe diarrhea, abdominal distention, or severe dehydration are assigned higher scores. The higher the score, the lower the successful rate of air reduction. It appears to be impossible to safely reduce an intussusception by air
Dark currant-jelly stools
1
Bright currant-jelly stools
2
Pure bloody
3
Mucus stools
4
Coexistence with diarrhea None
0
~3 times a day
1
>3 times a day
2
Frequent diarrhea
3
Abdominal distention No abdominal distention
0
Mild
1
Moderate
2
Severe
3
Dehydration No dehydration
0
Mild
1
Moderate
2
Severe
3
Total score
enema in a patient with a score of 15 or more. This scoring system has been examined retrospectively in 200 cases, and it holds promise of being a practical and reliable guide in the determination of initial treatment. The scoring system has been applied to all cases seen since October 1985 and, although the overall rate of air reduction has remained approximately the same, no perforations have thus far occurred. The value of the scoring system will be the subject of a future communication following its evaluation in a larger series of patients.
Discussion R.M. Filler (Toronto): I would like to say a few words about this paper because working in our Radiology Department, we have a Chinese radiologist also from Shanghai but not from the same hospital. She
also has had a tremendous experience with air reduction enema, and she has convinced our radiologists that this method is worthy of a trial for several reasons. Less radiation is needed with the reduction since air is
AIR PRESSURE ENEMA REDUCTION OF INTUSSUSCEPTION
much easier to see than barium. Intraluminal pressures can be controlled very accurately with the air pump, and there is a feeling that air is somewhat more effective than barium in achieving reduction. Intraluminal pressure control is better, and it appears that the head of the intussusception can be reduced a little more quickly. Finally, if there is a leak, it is better to have air in the peritoneum than contrast material. Whether this all turns out to be true or not is difficult to know at present since only 15 patients have been treated. However, the radiologists have been reasonably happy with the method. Undoubtedly many of you will be hearing about this technique in your hospitals since our group has been presenting this information to other pediatric radiology groups and I am told that there are a significant number of radiologists interested in purchasing this method. J. R. Wesley (Ann Arbor, MI): There were 11% in this large group of intussusception that were older children, and might well have been expected to have a pathologic leading point. Are the authors able to identify a pathologic leading point, if one exists, with the air contrast technique? I noticed that the presence of pathologic leading point was not included among the indications for surgery. 1s this problem addressed by the authors, and how do they handle this group of children? D. W. Hight (Hartford, CT): How is the barium enema used as a diagnostic measure? I wonder if these diagnoses are made purely on clinical grounds and then
1203
they proceed with the enema. How do they confirm that in every case these are in fact intussusceptions? D.M. Hays (Los Angeles): Do they quote a recurrence rate? We think barium enema reduction has about a 10% recurrence rate roughly. T.V. Santulli (New York): You said that 6% of the patients were operated on because this technique was unsuccessful. You did not tell us how many patients actually went directly to operation without this treatment in that same period. A. Shaw (closing): Unfortunately, some of the data that was requested by the discussants is not available in the manuscript. For instance, I cannot tell you what proportion of those operated on for intussusception represented failure of air pressure enema reduction and what proportion had their operation without attempt at air pressure reduction because of the presence of unfavorable clinical criteria. The operative findings are not discussed and no mention is made of lead points in children requiring surgical exploration. As Dr Abrams commented, the diagnostic accuracy of fluoroscopy using air insufflation is equal to that seen in this country using barium. I am sure that Drs Guo, Ma, and Zhou would very much appreciate the comments made here this morning. Certainly, when I was born in Shanghai I could never have anticipated standing before a group like this presenting this remarkable clinical paper some 50 odd years later. It is a joy and a privilege to do so.