Short-Term Outcomes of Improving Hydrostatic Pressures on Reducing Intussusception in Children

Short-Term Outcomes of Improving Hydrostatic Pressures on Reducing Intussusception in Children | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article Short-Term Outcomes of Improving Hydrostatic Pressures on Reducing Intussusception in Children Bingjie Wang, Ziwei Jian, Weicheng Huang, Beilei Huang, Fengguang Ye, and 1 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-4938928/v1 This work is licensed under a CC BY 4.0 License Status: Published Journal Publication published 08 Dec, 2024 Read the published version in Pediatric Surgery International → Version 1 posted 8 You are reading this latest preprint version Abstract Purpose The aim of this study is to analyze the effect of increasing enema pressure on enema outcomes. Methods We conducted a retrospective study to compare the effect of increasing enema pressure on enema outcomes. The primary outcome was the success rate of reduction, while secondary outcomes included intestinal perforation and recurrence rate. Results From May 2017 to April 2021, a total of 531 intussusceptions in 499 patients (Group A 247 patients, Group B 252 patients) were collected. The overall success reduction rate was 97.00%. The success reduction rate in Group A was 99.20% (245/247) and 94.8% (239/252) in Group B (P = 0.004). The overall recurrence rate within 48 hours after the initial enema reduction was 8.02%, and beyond 48 hours was 6.41%. The recurrence rates within 48 hours and beyond 48 hours were 9.39% and 6.53% in group A and 7.11% and 6.69% in group B, respectively (P = 0.526). No complications were associated with the enema reduction procedure. Conclusion Our study has shown that using a hydrostatic pressure of 130 mmHg for enema reduction is both effective and safe, with a higher success rate and no increased risk of complications. Study type: Retrospective cohort study Level of evidence: Therapeutic study, III Intussusception Hydrostatic Reduction Pressure Ultrasound-Guided Reduction Rate Figures Figure 1 Background Intussusception is a common acute abdominal disorder that occurs during infancy and childhood, typically between the ages of 3 months and 2 years, with a peak incidence between 6 and 18 months[ 1 ]. It is slightly more common in males and has an reported incidence of 33–71 cases per 100,000 person-years[ 2 – 4 ]. While it can affect both the small and large intestine, it typically occurs in the ileocecal region, known as ileocolic intussusception[ 5 ]. In the past few decades, the treatment for childhood intussusception has shifted from the initial emergency surgery to enema reduction. Although the use of enema reduction as the initial treatment has been widely agreed, controversy remained regarding the appropriate media. Since Guo et al[ 1 ] reported the effectiveness of pneumatic reduction in 1986, fluoroscopy guided air enema has gradually become the most popular method around the world, with some surveys [ 2 – 4 ] indicating that nearly 70% of medical institutions used pneumatic enema reduction, especially in China, the United States, and the United Kingdom. This could be explained by the meta-analysis performed by Sadigh et al[ 5 ], which showed that pneumatic reduction had a higher success rate than hydrostatic reduction. But the biggest drawback of pneumatic reduction is the exposure of children and medical teams to radiation. Additionally, some literatures [ 6 , 7 ] argued that the higher success rate is due to the higher pressure of pneumatic enema than that of hydrostatic enema. According to data, ultrasound has a high sensitivity (94%) and specificity (96%) for the diagnosis of intestinal obstruction[ 8 ]. This non-invasive and radiation-free technique enables quick and accurate confirmation or exclusion of intussusception, along with identifying other acute abdominal conditions[ 15 ]. Therefore, ultrasound-guided enema reduction is gradually accepted by more institutions as a therapeutic modality for childhood intussusception, which subsequently proved to be safe and reliable, as reported in many literatures[ 9 , 10 ], but they had not been widely adopted because of their relatively lower reduction success rate. Although many studies on hydrostatic enema have reported enema success rates of up to 95% [ 9 , 11 ]. In these studies, hydrostatic enema pressures ranged from 80mmHg to 180 mmHg[ 5 ], with majority limited to less than 120mmHg, which was considered to prevent intestinal perforation from occurring, as reported in the literatures by Kanglie et al[ 12 ] and Hannon et al[ 4 ]. Nowadays, relatively few studies have been reported comparing the relationship between enema pressure and the outcome of reduction in childhood intussusception. However, to date, no clinical studies have evaluated the outcome of enema reduction using hydrostatic pressure higher than 120 mmHg. This study aims to compare the effectiveness of two different hydrostatic pressures in ultrasound-guided saline enema reduction of childhood intussusception, and to investigate the safety and feasibility of increasing hydrostatic pressure in enema reduction. Methods Materials This retrospective cohort study was conducted with the permission of the institutional review board and ethics committee (No. 2021lwb159) of the hospital and was conducted in accordance with Good Clinical Practice guidelines and the principles of the Declaration of Helsinki. We retrospectively analyzed the data of consecutive patients with intussusception who received hydrostatic enema reduction at our institution from May 2017 to April 2021. Data was extracted from medical records, digital information systems, and archived ultrasound images. An ultrasound physician reevaluated the ultrasound images. Only the cases handled by three senior pediatric surgical residents were studied to eliminate other confounding factors related to technology and experience. All patients with intussusception were admitted to the hospital by emergency department doctors, then these three doctors took turns admitting patients according to a fixed duty schedule sequence. Recurrent cases occurring during different hospitalizations of the same patient were used as independent data. Patient inclusion criteria: 1), aged between 4 months and 14 years; 2), diagnosed by ultrasonography with typical images. Exclusion criteria: 1), patients with significant abdominal distension; 2), patients with peritonitis and perforation. The data collected for our study included patient demographic information such as gender, age, and weight. We also recorded symptoms such as paroxysmal crying, abdominal pain, vomiting, and bloody stools, as well as signs like palpable mass and its location. We noted the duration of symptoms, number of attempts