OPEN AIMJ ORIGINAL ARTICLE

Comparative Study between Hydrostatic and Pneumatic Reduction For Early Pediatric Surgery
Intussusception In Pediatrics
Hossam Eldin H. Taher 1*M.B.B.Ch; Mohammed A. Abdel Aziz 1MD; Ahmed A. Mostafa 2MD;
Youssef M. Ali 1MD

*Corresponding Author: ABSTRACT

Hossam Eldin H. Taher Background: : Intussusception is an operative emergency that occurs
[email protected] frequently in children, particularly infants. Intussusception can be treated
non-surgically or surgically. Intussusception is increasingly being treated
Received for publication December non-surgically.
27, 2021; Accepted April 02, 2022; Aim of The Work: To compare the safety and efficacy of hydrostatic
Published online April 02,2022. and pneumatic reductions for early intussusception in pediatrics and to
evaluate both techniques.
Copyright The Authors published Patients and Methods: Twenty patients were involved in this
by Al-Azhar University, Faculty of prospective single-blind randomized comparative study. They have been
Medicine, Cairo, Egypt. Users allocated into two groups at random: Group A, which comprises 10
have the right to read, download, patients who had hydrostatic reduction; and Group B, which comprises
copy, distribute, print, search, or 10 patients who had pneumatic reduction. The patients' ages at the time
link to the full texts of articles of reduction varied from 3 to 36 months, with an average and IQR range
under the following conditions: of 8 months (5-14). Regarding gender distribution, 11 of them were
Creative Commons Attribution- males (55%) while the remaining 9 (45%) were females with male to
Share Alike 4.0 International female ratio 1.2:1. The patient’s body weight ranged from 5.5 kilograms
Public License (CC BY-SA 4.0). to 13 kilograms with the mean weight of 8.57±1.94 kg.
Results: The rate of success was significantly higher in the pneumatic
doi: 10.21608/aimj.2022.113210.1756 group (80%) compared to the hydrostatic group (60%) after the first trial.
The rate of success was significantly higher in the hydrostatic group
1
Pediatric Surgery Department, (50%) when compared to the pneumatic group (0%) following the
Faculty of Medicine, Al-Azhar second trial.
University, Cairo , Egypt. Conclusion: Pneumatic reduction is a simple, quick, and mess-free
2
method. There is no need for a radiologist. Hydrostatic reduction is a safe
General Surgery Department, technique. It avoids exposure of the child to a significant amount of
Faculty of Medicine, Al-Azhar radiation.
University, Cairo , Egypt.
Keywords: Hydrostatic; pneumatic Reduction; early intussusception;
children.

Disclosure: The authors have no financial interest to declare in relation to the

content of this article. The Article Processing Charge was paid for by the
authors.
Authorship: All authors have a substantial contribution to the article.

INTRODUCTION

The invagination of one intestinal segment inside a limitations, such as evidence of peritonitis,
more distal segment is known as intussusception 1, 2. perforation, or a hemodynamically unwell patient 5,6.
It is the most prevalent reason for intestinal blockage When nonsurgical therapy is prohibited or has failed,
in infants, typically happening between the ages of 4 surgical techniques will be used. Nonsurgical
and 10 months 3. decrease success rates have been reported to vary
Intussusception results when the ileum invaginates from 46% to 94% in the literature 7. Under
into the cecum through the ileocecal valve in most ultrasonography or fluoroscopy, a hydrostatic or
infants. pneumatic pressure enema could be used. pneumatic
decrease employing air in the therapy of
The bowel's blood supply is pulled along as it intussusception is a very efficient option that offers
intussuscepts. leading to intestinal ischemia and extra benefits such as reduced cost, and a lower
potentially perforation. Intussusception can be lethal perforation risk 8. On the other hand, children with
2
. intussusception will be exposed to radiation if the
Intussusception is a frequent abdominal emergency pneumatic decrease approach is used under
in infants and children, with a one-to-four occurrence fluoroscopy. An alternate approach that avoids
in 2000 4. Idiopathic intussusception and pathologic radiation is ultrasound-guided hydrostatic decrease
lead-point intussusception are the two most common using normal saline. Both of these approaches have
types of intussusception. claimed rates of success of 80–90% 9.

