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CONTEMPORARY PEDIATRIC SURGERY
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Abstract Background: Intussusception is the one of the commonest causes of intestinal obstruction requiring urgent attention in early childhood. There is no gold standard of non-operative reduction. We report our 6 years’ experience in non-operative reduction using our “RIGHT” (Reduction of Intussusception under General anesthesia using Hydrostatic Technique) technique, emphasizing the need to perform the procedure in the operating room (OR) under general anesthesia. This prospective observational study covering the period from July 2014 till May 2020 included patients diagnosed with intussusception. Hydrostatic reduction was performed in the OR under general anesthesia by infusing a saline enema and the reduction was confirmed by ultrasound. Results: Forty-eight patients underwent reduction using the RIGHT technique. Successful reduction was achieved in 44 (91.6%) patients. Four (8.3%) patients needed surgery, three (6.2%) due to failed reduction and one (2.0%) due to perforation. One (2.2%) patient developed a recurrence. Conclusions: The “RIGHT” technique is a combination of the best available techniques of reduction of intussusception. It ensures patient safety by being performed in the OR, being pain free, avoiding radiation, avoiding the risk of aspiration associated with sedation, and also being able to immediately address a failure of reduction or a complication by surgical exploration. Keywords: Hydrostatic reduction, Saline enema, Non-operative reduction, Ultrasound guided, Operating room, RIGHT technique Background Intussusception is the one of the commonest cause of intestinal obstruction requiring urgent attention in neonatal and early childhood. Ileocolic intussusception in which the ileum telescopes into the colon is the commonest variety. If left undiagnosed or misdiagnosed and untreated, it may turn fatal due to gangrene and sloughing off of ileum leading to perforation peritonitis. Various methods of reduction have been tried for the last 300 years depending on available knowledge and resources of the era. Presently, the treatment options available are a permutation and combination of either of operative, hydrostatic, or pneumatic reduction, under fluoroscopy or ultrasound (USG) guidance, or laparoscopic guidance or manipulation. A combination of these modalities gives us 8–10 treatment options which are practiced by different surgeons based on their choice, comfort, and available resources. The presence of multiple treatment options for a particular entity reveals that there is no gold standard of treatment. Surprisingly, all these methods have been proven to be equally efficacious, hence defining the best treatment option is still elusive. Our experience is that non-operative reduction attempted in the radiology suite is quite unsafe and uncomfortable for the patient and the parents, messy for the operators, and has a © The Author(s). 2021 Open Access This article is licensed under a Creative Commons Attribution 4.0 International License, which permits use, sharing, adaptation, distribution and reproduction in any medium or format, as long as you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons licence, and indicate if changes were made. The images or other third party material in this article are included in the article's Creative Commons licence, unless indicated otherwise in a credit line to the material. If material is not included in the article's Creative Commons licence and your intended use is not permitted by statutory regulation or exceeds the permitted use, you will need to obtain permission directly from the copyright holder. Since its launch five years ago, the Department of Plastic and Reconstructive Surgery has been flourishing in size and scope. Our faculty numbers have more than doubled, our laboratories and clinical programs are impacting the field, and we continue to develop groundbreaking approaches and solutions by building on our interdisciplinary collaborations and forging new ones. Five years ago, our team set out under a banner of “Teamwork, Collaboration, Mentorship and Innovation,” a motto that continues to guide our approaches today in patient care, resident and fellow training, and cutting-edge research. Our 13 new clinical faculty members hail from 13 different residency programs, bringing with them complementary sets of skills and perspectives. In a spirit of lifelong curiosity and advancement, we learn from one another and offer our residents a wide array of professional styles and career pathway models. Intentionally seeking synergy by building bridges with overlapping disciplines, we have developed clinical and/or research collaborations with dozens of departments. Our work alongside colleagues in ENT, Orthopaedics, Dermatology, Immunology, Transplant, Neurosciences, Psychiatry, Biomedical Engineering, Genetics, Rehabilitation, Hematology, Urology and Bioethics is changing the role of reconstruction and plastic surgery in the clinic, and contributing to scientific advancement in a variety of fields. Our new Vascularized Composite Allotransplantation (VCA) Research Laboratory brings together investigations into transplant immunology, nerve regeneration and stem cell biology, supermicrosurgery, and regenerative medicine. The lab’s work made possible the first clinical protocol in VCA using minimal immunosuppression and shares its results worldwide in the new VCA Journal, which debuted in October 2014. New clinical VCA programs in face, genitourinary system and abdominal wall are being established. Our team’s 2012 double-arm transplant represented a culmination of efforts by faculty surgeons, collaborators and researchers. This milestone, now immortalized in the illustrated 126-year history of The Johns Hopkins Hospital lining a main corridor of the hospital, formally put plastic surgery on the map of Johns Hopkins. We are proud of our young department’s accomplishments and look forward to continuing to uphold our role in the institution’s venerable tradition for generations to come. W. P. Andrew Lee, M.D. The Milton T. Edgerton, M.D., Director and Professor of Plastic and Reconstructive Surgery From the Director W. P. Andrew Lee “We continue to develop groundbreaking approaches and solutions by building on our interdisciplinary collaborations and forging new ones.” Plastic and Reconstructive Surgery | 1 I n five short years, the Department of Plastic and Reconstructive Surgery has grown from a modestsized division to an independent, flourishing department that is second to none for scientific discovery and clinical advances. It has quickly developed a global reputation for its cutting-edge techniques, groundbreaking research and surgeons who are deeply driven to deliver the best possible care to their patients. Highlights of those five years include: Department of Plastic and Reconstructive Surgery: Looking Back on the Last Five Years ANNIVERSARY Over the past five years, the department has added one full professor, three associate professors and 10 assistant professors, including the department’s first faculty member at Johns Hopkins All Children’s Hospital in St. Petersburg, FL. A comprehensive research laboratory has been established conducting scientific investigation in transplant immunology, regenerative medicine, cutaneous cancer biology and nerve research and stem cell biology. Laboratory personnel now include three full-time research faculty members and about 20 pre- and postdoctoral fellows and technicians. Departmental sponsored research funding has increased some 20-fold on an annual basis (see graph). This research support comes from a variety of government, foundation, industry and institutional sources. Department of Defense funds make up approximately 80 percent of the total, with NIH, multiple foundation and industry grants making up the balance. A 2010 gift from Milton Edgerton, the first full-time plastic surgery chief at Johns Hopkins, and the blue moon fund established the Milton T. Edgerton, M.D., Professorship and Directorship of Plastic and Reconstructive Surgery, held since then by department director W. P. Andrew Lee. In spring 2015, the department opened a state-ofthe-art craniofacial center and high-tech dental lab to support the pediatric cleft and craniofacial program. The center will be capable of full digital imaging, planning and support of three-dimensional modeling. 2 | Plastic and Reconstructive Surgery The department has an expanded presence in clinical activities including Johns Hopkins Bayview Medical Center, Johns Hopkins Green Spring Station, Johns Hopkins White Marsh, Greater Baltimore Medical Center, Johns Hopkins Odenton, and All Children’s Hospital (St. Petersburg, FL), in
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