Journal of Pediatric Surgery 51 (2016) 179182

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Journal of Pediatric Surgery

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Indepent Review Articles

Twenty years' experience for reduction of ileocolic intussusceptions by

saline enema under sonography control
Valrie Flaum a,b,, Anne Schneider a, Cindy Gomes Ferreira b, Paul Philippe b, Consuelo Sebastia Sancho c,
Isabelle Lacreuse a, Raphael Moog a, Isabelle Kauffmann a, Meriam Koob c, Dominique Christmann c,
Valrie Douzal c, Franois Lefebvre d, Franois Becmeur a
a

Department of Pediatric Surgery, University Hospital Hautepierre, 67098, Strasbourg Cedex, France
Departement of Pediatric Surgery, Pediatric Clinic, Centre Hospitalier de Luxembourg, Luxembourg, Luxembourg
c
Department of Pediatric Radiology, University Hospital Hautepierre, Strasbourg, France
d
Statistics and Public Health Department, Medicine Faculty, Strasbourg, France
b

a r t i c l e

i n f o

Article history:
Received 10 February 2015
Received in revised form 15 September 2015
Accepted 16 September 2015
Key words:
Intussusception
Reduction
Children
Ultrasound
Sonography
Saline enema
Radiation

a b s t r a c t
Background: Ultrasonography is a well-established efcient diagnostic tool for ileocolic intussusceptions in children. It can also be used to control hydrostatic reduction by saline enemas. This reduction method presents the
advantage of avoiding radiations. Parents can even stay with their children during the procedure, which is
comforting for both. The purpose of this study was to present our 20 years' experience in intussusception reductions using saline enema under ultrasound control and to assess its efciency and safety.
Material and methods: This retrospective single center study included patients with ileocolic intussusceptions diagnosed by ultrasound between June 1993 and July 2013. We excluded the data of patients with spontaneous reduction or who underwent primary surgery because of contraindications to hydrostatic reduction (peritonitis,
medium or huge abdominal effusion, ischemia on Doppler, bowel perforation).
A saline enema was infused into the colon until the reduction was sonographically conrmed. The procedure was
repeated if not efcient. Light sedation was practiced in some children.
Results: Eighty-tree percent of the reductions were successful with a median of 1 attempt. Reduction success decreased with the number of attempts but was still by 16% after 4 attempts. The early recurrence rates were 14.5%,
and 61.2% of those had a successful second complete reduction. Forty-six patients needed surgery (11 of them
had a secondary intussusception). Sedation multiplies success by 10. In this period, only one complication is described.
Conclusion: Ultrasound guided intussusception reduction by saline enema is an efcient and safe procedure. It
prevents exposure of a young child to a signicant amount of radiation, with similar success rate. We had very
low complication rate (1/270 cases or 3). The success rate could be increased by standardized procedures including: systematic sedation, trained radiologists, accurate pressure measurement, and number and duration
of attempts.
2016 Elsevier Inc. All rights reserved.

Ultrasonography is a well-established efcient diagnostic tool for

ileocolic intussusceptions in children; it has a sensitivity rate of 98% to
100% and a specicity rate of 88% to 100% [1,2]. However, its efciency
in controlling the reduction is not well documented.
The standard treatments of ileocolic intussusceptions in children are
reduction by air or contrast uid enema, with X-ray control. The success
rate with these methods is reported between 72% [3] and 87% [4]. However, these techniques expose the children to radiation while undergoing reduction (mean dose area product of 11.4 cGy cm2 for air reduction
[19]). Another major disadvantage of these techniques is that the child

Corresponding author. Tel.: +33 6 77 76 87 05.

E-mail address: aumvalerie@hotmail.fr (V. Flaum).
http://dx.doi.org/10.1016/j.jpedsurg.2015.09.022
0022-3468/ 2016 Elsevier Inc. All rights reserved.

must be separated from the parents during uoroscopy. This is a source

of stress among children and parents.
Over the last 20 years, our center has used ultrasound rather than
uoroscopy for the diagnosis and for the treatment of ileocolic intussusceptions in children. The aim of this study is to report the outcomes of
this technique.