The majority of instances are idiopathic, Non- Nevertheless, there is still debate over the best way to
surgical and surgical techniques are currently reduce mortality and morbidity while maximizing
available for intussusception therapy. If there are no rates of success.

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As a result, we performed a randomized controlled The pressure gauge was connected to a hand-held
trial to examine the safety and efficacy of hydrostatic pump. The air was insufflated through the rectum
and pneumatic reductions with ultrasound and using a 3-way Foley's balloon catheter. The pressure
fluoroscopic monitoring, respectively. has been monitored using a sphygmomanometer
connected to the Foley catheter, which was
The goal of this research is to compare the efficacy connected to the pump's inlet. The age of the patient
and safety of hydrostatic and pneumatic reductions detects the caliber of the catheter that range from
using ultrasound and fluoroscopic monitoring, 18FG to 22FG.
respectively, as non-operative management for early
intussusception in pediatrics and to evaluate both Technique:
techniques with regard to time required for reduction,
maximum pressure used, number of attempts, success Under fluoroscopy, the Foley's catheter has been
rate of reduction, and complications during and after inserted into the rectum and the balloon has been
reduction inflated using 20 to 40 cc of air, the patient's gluteal
folds have been tied together.
PATIENTS AND METHODS
The hand pump was used to insufflate air with
This prospective single-blinded randomized intermittent fluoroscopy monitoring to a maximum
comparative study was undertaken by the Pediatric pressure of 100 mmHg. For three minutes, the
Surgery Unit of Al-Azhar University Hospitals. pressure was kept up. The insufflation was repeated
Twenty patients were enrolled in the study, all of after a minute. Three insufflations have been
whom had been admitted to the department in the conducted in total, each lasting 3 minutes. If the
time period from November 2020 to November 2021 intussusception had not been reduced by the conclusion
and diagnosed with intussusception. of three insufflations and the patient's vital signs were
stable, the operation would have been repeated
The study included patients with ages eligible for following a 4-to 12-hour interval. When the
study: 3 months- 3 Year of age, haemodynamically intussusception had not been reduced following the
stable children with no significant abdominal second try, the pneumatic reduction had been declared a
distention, no clinical or radiological signs of failure, and the patient had been referred to surgery 10.
peritonitis and symptoms less than 24 hours.
Ultrasound guided hydrostatic reduction:
While patients with shock, which isn't easily
corrected by intravenous hydration, significant Equipment:
abdominal distention, signs of peritonitis, symptoms
lasting more than 24 hours and clinical a. Initial abdominal ultrasound scan was done to
manifestations of small intestinal obstruction were confirm diagnosis. b. A Foley catheter has been
eliminated from the research. placed in the rectum of the child. c. A 30-ml syringe
was used to inject normal saline solution through the
Patients have been allocated into two groups at Foley's catheter.
random:
Technique:
Group A, which was comprised of 10 patients who
had hydrostatic reduction under US-guided. Following lubricating the rectum with KY jelly, the
child was placed in a left lateral position and a 3-way
Group B, which was comprised of 10 patients who Foley's catheter was inserted.
had pneumatic reduction under fluoroscopic guided.
In order to inflate the catheter's balloon, 30 mL of
These cases were diagnosed by: water has been injected. To achieve a tight anal seal,
the patient has been positioned in a supine position
History taking: (detailed history from parents): with and his thighs have been manually squeezed together.
stress on the following points: a. Age, b. Sex, c.
Presenting symptom(s): (colic, bleeding/rectum, A fluid line has been used to link one litre of normal
vomiting ), d. Feeding solid foods, e. History of saline (pre-warmed to normal body temperature) to
upper respiratory tract infection, f. History of the catheter, which has been suspended 100 cm
gastroenteritis, g. History of previous similar attacks. above the bed level. Under the influence of gravity,
normal saline was permitted to flow freely into the
Clinical Examination (and reporting the following rectum. Real-time ultrasound has been used to
points): body weight, temperature, lethargy or not, monitor the colon's gradual distension and the
abdominal distention, palpable abdominal mass, red intussusception's retrograde movement toward the
currant jelly stool, and palpable mass on PR. caecum.
Investigations: complete blood count, arterial blood A total of three tries at hydrostatic reduction have
gases, abdominal Ultrasound :(L.S: psuedokidney been performed, with every episode lasting three
sign &T.S: doughnut sign , pathological lead point, minutes, the abdomen was reexamined and the
free fluid), cases were selected randomly for either ultrasound is repeated to ensured success. If the
pneumatic or hydrostatic reduction. reduction fails, we can repeat the operation after a 4-
Informed consent: was obtained after detailed to 12-hour interval 11.
discusion with the parents.
Statistical analysis:
Pneumatic reduction technique: The statistical package for the social sciences,
Equipment: version 23.0, was employed to analyze the data