at reduction, enema time, ultrasound image data, and laboratory data such as white blood cell counts and C-reactive protein. Additionally, we recorded cases of bowel perforation and recurrence, as well as the length of hospital stay. In our study, we defined enema time as the duration from the beginning of saline inflow to the success of reduction. Ultrasound image data included intussusception diameter, location, and the presence of pathological lead points (PLP). We defined failed enema reduction as the inability to reduce intussusception by hydrostatic enema. The success and recurrence rates were used to evaluate the effectiveness of enema reduction, while the perforation rate was used to assess its safety. To be included in our study, patients with recurrent intussusception had to experience recurrence after the first enema reduction by the three pediatric surgeons, and all recurrences during the study period were counted. Recurrence within 48 hours after the initial enema reduction was considered an early recurrence, and recurrence more than 48 hours after the initial reduction was classified as a late recurrence. Methods Prior to enema reduction, the procedure was explained in detail to their parents and informed consent was obtained. Abdominal X-ray examinations were not required for any of the patients, and no medications, such as sedatives or antispasmodics, were administered prior to the reduction. Upon admission, the patient was immediately taken to the ultrasound room for enema reduction. The child's parents were present, and the patient was positioned supine on the treatment bed with bilateral thighs pressed together to ensure a tight seal of the anus. To begin the procedure, Hydrostatic enema reduction was performed by a pediatric surgeon and a sonographer. An 18F Foley catheter was inserted into the rectum and 10 ml of saline was injected into the Foley catheter balloon. Among the three pediatric surgeons, one used higher pressure as Group A, while the other two used lower pressure as Group B. An enema bag containing 1500 ml of saline (37°C to 40°C) were maintained at a height of 175 cm (Group A) or 150 cm (Group B) above the table, which produced 130 mmHg and 110 mmHg hydrostatic pressure, respectively. During the procedure, the patient's head was tilted to one side to prevent accidental aspiration due to vomiting. The normal saline in the enema bag was injected into the rectum, while the flow of intestinal fluid was monitored by ultrasound. Ultrasound-guided reduction of intussusception was studied using a 5–10 MHz transducer (Affiniti70 GE, Logiq book, USA). During enema reduction, ultrasound dynamically monitored the retrograde motion of the intussusception. As soon as the intussusceptum passed through the ileocecal valve, the enema bag was lowered to a height of 120cm. In case of residual ileoileal intussusception, the enema bag was raised to its initial height again to continue the enema reduction. The abdominal cavity was intermittently checked for signs of perforation, such as increased amount of intra-abdominal fluid and sudden disappearance of colonic fluid. Enema reduction was deemed unsuccessful until there were evidences of successful enema reduction, including disappearance of the intussusceptum, visibility of the ileocecal valve, and entry of saline into the small intestine. If the retrograde motion of the intussusception ceased for more than 5 minutes, the reduction was repeated up to three attempts per patient after an interval of 10–15 minutes(The height of Group A water bag is 175cm, while Group B water bag rises to 162cm, generating a pressure of 120mmHg).After completed hydrostatic reduction of intussusception, the normal saline injected into the intestinal tract was returned to the enema bag. Prior to Foley catheter removal, the sonographer carefully performed a complete abdominal scan with high-frequency and low-frequency probes to pay attention to pathological lead points. Afterwards, the patient was transferred to the pediatric surgical ward for further observation and care. Treatment included fasting, rehydration and completion of laboratory tests. After the oral carbon powder was expelled, usually about 6–8 hours, the patient was started on a liquid diet and gradually transitioned to a normal diet. Patients were eligible for discharge from the hospital after resuming normal eating and without any discomfort. Instruct the patient's parents to promptly review abdominal ultrasound if they experience discomfort symptoms (such as paroxysmal abdominal pain, vomiting, or fever) after discharge. Those patients who failed in enema reduction then subsequently underwent surgical intervention. All patients were followed up for 6 months after discharge from the hospital, either through outpatient visits or phone consultations. Statistical analyses Continuous variables were expressed in median and interquartile range (IQR) or simple range, and were compared and analyzed by Mann Whitney U test. Categorical variables for both groups were presented as counts and percentages and compared using the χ² test or Fisher's exact test. All P values were two-sided and those < 0.05 were statistically significant. SPSS Statistics for Windows, version 25.0, is used to conduct all statistical analyses (SPSS 25.0). Results From May 2017 to April 2021, a total of 531 intussusception cases were collected. All patients met the inclusion criteria. 32 cases of recurrent intussusceptions occurring during the same hospitalization were classified as duplicates and excluded. Ultimately, a total of 499 patients who visited our hospital, were enrolled in this study (Fig. 1 .). According to the usage of different hydrostatic pressures, the patients were separated into two groups: Group A (247 patients) and Group B (252 patients). Of the 499 patients, 484 patients were successfully reduced by hydrostatic enema, while 15 cases required surgical intervention Additionally, 72 patients experienced recurrence after the initial enema reduction (39 in group A and 33 in group B). 