1. Patients and methods

In this retrospective single center study, we reviewed the data of all
episodes of ileocolic intussusceptions diagnosed between June 1993
and July 2013. Among them, those related to attempts at hydrostatic reduction represent the body of this work (Table 1).

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V. Flaum et al. / Journal of Pediatric Surgery 51 (2016) 179182

We excluded the data of patients with spontaneous reduction or

who underwent primary surgery because of contraindication to hydrostatic reduction (peritonitis, medium or huge abdominal effusion, ischemia on Doppler, bowel perforation).
The children's pain was evaluated with an age adapted children's
pain scale. All of them received analgesia adapted to their pain score before attempted reduction (at least paracetamol). Sedation using
intrarectal midazolam solution (0.4 mg/kg) was used on an ad hoc
basis, depending on the clinical context.
The reduction attempt was done by a saline solution enema. The procedure was performed by the radiologists (with different levels of experience) with the presence of the pediatric surgeon, as follows: with the
child in a supine position and his parents next to him, a large-bore Foley
catheter was introduced in the rectum and maintained by inating its balloon with 60 ml air; the buttocks were pressed together in order to avoid
leaks. The rectal cannula was connected to a 1.5 L warm (37 C) saline
bottle suspended about 1 to 1.2 m above the table level to maintain the
appropriate hydrostatic pressure in the colon for the reduction. One to
1.5 L of solution was infused into the colon under ultrasonographic control and maintained a few minutes until the reduction was obtained and
the terminal ileum was lled with liquid.
The sonographic criteria for complete reduction were the total disappearance of the target sign and the massive ood of the small
bowel attesting that there was no obstruction left in the colon or
ileocecal area. If complete reduction was not achieved after 1 to 1.5 L
enema, the procedure was stopped and the cannula removed to evacuate the solution. Midazolam sedation was given to the child if it was not
done for the rst attempt. The procedure was repeated 10 minutes later,
with a maximum of 4 attempts. All patients with failed reduction
underwent a surgery.
All children were kept under medical supervision and an ultrasound
examination was repeated in all cases after 12 to 24 hours to exclude an
early recurrence.
We analyzed the success rate depending on the intussusception etiology, localization, patient's sex, age and weight. We also analyzed the
inuence of sedation, symptoms duration and recurrence number on
the likelihood of success.
For the statistical analysis discrete variables were expressed as
counts (percentage) and continuous variables as means standard deviation (SD). Frequency comparisons were done by using the chi-square
test or analyzed with mixed logistic models when data were repeated.
Comparisons of quantitative data were performed with generalized linear mixed models to take into account the distribution of the variable
(Gamma or Poisson). Multivariate analyses were done using all variables statistically signicant in bivariate analyses or according to clinical
importance. A stepwise regression was performed with backward selection. P b 0.05 was considered signicant. All analyses were performed
with R 3.0.2 software and the hglm package.

2. Results
A total of 347 episodes of ileocolic intussusceptions were diagnosed
during the study period. Fourteen patients were referred to our
center after failed attempts at conventional uoroscopy guide air or
contrast reduction.
Table 1
Population characteristics.
Sex
Age (months)
Weight (kg)
Symptom duration (hours)
Context of intussusception

168 boys
82 girls
23.8 (22.4)
11.6 (5.2)
39 (70)
260 idiopathic
11 secondary

Fig. 1. Success rate depending on reductions attempts.