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Pediatric Surgery

collected (SPSS Inc., Chicago, Illinois, USA). When and percentages were also employed to represent
the distribution of the quantitative data was qualitative variables. The Kolmogorov-Smirnov and
parametric (normal), the mean±SD, and ranges were Shapiro-Wilk tests were employed to determine data
reported. However, non-normally distributed normality. P-values of less than 0.05 were deemed
variables (non-parametric data) were represented as significant.
median with an inter-quartile range (IQR). Numbers

RESULTS
In comparing both groups, the median age was equal (8 months) and, in terms of other population data, no
statistically significant differences existed between the two groups.
Demographic data Group A Group B Total Test p-
(Hydrostatic) (Pneumatic) value value
(n=10) (n=10)
Age (months) 3-36 8(5-12) 4-35 9 (6-15) 3-36 8(5-14) 0.983 0.442
Range
Median (IQR)
Gender 6 (60%) 4 (40%) 5 (50%) 5 11 (55%) 9 FE 0.661
Male (50%) (45%)
Female
Body weight (kg) 5.5-12 6-13 5.5-13 0.399 0.695
Range 8.32±2.07 8.67±1.85 8.57±1.94
Mean±SD
Table 1: Comparison of groups based on demographic data.
Different presentations and their distribution between both groups are enlisted in table (2). Notably, none of those
variables showed statistical significant difference when both groups were compared.
Group A (Hydrostatic) Group B (Pneumatic) p-value
(n=10) (n=10)
Colic 10 (100%) 10 (100%) 1.000
Vomiting 9 (90%) 8 (80%) 0.542
Fever 2 (20%) 4 (40%) 0.342
Lethargy 3 (30%) 4 (40%) 0.648
Mild distention 1 (10%) 3 (30%) 0.648
Palpable mass 2 (20%) 4 (40%) 0.342
Red currant jelly stool 9 (90%) 9 (90%) 1.000
Leukocytosis 4 (40%) 6 (60%) 0.383
Table 2: Different presentations of study groups.
When contrasted to the hydrostatic group (60%), the pneumatic group had a higher rate of success (80%), but the
difference was insignificant (p-value 0.05 NS).
Success rate after 2nd trial: was higher in the hydrostatic group (50%) when compared to the pneumatic group (0%)
The result was equal in both groups, with success rate of 80%
Incidence of perforation in hydrostatic group was zero percent after 2nd trial, and it was zero percent in pneumatic
group in table (3).
Group A Group B Test value p-value
(Hydrostatic) (Pneumatic)
(n=10) (n=10)
Perforation 0 (0%) 0 (0%) 0.000 1.000
Table 3: Perforation rate in both groups.
Regarding the time of the procedure, it was significantly shorter in the pneumatic groups (table 4). It ranged from
10 to 30 minutes in the hydrostatic group with a median time of 21 (13-28) minutes whereas in pneumatic group, it
ranged from 2 to 20 minutes with the median time 10 (4-17) minutes.
Reduction time “min” Group A Group B Test p-value
(Hydrostatic) (Pneumatic) value
(n=10) (n=10)
Range 10-30 2-20 8.682 <0.001**
Median (IQR) 21 (13-28) 10 (4-17)
Table 4: Reduction time of both groups.
Second trial enema reduction:

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There were 6 cases who underwent second trial enema reduction with success rate of 33.3%
There were 4 cases in hydrostatic group underwent 2nd trial with success rate 50%. In pneumatic group only 2
cases required 2nd trial with success rate zero percent.