表 1 Table 1 Baseline characteristics of the study population. Variable All Group A Group B P-Value N = 499 N = 247 N = 252 Sex 0.936 a Female, n (%) 187(37.5) 93(37.7) 94(37.3) Male, n (%) 312(62.5) 154(62.3) 158(62.7) Age, m, median (IQR) 21(11.0,34.0) 21(10.0,33.0) 21.0(11.0,34.00) 0.385 b Body weight, Kg, median (IQR) 11.00(9.00,13.50) 10.5(9.00,13.5) 11.0(9.50,13.38) 0.360 b DOS,h, median (IQR) 12.00(7,24) 12(6,24) 13(8,24) 0.755 b Symptoms n (%) Paroxysmal crying 220(44.10) 69(27.9) 151(59.9) - Vomiting 231(46.3) 92(37.2) 139(55.2) - Bloody stool 108(21.6) 47(19.0) 61(24.2) 0.160 a Abdominal pain 207(41.5) 123(49.80) 84(33.3) - Abdominal mass 490(98.2) 243(98.4) 247(98.0) - Location of the mass n (%) 0.042 Right lower quadrant 6(1.2) 0(0.00) 6(2.4) Right upper quadrant 489(98.2) 246(99.6) 243(96.8) Left upper quadrant 3(0.6) 1(0.4) 2(0.8) Left lower quadrant 0 (0.00) 0 (0.00) 0 (0.00) Diameter, mm, median (IQR) 31(28,33) 30(28,33) 31(29,33) 0.135 b The types of Intussusceptions, n(%) 0.257 a Ileocolic 487(97.6) 243(98.4) 244(96.80) --2 Ileo-ileal 12(2.4) 4(1.6) 8(3.2) [2] a: The P value was calculated by means of Chi-square test or Fisher’s exact test b: The P value was calculated by means of Mann–Whitney U-test. Abbreviation: IQR, interquartile range, DOS, duration of symptoms. Table 2 Evaluation of patients in the two groups. All, n (%) Group A, n (%) Group B n (%) P-Value Success rate 484(97.0) 24(99.2) 23(94.8) 0.004 a Enema time Min, Median (IQR) 10(5,15) 5(4,7) 15(10,16) < 0.001 b Number of enema attempts < 0.001 a 1 357(71.7) 224(90.7) 134(53.2) 2 103(20.7) 12(4.9) 91(36.1) 3 38(7.6) 11(4.5) 27(10.7) WBC counts×109 ,Median(IQR) 10.65 (8.33,13.4) 10.24 (8.09,12.82) 11.01 (8.69,13.92) 0.015 b CRP,mg/dl, Median (IQR) 5.85(2.31,11.30) 6.0 (2.59,10.53) 5.60 (2.2, 11.74) 0.829 b Fever 16(3.2) 6(2.4) 10(4.0) 0.329 a Hospital stay, d, Median(IQR) 2(2,3) 2(2,3) 2(2,2) < 0.001 b Perforation 0 (0.00) 0 (0.00) 0 (0.00) 0 a The characteristics of the patients at baseline were similar in the two trial groups (Table 1 ). The median age was 21.00 months (IQR,11.00 to 34.00). The average weight was 11.00 kg (IQR,9.00 to 13.50). The duration of symptoms was 12.00 hours (IQR, 7.00 to 24.00). There were no significant differences between the two groups in terms of gender (P = 0.936), age (P = 0.385), body weight (P = 0.360), or duration of symptoms (0.755). The contrasting outcomes of the two groups are shown in Table 2 . The overall success reduction rate was 97.00%, with Group A showing a significantly superior success rate of hydrostatic reduction (99.20%) compared to Group B (94.8%) (p = 0.004). The enema time in Group A was 5 minutes (IQR, 4 to 7), while in Group B was 15 minutes (IQR, 10 to 16). The process in Group A took less time than in Group B, and the difference was statistically significant (P < 0.001). In both groups, the median length of stay in hospital was two days. The median of White blood cells counts was 10.24 × 10⁹/L (IQR,8.09 to 12.82)in Group A versus 11.01× 10⁹/L (IQR, 8.69 to 13.92) in Group B, and the difference was statistically significant (P = 0.015).The median C-reactive protein was 6.0mg/dl (IQR, 2.59 to 10.53༉in Group A versus 5.60mg/dl (IQR, 2.2 to 11.74) in Group B with no significant difference(P = 0.829). There was no statistical difference between the two groups in the proportion of patients who developed fever during their hospitalization (P = 0.329). No perforation or intestinal necrosis was found in those patients who were successfully reduced by hydrostatic enema. Table 4 shows the analysis of the failure cases of enema reduction. The ileoileocolic intussusception (53.33%) was the most common type. Among the 15 surgical patients, 60%(9/15) cases had idiopathic intussusception and 6/15 (40%) patients had a pathological lead point (3 Meckel's diverticulum, 2 intestinal polyp, 1 Peutz-Jeghers's syndrome). 26.67% (4/15) patients had intestinal necrosis and underwent intestinal resection (1 in Group A and 3 in Group B). 53.33% (8/15)patients performed simple surgical reduction, including 1 in Group A and 7 in Group B. All 15 patients were finally discharged and recovered well after operation. No recurrence occurred in the 15 patients after surgical reduction. Table 5 presents a comparison of recurrent intussusceptions between the two groups. The overall recurrence rate of intussusception within 48 hours after the initial hydrostatic enema reduction was 7.34%, while the recurrence rate beyond 48 hours was 6.97%. Although the recurrence rates within 48 hours and beyond 48 hours in Group A (8.85%, 6.15%, respectively) were higher than those in Group B (7.75%, 5.90%, respectively), there was no significant difference between the two groups (P = 0.514). All recurrent patients were discharged after successful reduction with the same pressure enema as the initial. If there are more than three recurrences, abdominal magnetic resonance imaging (MRI) and ectopic gastric mucosal imaging (ECT) are recommended to identify a pathologic lead point. In a stratified analysis of patients with bloody stools in the two groups, we found that the success rate was significantly higher in Group A (95.70%) than in Group B (83.6%) (P = 0.047). The follow-up period for all patients lasted 6 months, during which there were no reports of adverse outcomes or deaths, as confirmed through both outpatient follow-up and telephone contact. Discussion In this retrospective cohort study, the use of 130mmHg hydrostatic pressure during the ultrasound-guided saline enema reduction led to a significantly higher successful reduction rate in Group A than in Group B. During the four years of study, a total of 531 intussusception cases in 499 patients were collected, the overall success reduction rate was 97.00%, which was consistent with the literatures reported by Bai et al[ 9 ] and Xie et al[ 11 ]. In our subgroup study, Group A achieved a higher reduction success rate (99.2%) by increasing the enema pressure (130 mmHg), which was significantly higher than that of (94.8%) in Group B (110 mmHg), with a statistically significant difference (P = 0.004). Additionally, by increasing the pressure up to 130 mmHg, it also reduced the enema time. The median enema time for reduction in Group A was 5mins (IQR,4to7), which was significantly superior to that in Group B(P < 0.001). Meanwhile, successful reduction on the first attempt occurred in 90.7% (224/247) of patients in Group A, comparing with only 53.0% (133/251) in group B, and the difference between the two groups was statistically significant (P < 0.001). Prolonged symptoms of intussusception have been linked to intestinal edema, ischemic necrosis, and a higher risk of perforation [ 20 , 21 ]. Therefore, increasing pressure can rapidly alleviate the child's symptoms by resetting the intussusception, leading to a reduction in adverse events. These results may be attributed to our enhancement of the success rate by increasing hydrostatic pressure. The primary analysis in our study was performed according to the Bernoulli’s equation principle, which stated that the higher the height of the water column, the higher the enema pressure. Given a relatively stable isotonic saline flow rate, we solely focused on the fluid height difference that corresponds to pressure magnitude, as discussed in the literature by Liu et al. [ 23 ] and Kanglie et al. [ 19 ], who indicated the relationship between bag height and hydrostatic pressure. Moreover, a previous study by Zambuto et al. [ 7 ] showed that the pressure exerted