Fifty-six of them were treated by primary surgery because of contraindications to hydrostatic reduction. In 20, spontaneous resolution was diagnosed by ultrasound before the start of the hydrostatic reduction.
Those 76 sets of data were excluded.
Thus, 271 attempts in 250 patients (21 late recurrences) were studied.
The mean age at rst intussusception was 23.4 months (1.4196.5)
and the median age was 17.6 months. The median duration of symptoms before diagnosis was 24 hours (range 1720 hours). The median
hospital stay was 24 hours (range 12840 hours).
Only 11.5% of the children were sedated by midazolam before the
reduction attempt.
Of the 250 children with a rst intussusception episode, 213 (85.2%)
were successfully reduced initially and 37 needed surgery. Among these
213 children, 31 (14.5%) experienced one or several early recurrences
within ve days. Of these, 19 (61.2%) underwent further successful saline reduction, 4 (13%) were spontaneously reduced on further evaluation, and 8 (25.8%) required surgery (3 Meckel's and 5 failures of the
repeated hydrostatic reduction). Thus, 205 children could be discharged
without surgery (success rate of 82% with a rst episode).
They were a further 21 late recurrences, occurring after a median
time of 9.5 months, 20 of them were reduced with the saline enema;
one failed, but the surgical exploration did not nd any secondary etiology. Thus, the overall success rate for this technique is 83% (225/271).
Among the 46 patients that needed secondary surgery, we discovered,
during surgery, undiagnosed secondary intussusceptions (9 Meckel's diverticula, 1 polyp and 1 lymphoma) in 11 children. A median of 1 attempt
per child (range 14 attempts) was necessary to obtain the reduction and
4/5 intussusceptions were reduced after the rst attempt. The probability
of reduction decreased with the number of attempts, 93% (135/145) of
success after one attempt but it was still of 16% (1/6) after the 4th attempt
(Cf. Fig. 1).
Eighty-eight percent of the idiopathic intussusceptions were reduced. We were able to reduce the intussusceptions of 11/14 patients
referred to us after failed conventional attempts at other institutions.
The head of the intussusceptum was localized at the ileocecal valve
in 40%, in the ascending colon in 45%, in the transverse in 10% and in
the left colon in 5%. The success rate was 84% when located at the
ileocecal valve, 94% in the ascending colon, 88% in the transverse
colon and only 35% in the left colon (cf. Table 2).
The comparative statistical analysis is presented in Table 3. Neither patients' characteristics (age, gender, weight) nor clinical symptoms
(vomiting, stool bleeding and symptoms duration) were associated to reduction success. The success rate was signicantly associated to: idiopathic intussusceptions (OR, 115.0 [5.52423.1]; P = .003); ileocecal and
ascending colon localization (OR, 174.4 [7.24193.7]; P = .002); absence

Table 2
Success rate depending on localization.
Localization

Total

Success

Failure

Ileocecal region
Ascending colon
Transverse colon
Left colon

108 (40%)
121 (45%)
25 (10%)
14 (5%)

91 (84%)
114 (94%)
22 (88%)
5 (36%)

17 (16%)
7 (6%)
3 (12%)
9 (64%)

V. Flaum et al. / Journal of Pediatric Surgery 51 (2016) 179182

181

Table 3
Comparative statistical analysis.

Gender (%)
Age (months)
Weight (kg)
Context (%)
Vomiting (%)
Stool bleeding (%)
Ileocecal and ascending colon localization
Absence of mild effusion (%)
Sedation (%)
Number of reduction attempts (%)

Reduction success (n = 232)

Reduction failure (n = 39)

Multivariate analysis

Male (85)
Female (86)
24.8
11.5
Idiopathic (88)
Secondary (46)
109/136 (80)
30/39 (77)
91/108 (84)
228/259 (88)
23/31 (74)
0.7

Male (15)
Female (14)
21.7
11.1
Idiopathic (12)
Secondary (54)
27/136 (20)
9/39 (23)
17/108 (16)
31/259 (12)
8/31 (26)
1.2

0.9

NS

0.3
0.6
0.0003

NS
NS
OR, 115.0 [5.52423.1]; P = .003

.008
0.1
5.3 105
8.3 106
0.04
1.6 1011

NS
NS
OR, 174.4 [7.24193.7]; P = .002
OR, 830.3 [32.319009.7]; P = 4.6 105
OR, 10.8 [1.295.2]; P = .03
NS

of mild abdominal effusion at sonography (OR, 830.3 [32.319009.7];

P = 4.6 105) and sedation (OR, 10.8 [1.295.2], P = .03).
One complication was seen: an ileo-cecal perforation diagnosed
24 hours after successful reduction in a child with duration of symptoms
of 48 hours and a reduced blood ow on initial Doppler ultrasonographic assessment.