Outcome Successful 2nd trial Total X2 p-value

No. % No. %
Hydrostatic group 2 50.0% 4 40.0% 2.333 0.127
Pneumatic group 0 0.0% 2 20.0% 0.000 1.000
Total 2 33.3% 6 30.0%
Table 5: Correlation between second trial in both groups and outcome.

DISCUSSION the available literature, the rate of success of enema

reduction differs greatly.
Non-surgical and surgical management of
intussusception are two options for treatment.. The published rate of success of non-operative
Hydrostatic and pneumatic reductions are two non- reduction of intussusception in some studies ranges
surgical options for intussusception therapy 12. A from 70% to 95% and is similar in both pneumatic
high rate of success in non-surgical treatment of and hydrostatic reduction 13,14,23.
intussusception was reported 13.
Shiels et al., 24 and Lui et al., 25 who performed
In our study, the children's ages at the time of pneumatic reduction reported success rates of 87%
reduction varied from 3 to 36 months, with an (65\75) and 84% (152\181) respectively. At the same
average and IQR range of 8 months (5-14). The same time, Wood et al., 26, González-Spínola et al., 27, and
age range was reported in multiple studies 12,13,14. Nayak & Jagdish, 28 with hydrostatic reduction
However, Kaiser et al. 15 reported wider age range reported success rates of 85% (63\75), 81.9%
from 16 days to 12 years. Mooney et al. 16 similarly (159\194), and 81% (83\102) respectively; which are
referred to the wide variation of age among cases of very close to the previous results of pneumatic
intussusception. but, 75% of instances happen during reduction.
the first two years of life, and 90% happen during the
first three years of life. In 147 patients, prospective research compared air
reduction, barium reduction with fluoroscopy, and
Different presentations were observed in the patients saline reduction with ultrasonography guidance for
included in this study. Frequently, more than one intussusception diagnosis and therapy. In 45 out of
symptom was noted. 50 children, air reduction was successful (90%).
Vomiting was found in 85% of cases of our study. Barium enema was successful in 35 of 50 children
Other studies reported similar high incidences of (70%), while the US was successful in 32 of 47
vomiting. The incidence was 80% 86%, 81% children (67%) 29.
according to Tareen et al., (19), Van den Ende et al. 20,
and Kaiser et al., 15 respectively. Similar to These previous results of a higher rate of success of
McDermott et al., 17, we discovered no statistically pneumatic reduction are similar to our observation of
significant correlation between the outcomes of a significantly higher rate of success of pneumatic
reduction and vomiting. reduction after the 1st trial.

In the present study, palpable abdominal mass was Of the 20 cases of our study, 6 cases underwent 2nd
found in 30% of cases. This is comparable to the trial for failed initial attempt. 2/6 cases had showed
results of Van den Ende et al., (20) and Kaiser et al., 15 successful reduction at success rate of 33.3%. The
who found an occurrence of 35% and 24% success rate for delayed repeat trials ranges from 57
respectively, but lower than the incidence of 50% to 72% 31,32. Our research exhibited a lower success
reported by Tareen et al. 19. In the present study, the rate of delayed repeat enema. This can be explained
presence of palpable mass did not significantly affect as most cases requiring a delayed repeat enema
the outcome of reduction. McDermott et al. 17, present late with symptoms lasting longer than 12
Okuyama et al., 22, and Fragoso et al. 18 referred to hours.
the same observation. However, other studies have In the present study, there were 4 cases in hydrostatic
reported that palpable abdominal mass significantly group underwent second trial with success rate 50%.
affect poor outcome 21. In pneumatic group only 2 cases required second trial
In the present study, we found that successful with success rate 0 %. Successful second trial of
reduction after 1s trial was 80% in pneumatic group pneumatic reduction is 59%, 50%, 43% 32,33,34
while 60% in hydrostatic group. Zulfiqar MA et al., respectively. At least 30 mins following the first
10
reported that the rate of success of pneumatic partial resolution, a successful second trial of
reduction is greater than the success rate of ultrasoud guided saline enema reduction is 15% 35.
hydrostatic reduction and his explanation was that as Hospital admission is a routine policy after
air surrounds the intussusceptum more fully, it exerts successful enema reduction in our department. A 24-
more continuous pressure, which may lead to less hour in- hospital observation is required for possible
friction and, as a consequence, easier reduction. In early recurrence or post-reduction complication.
Contrastingly, Jinzhe et al 36 stated outpatient