on the intestinal wall was more uniform during hydrostatic enema than during pneumatic enema. The explanation that greater pressure facilitates more successful reduction can also be supported by the enema procedure. When intussusception passes through the ileocecal valve, it often becomes more challenging and requires greater hydrostatic pressure. Liu et al[ 13 ] also documented that the patient was more likely to be successfully reduced at a time when a Valsalva maneuver was induced by the patient’s crying or mounting, and also documented a significant increase in intra-intestinal pressure when the Valsalva maneuver was induced. Also for the patient in Group B who failed to be reduced, our operative exploration confirmed this, with only a small portion of the ileocecal portion of the intussusception remaining to be reduced. In Group A, a 5-year-old boy who failed to reset was an ileocolic intussusception with multiple enlarged lymph nodes inside the intussusception, which made the intussusceptum significantly larger and could not pass through the ileocecal valve. In addition, it has been reported in the literatures [ 14 – 16 ] that the pressure in the intestinal lumen can reach up to 200 mmHg. We hypothesize that the perforation after hydrostatic enema is not directly related to the hydrostatic pressure, but is link to the gangrene of the small intestine in the intussusceptum. Therefore, increasing the pressure to 130 mmHg is relatively safe. Currently, the literature suggests that the perforation rate of pneumatic and hydrostatic enema reduction was similar, with both having a perforation rate of approximately 0.8% [ 27 ]. In addition, our study observed no occurrence of adverse events. Furthermore, patients who were successfully treated and discharged also did not experience any adverse events during the follow-up period. It is worth noting that C-reactive protein levels, as discussed in a previous study by Sproston et al [ 28 ], can serve as a reliable indicator for assessing the severity of disease in relation to injury, infection, and inflammatory responses. We examined the CRP of patients in both groups separately after enema reduction, and the median CRP was 6.0mg/dl (IQR,2.59to 10.53) in Group A and 5.60 mg/dl (IQR,2.2to11.74) in Group B. The values were low in both groups and did not differ substantially between the two groups(P = 0.829). In addition, Additionally, both groups of patients who underwent successful enema reduction did not exhibit any symptoms of peritonitis upon abdominal examination. The median white blood cell (WBC) counts in Group A was 10.24×109 (IQR 8.09 to 12.82), which was slightly lower than the median WBC counts in Group B of 11.01×109 (IQR, 8.690 to 13.92), and although the difference in WBC counts between the two groups was statistically significant (P < 0.001), the clinical difference was small and insignificant. The incidence of fever after enema reduction was not statistically significant between the two groups (P = 0.329). As a result, we did not find any evidence to suggest that the use of enemas increased the risk of abdominal infection. Therefore, we do not recommend the use of prophylactic antibiotics given the low probability of fever and the lack of evidence showing a bacterial infection resulting from the insignificant increase in WBC counts and CRP after the use of enemas. Our findings are consistent with previous studies [29–31]. Table 3 Evaluation of patients with bloody stool Variable All, n% Group A, n% Group B, n% P-Value Success rate 96(88.9) 45(95.7) 51(83.6) 0.047 Enema time min, Median(IQR) 11(5,19) 5(5,12) 15(10,27.5) <0.001 Number of enema attempts 1 60(55.6) 36(76.6) 24(39.3) <0.001 2 27(25.0) 5(10.6) 22(36.1) 3 21(19.4) 6(12.8) 15(24.6) Table 4 Analysis of the failure cases of enema reduction in the two groups Variable All, (n, %) N=15 Group A, (n, %) N=2 Group B, (n, %) N=13 The types of Intussusceptions Ileocolic 7（46.67） 1（50.00） 6（46.15） Ileo-ileocolic 8(53.33) 1（50.00） 7（53.85） Etiology Idiopathic 9（60.00） 2（100.00） 7（53.85） Secondary 6（40.00） 0（0） 6（46.15） The method of operation Simple reduction 8 1 7 Resection due to Intestinal necrosis 4 1 3 Pathologic lead point Meckel’s diverticulum 3 0 3 Intestinal polyp 2 0 2 Peutz-Jeghers syndrome 1 0 1 Table 5 Comparison of intussusception recurrence between the two groups. Variable[3] Al, n% Group A, n% Group B, n% P-Value N=72 N=39 N=33 Recurrence after first enema Early recurrence 40（8.02） 23（9.39） 17（7.11） 0.526 a Late recurrence 32（6.41） 16（6.53） 16（6.69） Numbers of Recurrence 1 time 56（77.8） 38（97.4） 18（54.5） <0.001 a ≥2 times 16（22.2） 1（2.6） 1（45.5） [3] a: The P value was calculated by means of Chi-square test or Fisher’s exact test Children with ileoileal intussusceptions are at a greater risk for loss of intestinal viability than other types of intussusception [ 17 ], so higher enema pressure and shorter enema duration may minimize the risk of necrosis in this portion of the small intestine. Ultrasound can identify small intestinal intussusception and indicate whether there a decrease in blood flow signal in intussusception[ 18 ]. In our study, due to the higher enema pressure in Group A, 3/4 of ileo-ileocolic intussusceptions were successfully reduced, while only 1/8 of ileo-ileocolic intussusceptions in Group B was reduced. In our study, we also observed a case of a 4-year-old girl with an ileo-ileocolic intussusception in Group A, who failed the enema reduction. During the course of enema reduction, the intussusceptum passed through the ileocecal valve, but the small bowel intussusception remained, and the intra-operative investigation further confirmed that the inserted small intestine had been necrotic. It had been reported in the literature[ 19 ] bloody stool was considered as a risk factor for failure of hydrostatic reduction of intussusception. Thus, we performed a subgroup analysis on the cases of bloody intussusception (Table 3 ), and demonstrated that increasing the pressure led to a higher success rate of enema reduction(95.7% vs 83.6%, P = 0.047), and the enema time and enema attempts are significantly superior than those in the lower pressure group (both differences P < 0.001). Approximately 6% of childhood intussuceptions have pathologic lead points (PLP), such as a Meckel’s diverticulum, enteric duplication cyst, polyp or lymphoma. As to the issue of pathological lead points, it is not a contraindication to enema reduction in our study. The literature reported a relationship between pathological lead points and recurrence of intussusception[ 20 ], but not a definite relationship with successful reduction. We deem that even a PLP exists, enema reduction should still be attempted. Early reduction will help to avoid the aggravation of edema and even ischemic necrosis caused