Clinical Radiology 69 (2014) e432ee432
Contents lists available at ScienceDirect
Clinical Radiology journal homepage: www.clinicalradiologyonline.net
Correspondence
Re: UK intussusception audit: A national survey of practice and audit of reduction rates Sir d We read with much interest the report of the recent UK Intussusception Audit by Hannon and colleagues1 and the accompanying commentary by Wilkinson.2 Hannon et al.1 mention that bowel perforation is the single most important complication of air enema in attempted radiological intussusception reduction. Wilkinson2 discusses the underlying technical issues, and opines that paediatric radiologists should be bolder, and not limit themselves to an upper air pressure limit of 120 mmHg, as has been previously recommended by the British Society of Paediatric Radiology (BSPR).3 He accepts that the bowel might perforate more often if there were to be no upper limit on air pressure. In our centre, we use an air-enema kit with a pressurecontrol valve and a digital pressure readout monitor. Radiological air enemas are led by consultant paediatric radiologists, with paediatric surgical colleagues present in the room. Inflation of a rectal catheter balloon is left to the radiologist’s personal preference. We achieve successful air reduction in 76% of attempted cases. It is our experience that even strict adherence to the previous BSPR recommendations does not prevent bowel perforation. Although our numbers are limited [54 air enemas over 4 years, from January 2010 to December 2013, with two (3.7%) bowel perforations occurring during attempted air reduction] our experience is that patient factors, such as younger age (5 months), and longer symptom duration (>2 days) predispose to perforation. Other authors report similar experience, explaining that younger infants might have thinner bowel walls, and that bowel ischaemia is more likely with longer symptom duration.4 Furthermore, it is very difficult to pinpoint symptom duration with certainty, especially as our patients come to our tertiary referral centre from a broad catchment area covering all of Kent, Surrey, and Sussex. Paediatric radiologists are coming under increasing pressure from their surgical colleagues to increase
DOI of original article: http://dx.doi.org/10.1016/j.crad.2014.05.007.
successful radiological reduction rates; not least because the child avoids general anaesthesia and surgery, in the short term, and complications of abdominal surgery, such as adhesion formation, in the longer-term. If UK paediatric radiologists follow the route suggested by Wilkinson,2 it is mandatory that every paediatric radiology department should be prepared to recognize and deal with bowel perforation in a timely and effective manner. In our department, we have designed a “safety kit”, similar to that described by Fallon et al.4 The essential component of this kit is a green Venflon cannula (18 G), that can be inserted in the supra-umbilical position, in the midline, and the needle withdrawn; leaving the plastic cannula in situ. This is a crucial measure when there are signs of intraperitoneal tension, which is potentially lethal. We agree with Hannon et al.1 that a multidisciplinary approach to performing air enemas, with a paediatric surgical presence in the radiology suite, is useful, both in improving success rates of air enemas, and in dealing with perforations, should they occur.
References 1. Hannon E, Williams R, Allan R, et al. UK intussusception audit: a national survey of practice and audit of reduction rates. Clin Radiol 2014;69:344e9. 2. Wilkinson AG. Commentary on UK intussusception audit: a national survey of practice and audit of reduction rates. Clin Radiol 2014;69:342e3. 3. McHugh K. Intussusception reduction. British Society of Paediatric Radiology draft guidelines for suggested safe practice. Available at: http://www.bspr. org.uk/intuss.htm; 2003. April (subsequently withdrawn). 4. Fallon SC, Kim ES, Naik-Mathuria BJ, et al. Needle decompression to avoid tension pneumoperitoneum and hemodynamic compromise after pneumatic reduction of pediatric intussusception. Pediatr Radiol 2013;43:662e7.
I. Moorthy*, E. Sellon, J. Muscat, S. Islam Brighton and Sussex University Hospitals NHS Trust, Brighton, UK E-mail addresses: [email protected], [email protected] (I. Moorthy)
* Guarantor and correspondent: I. Moorthy, Brighton and Sussex University Hospitals NHS Trust, Brighton, UK.