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Pediatric Surgery

management of 87% of cases after successful successful non-operative treatment. Pediatr Radiol.
reduction but without clear demonstration of the 2013; 43(6):649–56.
safety of this practice due to lack of follow up. A
retrospective study was conducted on 568 8. Margarit Mallol J, Ribó Cruz JM, Martín Hortiguela
intussusception patients, of whom 329 had been ME, et al. Acute intestinal invagination: hydrostatic
admitted following reduction and 239 had been reduction vs. pneumatic reduction. An Esp Pediatr.
treated as outpatients with early release from the 1993; 38(1): 17–9.
emergency department. In all groups, total recurrence 9. Rohrschneider W. Invagination. Radiologe, 1997;
rates and the requirement for surgical intervention 37(6):446–53.
were similar, with no increased morbidity or death
recorded 30. 10. Zulfiqar M, Noryati M, Hamzaini A, et al.
Pneumatic reduction of intussusception using
CONCLUSION equipment readily available in the hospital. The
Pneumatic reduction is a simple, quick, and mess- medical journal of Malaysia. 2006; 61(2):1999-
free method. There is no need for radiologist but 2039.
there is risk of exposure to radiation. US-guided
11. Chukwubuike KE and Nduagubam OC. Hydrostatic
saline enema for intussusception reduction is a safe
reduction of intussusception in children: a single centre
treatment. It protects the child from being exposed to experience. The Pan African Medical Journal. 2020;
a significant level of radiation. A clear echogram can 36-42.
be obtained using transverse and longitudinal scans..
During reduction, ileo-ileo-colic intussusception can 12. Khorana J, Singhavejsakul J, Ukarapol N, et al.
be detected. The method of sonography has another Enema reduction of intussusception: The success
benefit in that it is capable of identifying pathological rate of hydrostatic and pneumatic reduction. Ther
Clin Risk Manag. 2015; 11, 1837-42.
lead point during reduction, such as Meckel
diverticulum. Perforation can be recognized 13. Saxena AK and Hollwarth ME. Factors influencing
promptly. However, this technique requires longer management and comparison of outcomes in
time than pneumatic reduction. It needs an expert paediatric intussusceptions. Acta Paediatr. 2007;
radiologist. There is more potential peritoneal 96(8): 1199-202.
contamination if perforation occurs. 14. Shekherdimian S and Lee SL. Management of
pediatric intussusception in general hospitals:
REFERENCES diagnosis, treatment, and differences based on age.
World J Pediatr. 2011; 7(1): 70-3.
1. Bines JE, Kohl KS, Forster J, et al. Acute 15. Kaiser AD, Applegate KE and Ladd AP. Current
intussusception in infants and children as an adverse success in the treatment of intussusception in
event following immunization: case definition and children. Surgery. 2007; 142(4): 469-77.
guidelines of data collection, analysis, and
presentation. Vaccine. 2004; 22: 569–74. 16. Mooney DP, Steinthorsson G and Shorter NA.
Perinatal intussusception in premature infants. J
2. Bines JE, Patel M and Parashar U. Assessment of Pediatr Surg. 1996; 31(5): 695-7.
postlicensure safety of rotavirus vaccines, with 17. McDermott V, Taylor T, Mackenzie S, et al.
emphasis on intussusception. J Infect Dis 200 Pneumatic reduction of intussusception: clinical
Suppl. 2009; 1: S282–90. experience and factors affecting outcome. Clinical
Radiology. 1994; 49(1): 30-4.
3. WHO. Acute intussusception in infants and
children. Incidence, clinical presentation and 18. Fragoso AC, Campos M, Tavares C, et al.
management: a global perspective. Geneva: World Pneumatic reduction of childhood intussusception.
Health Organization. 2002; Document WHO/V & Is prediction of failure important? J Pediatr Surg.
B/02.19. 1–98. 2007; 42(9): 1504-8.
19. Tareen F, Ryan S, Avanzini S, et al. Does the length
4. Columbani PM and Scholz S. Intussusception. In: of the history influence the outcome of pneumatic
Coran AG, Adzick NS, Krummel TM, Laberge J- reduction of intussusception in children? Pediatric
M, Shamberger RC, Caldamone AA, editors surgery international. 2011; 27(6): 587-9.
Pediatric surgery, 7th ed., vol. 2. USA: Saunders.
2012; p. 1093–110. 20. Van den Ende E, Allema JH, Hazebroek FW, et al.
Success with hydrostatic reduction of
5. Ito Y, Kusakawa I, Murata Y, et al. Japanese intussusception in relation to duration of symptoms.
guidelines for the management of intussusception in Archives of disease in childhood. 90(10): 2005;
children, 2011. Pediatr Int. 2012; 54(6):948–58. 1071-2.
6. Flaum V, Schneider A, Gomes Ferreira C, et al. 21. Kritsaneepaiboon, S., & Sangkhathat, S. (2011).
Twenty years' experience for reduction of ileocolic Pneumatic reduction of intussusception: factors
intussusceptions by saline enema under sonography affecting outcome in Thailand. Asian Biomed. 5(2):
control. J Pediatr Surg. 2016; 51(1):179–82. 235-8.
7. Bekdash B, Marven SS and Sprigg A. Reduction of 22. Okuyama H, Nakai H and Okada A. Is barium
intussusception: defining a better index of enema reduction safe and effective in patients with