by intestinal wall and mesenteric compression. Moreover, after successful reduction, we can choose more minimally invasive methods to treat the PLP, such as colonoscopy or laparoscopy, thus minimizing trauma to patients. In Group A, one patient with Meckel’s diverticulum was found during enema reduction. Laparoscopic treatment was performed after successful reduction. Delayed surgical treatment is conducive to reducing intestinal edema and reducing the risk of postoperative anastomotic leakage. We believe that a symptom duration of more than 48 hours should not be considered a contraindication to enema reduction. However, as time went on, the intestinal edema becomes more pronounced, making enema reduction more challenging. Despite this, Lim et al [35] found no correlation between symptom duration and reduction failure. Therefore, we still recommend attempting enema reduction. In Group A, 17 cases with symptom onset exceeding 72 hours were successfully reduced by enema, while in Group B, 6 out of 8 cases with onset time over 72 hours were successful, and 2 cases failed. Furthermore, no instances of intestinal necrosis were discovered during surgical exploration. The failure rate of enema reduction was positively correlated with the duration of symptoms, which is consistent with that reported by Yao et al [ 17 ]. Recurrence after enema is a common event after non-surgical treatment of intussusception. The overall recurrence rate for recurrent intussusception following successful nonoperative reduction is approximately 10.0% [ 21 ]. Early recurrence of intussusception within 48 hours after reduction is more common [ 22 ]. In our study, the overall recurrence rate in the first 48 hours post successful reduction was 7.34% and the recurrence rate more than 48 hours after successful enema reduction was 6.97%, which was close to the recurrence rate reported in a meta-analysis by Gray et al [ 21 ]. Furthermore, recurrence rates were similar in both groups, with no statistically significant differences, and neither group reported any additional morbidity or mortality. Importantly, none of the patients with recurrent intussusception had an adverse outcome. The treatment of recurrent intussusception should be the same as the initial treatment [ 23 ]. Furthermore, some previous studies [ 24 , 25 ] had shown that discharge from the hospital after a successful enema reduction did not increase adverse events. More interestingly, in our study, it was found that most of the intussusceptions in group A recurred once (97.4%), which was statistically significant compared with group B(P < 0.001). The reason may be that the enema time is short and the compression and expansion effect on ileocecal valve is light. As early recurrence is relatively concentrated within 48 hours after enema reduction, we recommend that patients should be admitted to hospital for observation after reduction. Another reason is that some patients are already combined with dehydration and electrolyte disorders at the time of admission, then hospitalization can further improve prognosis and reduce complications. According to the literatures reported [ 26 , 27 ], pathological lead points may lead to recurrence. Therefore, in our institution, abdominal magnetic resonance imaging (MRI) scans and ectopic gastric mucosal imaging (ECT) were recommended to detect the presence of pathological lead points that may have been missed by ultrasound if a patient had more than three recurrences. This is similar to the approach reported by Hutchason et al [ 28 ]. Limitation : Our study has several limitations that should be acknowledged. First, it is a retrospective study rather than a randomized controlled trial (RCT), which may lead to potential selective bias and lower quality of evidence. However, in terms of patient selection, we have limited enema reduction handled by the three senior residents to reduce the difference in experience. Another limitation is that the experience of sonographers involved in this study varied, and we cannot rule out the possibility that some patients may have had some unrecognized PLP. Conclusion In conclusion, our retrospective study suggests that increasing enema pressure up to 130 mmHg (175 cm) in ultrasound-guided saline enema for hydrostatic reduction of childhood intussusception is viable, safe and effective. Furthermore, the success rate of this approach is higher and there are no increased complications. Ultrasound-guided hydrostatic enema therapy is considered one of the ideal methods for the nonsurgical treatment of childhood intussusception. However, to establish its wider clinical use, multicenter randomized controlled studies are necessary to provide robust evidence. Financial support statement : This study was supported from Startup Fund for scientific research, Fujian Medical University;(Grant number: 2021QH1263) Declarations Financial support statement: This study was supported from Startup Fund for scientific research, Fujian Medical University;(Grant number: 2021QH1263) Compliance with ethical standards Conflict of interest The authors declare that they have no conflict of interest. Ethical approval For this type of study formal consent is not required. Informed consent Informed consent was obtained from all individual participants included in the study. References Guo JZ, Ma XY, Zhou QH: Results of air pressure enema reduction of intussusception: 6,396 cases in 13 years. J Pediatr Surg 1986, 21(12):1201-1203.http://doi.org/10.1016/0022-3468(86)90040-0. Tang XB, Zhao JY, Bai YZ: Status survey on enema reduction of paediatric intussusception in china. J Int Med Res 2019, 47(2):859-866.http://doi.org/10.1177/0300060518814120. Stein-Wexler R, O'connor R, Daldrup-Link H, Wootton-Gorges SL: Current methods for reducing intussusception: Survey results. Pediatr Radiol 2015, 45(5):667-674.http://doi.org/10.1007/s00247-014-3214-7. Hannon E, Williams R, Allan R, Okoye B: Uk intussusception audit: A national survey of practice and audit of reduction rates. Clin Radiol 2014, 69(4):344-349.http://doi.org/10.1016/j.crad.2013.10.024. Sadigh G, Zou KH, Razavi SA, Khan R, Applegate KE: Meta-analysis of air versus liquid enema for intussusception reduction in children. AJR Am J Roentgenol 2015, 205(5):W542-549.http://doi.org/10.2214/AJR.14.14060. Sargent MA, Wilson BP: Are hydrostatic and pneumatic methods of intussusception reduction comparable? Pediatr Radiol 1991, 21(5):346-349.http://doi.org/10.1007/bf02011483. Zambuto D, Bramson RT, Blickman JG: Intracolonic pressure measurements during hydrostatic and air contrast barium enema studies in children. Radiology 1995, 196(1):55-58.http://doi.org/10.1148/radiology.196.1.7784589. Li XZ, Wang H, Song J, Liu Y, Lin YQ, Sun ZX: Ultrasonographic diagnosis of intussusception in children: A