0009-9260/$ e see front matter Ó 2014 The Royal College of Radiologists. Published by Elsevier Ltd. All rights reserved. http://dx.doi.org/10.1016/j.crad.2014.05.008
Contents lists available at ScienceDirect
Clinical Radiology journal homepage: www.clinicalradiologyonline.net
Correspondence
Re: UK intussusception audit: A national survey of practice and audit of reduction rates Sir d We read with much interest the report of the recent UK Intussusception Audit by Hannon and colleagues1 and the accompanying commentary by Wilkinson.2 Hannon et al.1 mention that bowel perforation is the single most important complication of air enema in attempted radiological intussusception reduction. Wilkinson2 discusses the underlying technical issues, and opines that paediatric radiologists should be bolder, and not limit themselves to an upper air pressure limit of 120 mmHg, as has been previously recommended by the British Society of Paediatric Radiology (BSPR).3 He accepts that the bowel might perforate more often if there were to be no upper limit on air pressure. In our centre, we use an air-enema kit with a pressurecontrol valve and a digital pressure readout monitor. Radiological air enemas are led by consultant paediatric radiologists, with paediatric surgical colleagues present in the room. Inflation of a rectal catheter balloon is left to the radiologist’s personal preference. We achieve successful air reduction in 76% of attempted cases. It is our experience that even strict adherence to the previous BSPR recommendations does not prevent bowel perforation. Although our numbers are limited [54 air enemas over 4 years, from January 2010 to December 2013, with two (3.7%) bowel perforations occurring during attempted air reduction] our experience is that patient factors, such as younger age (5 months), and longer symptom duration (>2 days) predispose to perforation. Other authors report similar experience, explaining that younger infants might have thinner bowel walls, and that bowel ischaemia is more likely with longer symptom duration.4 Furthermore, it is very difficult to pinpoint symptom duration with certainty, especially as our patients come to our tertiary referral centre from a broad catchment area covering all of Kent, Surrey, and Sussex. Paediatric radiologists are coming under increasing pressure from their surgical colleagues to increase
DOI of original article: http://dx.doi.org/10.1016/j.crad.2014.05.007.
successful radiological reduction rates; not least because the child avoids general anaesthesia and surgery, in the short term, and complications of abdominal surgery, such as adhesion formation, in the longer-term. If UK paediatric radiologists follow the route suggested by Wilkinson,2 it is mandatory that every paediatric radiology department should be prepared to recognize and deal with bowel perforation in a timely and effective manner. In our department, we have designed a “safety kit”, similar to that described by Fallon et al.4 The essential component of this kit is a green Venflon cannula (18 G), that can be inserted in the supra-umbilical position, in the midline, and the needle withdrawn; leaving the plastic cannula in situ. This is a crucial measure when there are signs of intraperitoneal tension, which is potentially lethal. We agree with Hannon et al.1 that a multidisciplinary approach to performing air enemas, with a paediatric surgical presence in the radiology suite, is useful, both in improving success rates of air enemas, and in dealing with perforations, should they occur.
References 1. Hannon E, Williams R, Allan R, et al. UK intussusception audit: a national survey of practice and audit of reduction rates. Clin Radiol 2014;69:344e9. 2. Wilkinson AG. Commentary on UK intussusception audit: a national survey of practice and audit of reduction rates. Clin Radiol 2014;69:342e3. 3. McHugh K. Intussusception reduction. British Society of Paediatric Radiology draft guidelines for suggested safe practice. Available at: http://www.bspr. org.uk/intuss.htm; 2003. April (subsequently withdrawn). 4. Fallon SC, Kim ES, Naik-Mathuria BJ, et al. Needle decompression to avoid tension pneumoperitoneum and hemodynamic compromise after pneumatic reduction of pediatric intussusception. Pediatr Radiol 2013;43:662e7.
I. Moorthy*, E. Sellon, J. Muscat, S. Islam Brighton and Sussex University Hospitals NHS Trust, Brighton, UK E-mail addresses: [email protected], [email protected] (I. Moorthy)
* Guarantor and correspondent: I. Moorthy, Brighton and Sussex University Hospitals NHS Trust, Brighton, UK.
0009-9260/$ e see front matter Ó 2014 The Royal College of Radiologists. Published by Elsevier Ltd. All rights reserved. http://dx.doi.org/10.1016/j.crad.2014.05.008