5
 AIMJ April 2022

a long duration of intussusception? Pediatric

surgery international. 1999; 15(2): 105-7.
23. Ramachandran, P. (2009). Intussusception. In: Puri
p, & m., H. (Eds.). Pediatric Surgery: Diagnosis
and Management. Springer-Verlag Berlin
Heidelberg. 2009; 485-90.
24. Shiels W, Maves CK, Hedlund G, et al. Air enema for
diagnosis and reduction of intussusception: clinical
experience and pressure correlates. Radiology. 1991;
181(1): 169-72.
25. Lui KW, Wong HF, Cheung YC, et al. Air enema
for diagnosis and reduction of intussusception in
children ; clinical experience and fluoroscopy time
correlation. J Pediatr Surg. 2001; 36(3):479-81.
26. Wood S, Kim JS, Suh SJ, et al. Childhood
intussusception: US-guided hydrostatic reduction.
Radiology. 199; 182(1): 77-80.
27. González-Spínola J, Del Pozo G, Tejedor D, et al.
Intussusception: the accuracy of ultrasound-guided
saline enema and the usefulness of a delayed
attempt at reduction. J Pediatr Surg. 1999; 34(6):
1016-20.
28. Nayak, D., & Jagdish, S. Ultrasound guided
hydrostatic reduction of intussusception in children
by saline enema: our experience. Indian Journal of
Surgery. 2008; 70(1): 8-13.
29. Hadidi AT and El Shal N. Papers Presented at the
45th Annual international Congress of the British
Association of Paediatric Surgeons Childhood
intussusception: A comparative study of
nonsurgical management. J Pediatr Surg. 1999;
34(2): 304-7.
30. Beres AL and Baird R. An institutional analysis and
systematic review with meta-analysis of pneumatic
versus hydrostatic reduction for pediatric
intussusception. Surgery. 2013; 15(2): 328-34.
31. Lautz TB, Thurm CW and Rothstein DH. Delayed
repeat enemas are safe and cost-effective in the
management of pediatric intussusception. J Pediatr
Surg. 2015; 50(3): 423-7.
32. Pazo A, Hill J and Losek J. Delayed Repeat Enema
Management of Failed Initial Enema-Reduction
Intussusception. Annals of Emergency Medicine.
2009; 54(3): 15-6.
33. Sandler A, Ein S, Connolly B, et al. Unsuccessful
air-enema reduction of intussusception: is a second
attempt worthwhile? Pediatric surgery
international. 1999; 15(3): 214-6.
34. Navarro O and Daneman A. Intussusception. Pediatr
Radiol. 2004; 34(4): 305-12.
35. Gorenstein A, Raucher A, Serour F, et al.
Intussusception in children: reduction with repeated,
delayed air enema. Radiology. 1998; 206(3): 721-4.
36. Jinzhe Z, Yenxia W and Linchi W. Rectal inflation
reduction of intussusception in infants. J Pediatr
Surg. 1986; 21(1): 30-2.