systematic review and meta-analysis. J Ultrasound Med 2021, 40(6):1077-1084.http://doi.org/10.1002/jum.15504. Bai YZ, Qu RB, Wang GD, Zhang KR, Li Y, Huang Y, Zhang ZB, Zhang SC, Zhang HL, Zhou X, Wang WL: Ultrasound-guided hydrostatic reduction of intussusceptions by saline enema: A review of 5218 cases in 17 years. Am J Surg 2006, 192(3):273-275.http://doi.org/10.1016/j.amjsurg.2006.04.013. Karadag CA, Abbasoglu L, Sever N, Kalyoncu MK, Yildiz A, Akin M, Candan M, Dokucu AI: Ultrasound-guided hydrostatic reduction of intussusception with saline: Safe and effective. J Pediatr Surg 2015, 50(9):1563-1565.http://doi.org/10.1016/j.jpedsurg.2015.03.046. Xie X, Wu Y, Wang Q, Zhao Y, Chen G, Xiang B: A randomized trial of pneumatic reduction versus hydrostatic reduction for intussusception in pediatric patients. J Pediatr Surg 2018, 53(8):1464-1468.http://doi.org/10.1016/j.jpedsurg.2017.08.005. Kanglie M, De Graaf N, Beije F, Brouwers EMJ, Theuns-Valks SDM, Jansen FH, De Roy Van Zuidewijn DBW, Verhoeven B, Van Rijn RR, Bakx R, Dutch Intussusception G: The incidence of negative intraoperative findings after unsuccessful hydrostatic reduction of ileocolic intussusception in children: A retrospective analysis. J Pediatr Surg 2019, 54(3):500-506.http://doi.org/10.1016/j.jpedsurg.2018.05.006. Liu X, Yu HK, Gu LX, Chen JK, Wen ZB: Atropine premedication facilitates ultrasound-guided reduction by saline enema in children with intussusception. Front Pharmacol 2019, 10:43.http://doi.org/10.3389/fphar.2019.00043. Pensabene, L.: Colonic manometry in children with defecatory disorders role in diagnosis and management. The American Journal of Gastroenterology 2003, 98(5):1052-1057.http://doi.org/10.1016/s0002-9270(03)00130-8. Giorgio V, Borrelli O, Smith VV, Rampling D, Koglmeier J, Shah N, Thapar N, Curry J, Lindley KJ: High-resolution colonic manometry accurately predicts colonic neuromuscular pathological phenotype in pediatric slow transit constipation. Neurogastroenterol Motil 2013, 25(1):70-78 e78-79.http://doi.org/10.1111/nmo.12016. Dinning PG, Benninga MA, Southwell BR, Scott SM: Paediatric and adult colonic manometry: A tool to help unravel the pathophysiology of constipation. World J Gastroenterol 2010, 16(41):5162-5172.http://doi.org/10.3748/wjg.v16.i41.5162. Yao XM, Chen ZL, Shen DL, Zhou QS, Huang SS, Cai ZR, Tong YL, Wang M, Ren Y, Lai XH, Chen XM: Risk factors for pediatric intussusception complicated by loss of intestine viability in china from june 2009 to may 2014: A retrospective study. Pediatr Surg Int 2015, 31(2):163-166.http://doi.org/10.1007/s00383-014-3653-0. Zhang M, Zhou X, Hu Q, Jin L: Accurately distinguishing pediatric ileocolic intussusception from small-bowel intussusception using ultrasonography. J Pediatr Surg 2021, 56(4):721-726.http://doi.org/10.1016/j.jpedsurg.2020.06.014. Xiaolong X, Yang W, Qi W, Yiyang Z, Bo X: Risk factors for failure of hydrostatic reduction of intussusception in pediatric patients: A retrospective study. Medicine (Baltimore) 2019, 98(1):e13826.http://doi.org/10.1097/MD.0000000000013826. Shen G, Zhang C, Li J, Zhang J, Liu Y, Guan Z, Hu Q: Risk factors for short-term recurrent intussusception and reduction failure after ultrasound-guided saline enema. Pediatr Surg Int 2018, 34(11):1225-1231.http://doi.org/10.1007/s00383-018-4340-3. Gray MP, Li SH, Hoffmann RG, Gorelick MH: Recurrence rates after intussusception enema reduction: A meta-analysis. Pediatrics 2014, 134(1):110-119.http://doi.org/10.1542/peds.2013-3102. Ferrantella A, Quinn K, Parreco J, Quiroz HJ, Willobee BA, Ryon E, Thorson CM, Sola JE, Perez EA: Incidence of recurrent intussusception in young children: A nationwide readmissions analysis. J Pediatr Surg 2020, 55(6):1023-1025.http://doi.org/10.1016/j.jpedsurg.2020.02.034. Cho MJ, Nam CW, Choi SH, Hwang EH: Management of recurrent ileocolic intussusception. J Pediatr Surg 2020, 55(10):2150-2153.http://doi.org/10.1016/j.jpedsurg.2019.09.039. Raval MV, Minneci PC, Deans KJ, Kurtovic KJ, Dietrich A, Bates DG, Rangel SJ, Moss RL, Kenney BD: Improving quality and efficiency for intussusception management after successful enema reduction. Pediatrics 2015, 136(5):e1345-1352.http://doi.org/10.1542/peds.2014-3122. Beres AL, Baird R, Fung E, Hsieh H, Abou-Khalil M, Ted Gerstle J: Comparative outcome analysis of the management of pediatric intussusception with or without surgical admission. J Pediatr Surg 2014, 49(5):750-752.http://doi.org/10.1016/j.jpedsurg.2014.02.059. Guo WL, Hu ZC, Tan YL, Sheng M, Wang J: Risk factors for recurrent intussusception in children: A retrospective cohort study. BMJ Open 2017, 7(11):e018604.http://doi.org/10.1136/bmjopen-2017-018604. Ye X, Tang R, Chen S, Lin Z, Zhu J: Risk factors for recurrent intussusception in children: A systematic review and meta-analysis. Front Pediatr 2019, 7:145.http://doi.org/10.3389/fped.2019.00145. Hutchason A, Sura A, Vettikattu N, Goodarzian F: Clinical management and recommendations for children with more than four episodes of recurrent intussusception following successful reduction of each: An institutional review. Clin Radiol 2020, 75(11):864-867.http://doi.org/10.1016/j.crad.2020.08.009. Additional Declarations No competing interests reported. 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Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-4938928","acceptedTermsAndConditions":true,"allowDirectSubmit":false,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":354231411,"identity":"fd7f9d74-a203-497e-a021-f702929f854f","order_by":0,"name":"Bingjie Wang","email":"","orcid":"","institution":"Zhangzhou Affiliated Hospital of Fujian medical University","correspondingAuthor":false,"prefix":"","firstName":"Bingjie","middleName":"","lastName":"Wang","suffix":""},{"id":354231412,"identity":"1dc30c42-be42-403e-9b31-cff671632cf0","order_by":1,"name":"Ziwei Jian","email":"","orcid":"","institution":"Zhangzhou Affiliated Hospital of Fujian medical University","correspondingAuthor":false,"prefix":"","firstName":"Ziwei","middleName":"","lastName":"Jian","suffix":""},{"id":354231413,"identity":"3e3668ce-837b-420a-868f-a4560574971d","order_by":2,"name":"Weicheng Huang","email":"","orcid":"","institution":"Zhangzhou Affiliated Hospital of Fujian medical University","correspondingAuthor":false,"prefix":"","firstName":"Weicheng","middleName":"","lastName":"Huang","suffix":""},{"id":354231414,"identity":"6a8b60e3-c019-436f-b9fc-5981b5278b9c","order_by":3,"name":"Beilei Huang","email":"","orcid":"","institution":"Zhangzhou Affiliated Hospital of Fujian medical University","correspondingAuthor":false,"prefix":"","firstName":"Beilei","middleName":"","lastName":"Huang","suffix":""},{"id":354231415,"identity":"26a55c0d-46cb-4c39-97f9-26cea2e49260","order_by":4,"name":"Fengguang Ye","email":"","orcid":"","institution":"Zhangzhou