3. Discussion
The successful reduction of ileocolic intussusception by warm saline
enema under real-time sonography guidance was rst described in
1982 by Kim et al. [7], in 2 patients.
Several reports have described this technique further [810,16]: patient in supine position, insertion of a balloon catheter into the rectum,
and infusion of warm saline solution at 100 to 120 cm of hydrostatic
pressure. The procedure was done until the total disappearance of the
target sign and the massive solution reux through the ileocecal valve
into the terminal ileum were observed under ultrasonography.
The published success rate ranges from 76% [5] to 95% [6] and is similar to the expected results of conventional, uoroscopy-guided contrast
or air enema reduction [5,6,810]. The success rate in the current series
does not appear different from published results (Table 4).
In Kim et al.'s [7] and Bai et al.'s [8] studies all children were
premedicated by chlorpromazine before reduction with a success rate
of 96%. In Rohrschneider's and Trger's study they were premedicated
with diazepam or chloral hydrate and the success rate was 91% [10].
Our data show a positive correlation between the use of sedation and
successful reduction. Thus, our low sedation rate (only 11, 5%) could
be a factor in our lower success rate, and we plan to introduce a protocol
for systematic sedation in the future.
The retrospective collection of data did not permit an accurate assessment of the procedure time. Some authors found an association
with success rate: Rohrschneider and Trger [10] showed a better reduction rate with longer procedures (increasing success rate from 65%
to 91% if procedures lasted more than 45 minutes). Unfortunately we

had only 32 data with procedure time and the mean reduction time
was 7 minutes.
After a failed attempt, the decision to try further reduction or to take
the child to surgery was made by the radiologist and the pediatric surgeon on clinical grounds, without denitive criteria.
The hydrostatic pressure was not precisely controlled, with the
enema bottle being placed approximately 120 cm above the table. We
had no perforation diagnosed during the course of the reduction at
this pressure.
Bai et al. [8] and Crystal et al. [9] found moreover a correlation between the radiologists experience level and the success rate; in our center, those levels were heterogeneous: reductions were attempted by
inexperienced residents as often as by attending radiologists. A more
formal technical protocol should decrease this variability.
He et al. [11] looked at the risk factors for failure of sonographic reduction. Sex, age and duration of symptoms had no impact on the reducibility, whereas localization (left colon), bloody stools, free
peritoneal uid and uid trapped in the intussusceptum were risk factors for failure. We observed the same results but our statistical analysis
demonstrated no signicant association, neither with the left colon localization nor with bloody stools.
We treated one patient with saline enema although the initial Doppler
sonography showed a lower blood ow; a perforation was diagnosed
24 hours after successful reduction. This illustrates that saline enema is
only a safe procedure if selection criteria are respected and conrms that
gravity signs previously described are correlated to bowel compromise
and are contraindications to attempted enema reduction, of any form.
Rohrschneider and Trger [10] suggest trying a last reduction attempt
under general anesthesia before surgery, a technique that would be facilitated in the operating room by the use of ultrasonographic guidance. It
could also improve the outcomes of the ultrasound management.
4. Conclusion
Ultrasound guided intussusception reduction by saline enema is an
efcient and safe procedure. It prevents exposure of a young child to a

Table 4
Study comparison for US-guided reduction in intussusceptions.

Peh et al. [6]

Shehata et al. [12]
Wang and Liu [5]
Di Renzo et al. [13]
Rohrschneider and Trger [10]
Bai et al. [8]
Crystal et al. [9]
Gonzalez-Spinola et al. [14]
Digant et al. [15]
Menke and Kahl [16]
Chan et al. [17]
Choi et al. [18]

Reduction number

Success rate (%)

Sedation

Recurrence rate

Complications

25
1061
377
20
46
5218
99
194
30
49
26
115

76
85.5
95.5
75
91
95.5
89
85
87
83.7
73
80.9

Yes
?
Yes
?
Yes
Yes
?
No
Yes (general anesthesia)
No
Yes
?

Unknown
7.2
Unknown
5
15
5.6
18
9.7
0
10.2
11.5
5.2

0
6
1
0
0
9
0
0
0
0
0
0

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V. Flaum et al. / Journal of Pediatric Surgery 51 (2016) 179182

signicant amount of radiation, with similar success rate to uoroscopy

guidance reductions. We had very low complication rate (1/270 cases or
3). The success rate could be increased by standardized procedures
including: systematic sedation, trained radiologists, accurate pressure
measurement, and number and duration of attempts.
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