Affiliated Hospital of Fujian medical University","correspondingAuthor":false,"prefix":"","firstName":"Fengguang","middleName":"","lastName":"Ye","suffix":""},{"id":354231416,"identity":"2e77d3e5-8d87-4519-ad3f-3b8cef4fbac0","order_by":5,"name":"Jinrong Chen","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAAA2UlEQVRIiWNgGAWjYDACCShmYG8++CChooYULTzHkg0enDlGpBYII8dM8mELM2Ed/LObjz2w3GOTJ+9zLK0isYGNgb+9OwG/JXeOpRtIPEsrNjzefOxG4g4ZBokzZzfg1WIAdI+ExIHDiRt7jqXdSDzDBhTJJaQl/xtEy4wcs4LENmZitOSwgbXMB1rHQJQWiRtpIIelJW4ABrJEwpljPAT9wj8j+Zm0xAGbxPntzQc//qiokeNv78WvBQSYQXFjcADC4SGoHAQYPwAJ+Qai1I6CUTAKRsFIBABvNkyA28IzigAAAABJRU5ErkJggg==","orcid":"","institution":"Zhangzhou Affiliated Hospital of Fujian medical University","correspondingAuthor":true,"prefix":"","firstName":"Jinrong","middleName":"","lastName":"Chen","suffix":""}],"badges":[],"createdAt":"2024-08-19 13:24:50","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-4938928/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-4938928/v1","draftVersion":[],"editorialEvents":[{"content":"https://doi.org/10.1007/s00383-024-05919-2","type":"published","date":"2024-12-08T15:56:51+00:00"}],"editorialNote":"","failedWorkflow":false,"files":[{"id":66572322,"identity":"4464462f-e05f-4301-bc30-19172bf54eb9","added_by":"auto","created_at":"2024-10-14 11:54:05","extension":"png","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":11881,"visible":true,"origin":"","legend":"\u003cp\u003e\u003cstrong\u003eStudy flow of two hydrostatic pressures reduction.\u003c/strong\u003e\u003c/p\u003e","description":"","filename":"1.png","url":"https://assets-eu.researchsquare.com/files/rs-4938928/v1/532aaf24d23936c13d8e9ff3.png"},{"id":70964568,"identity":"e65c702c-198a-43ca-be70-2565a2cb732e","added_by":"auto","created_at":"2024-12-09 16:08:14","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":625715,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-4938928/v1/de116993-8be3-41a0-aa10-30a6e94e0623.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"Short-Term Outcomes of Improving Hydrostatic Pressures on Reducing Intussusception in Children","fulltext":[{"header":"Background","content":"\u003cp\u003eIntussusception is a common acute abdominal disorder that occurs during infancy and childhood, typically between the ages of 3 months and 2 years, with a peak incidence between 6 and 18 months[\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e]. It is slightly more common in males and has an reported incidence of 33\u0026ndash;71 cases per 100,000 person-years[\u003cspan additionalcitationids=\"CR3\" citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e]. While it can affect both the small and large intestine, it typically occurs in the ileocecal region, known as ileocolic intussusception[\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eIn the past few decades, the treatment for childhood intussusception has shifted from the initial emergency surgery to enema reduction. Although the use of enema reduction as the initial treatment has been widely agreed, controversy remained regarding the appropriate media. Since Guo et al[\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e] reported the effectiveness of pneumatic reduction in 1986, fluoroscopy guided air enema has gradually become the most popular method around the world, with some surveys [\u003cspan additionalcitationids=\"CR3\" citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e] indicating that nearly 70% of medical institutions used pneumatic enema reduction, especially in China, the United States, and the United Kingdom. This could be explained by the meta-analysis performed by Sadigh et al[\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e], which showed that pneumatic reduction had a higher success rate than hydrostatic reduction. But the biggest drawback of pneumatic reduction is the exposure of children and medical teams to radiation. Additionally, some literatures [\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e, \u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e] argued that the higher success rate is due to the higher pressure of pneumatic enema than that of hydrostatic enema.\u003c/p\u003e \u003cp\u003eAccording to data, ultrasound has a high sensitivity (94%) and specificity (96%) for the diagnosis of intestinal obstruction[\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e]. This non-invasive and radiation-free technique enables quick and accurate confirmation or exclusion of intussusception, along with identifying other acute abdominal conditions[\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e]. Therefore, ultrasound-guided enema reduction is gradually accepted by more institutions as a therapeutic modality for childhood intussusception, which subsequently proved to be safe and reliable, as reported in many literatures[\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e, \u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e], but they had not been widely adopted because of their relatively lower reduction success rate. Although many studies on hydrostatic enema have reported enema success rates of up to 95% [\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e, \u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e]. In these studies, hydrostatic enema pressures ranged from 80mmHg to 180 mmHg[\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e], with majority limited to less than 120mmHg, which was considered to prevent intestinal perforation from occurring, as reported in the literatures by Kanglie et al[\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e] and Hannon et al[\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eNowadays, relatively few studies have been reported comparing the relationship between enema pressure and the outcome of reduction in childhood intussusception. However, to date, no clinical studies have evaluated the outcome of enema reduction using hydrostatic pressure higher than 120 mmHg. This study aims to compare the effectiveness of two different hydrostatic pressures in ultrasound-guided saline enema reduction of childhood intussusception, and to investigate the safety and feasibility of increasing hydrostatic pressure in enema reduction.\u003c/p\u003e"},{"header":"Methods","content":"\u003cdiv id=\"Sec3\" class=\"Section2\"\u003e \u003ch2\u003eMaterials\u003c/h2\u003e \u003cp\u003eThis retrospective cohort study was conducted with the permission of the institutional review board and ethics committee (No. 2021lwb159) of the hospital and was conducted in accordance with Good Clinical Practice guidelines and the principles of the Declaration of Helsinki. We retrospectively analyzed the data of consecutive patients with intussusception who received hydrostatic enema reduction at our institution from May 2017 to April 2021. Data was extracted from medical records, digital information systems, and archived ultrasound images. An ultrasound physician reevaluated the ultrasound images. Only the cases handled by three senior pediatric surgical residents were studied to eliminate other confounding factors related to technology and experience. All patients with intussusception were admitted to the hospital by emergency department doctors, then these three doctors took turns admitting patients according to a fixed duty schedule sequence. Recurrent cases occurring during different hospitalizations of the same patient were used as independent data. Patient inclusion criteria: 1), aged between 4 months and 14 years; 2), diagnosed by ultrasonography with typical images. Exclusion criteria: 1), patients with significant abdominal distension; 2), patients with peritonitis and perforation.\u003c/p\u003e \u003cp\u003eThe data collected for our study included patient demographic information such as gender, age, and weight. We also recorded symptoms such as paroxysmal crying, abdominal pain, vomiting, and bloody stools, as well as signs like palpable mass and its location. We noted the duration of symptoms, number of attempts at reduction, enema time, ultrasound image data, and laboratory data such as white blood cell counts and C-reactive protein. Additionally, we recorded cases of bowel perforation and recurrence, as well as the length of hospital stay. In our study, we defined enema time as the duration from the beginning of saline inflow to the success of reduction. Ultrasound image data included intussusception diameter, location, and the presence of pathological lead points (PLP). We defined failed enema reduction as the inability to reduce intussusception by hydrostatic enema. The success and recurrence rates were used to evaluate the effectiveness of enema reduction, while the perforation rate was used to assess its safety. To be included in our study, patients with recurrent intussusception had to experience recurrence after the first enema reduction by the three pediatric surgeons, and all recurrences during the study period were counted. Recurrence within 48 hours after the initial enema reduction was considered an early recurrence, and recurrence more than 48 hours after the initial reduction was classified as a late recurrence.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec4\" class=\"Section2\"\u003e \u003ch2\u003eMethods\u003c/h2\u003e \u003cp\u003e Prior to enema reduction, the procedure was explained in detail to their parents and informed consent was obtained. Abdominal X-ray examinations were not required for any of the patients, and no medications, such as sedatives or antispasmodics, were administered prior to the reduction.\u003c/p\u003e \u003cp\u003eUpon admission, the patient was immediately taken to the ultrasound room for enema reduction. The child's parents were present, and the patient was positioned supine on the treatment bed with bilateral thighs pressed together to ensure a tight seal of the anus. To begin the procedure, Hydrostatic enema reduction was performed by a pediatric surgeon and a sonographer. An 18F Foley catheter was inserted into the rectum and 10 ml of saline was injected into the Foley catheter balloon. Among the three pediatric surgeons, one used higher pressure as Group A, while the other two used lower pressure as Group B. An enema bag containing 1500 ml of saline (37\u0026deg;C to 40\u0026deg;C) were maintained at a height of 175 cm (Group A) or 150 cm (Group B) above the table, which produced 130 mmHg and 110 mmHg hydrostatic pressure, respectively. During the procedure, the patient's head was tilted to one side to prevent accidental aspiration due to vomiting. The normal saline in the enema bag was injected into the rectum, while the flow of intestinal fluid was monitored by ultrasound. Ultrasound-guided reduction of intussusception was studied using a 5\u0026ndash;10 MHz transducer (Affiniti70 GE, Logiq book, USA).\u003c/p\u003e \u003cp\u003eDuring enema reduction, ultrasound dynamically monitored the retrograde motion of the intussusception. As soon as the intussusceptum passed through the ileocecal valve, the enema bag was lowered to a height of 120cm. In case of residual ileoileal intussusception, the enema bag was raised to its initial height again to continue the enema reduction. The abdominal cavity was intermittently checked for signs of perforation, such as increased amount of intra-abdominal fluid and sudden disappearance of colonic fluid. Enema reduction was deemed unsuccessful until there were evidences of successful enema reduction, including disappearance of the intussusceptum, visibility of the ileocecal valve, and entry of saline into the small intestine. If the retrograde motion of the intussusception ceased for more than 5 minutes, the reduction was repeated up to three attempts per patient after an interval of 10\u0026ndash;15 minutes(The height of Group A water bag is 175cm, while Group B water bag rises to 162cm, generating a pressure of 120mmHg).After completed hydrostatic reduction of intussusception, the normal saline injected into the intestinal tract was returned to the enema bag. Prior to Foley catheter removal, the sonographer carefully performed a complete abdominal scan with high-frequency and low-frequency probes to pay attention to pathological lead points. Afterwards, the patient was transferred to the pediatric surgical ward for further observation and care. Treatment included fasting, rehydration and completion of laboratory tests. After the oral carbon powder was expelled, usually about 6\u0026ndash;8 hours, the patient was started on a liquid diet and gradually transitioned to a normal diet. Patients were eligible for discharge from the hospital after resuming normal eating and without any discomfort. Instruct the patient's parents to promptly review abdominal ultrasound if they experience discomfort symptoms (such as paroxysmal abdominal pain, vomiting, or fever) after discharge. Those patients who failed in enema reduction then subsequently underwent surgical intervention.\u003c/p\u003e \u003cp\u003eAll patients were followed up for 6 months after discharge from the hospital, either through outpatient visits or phone consultations.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec5\" class=\"Section2\"\u003e \u003ch2\u003eStatistical analyses\u003c/h2\u003e \u003cp\u003eContinuous variables were expressed in median and interquartile range (IQR) or simple range, and were compared and analyzed by Mann Whitney U test. Categorical variables for both groups were presented as counts and percentages and compared using the χ\u0026sup2; test or Fisher's exact test. All P values were two-sided and those\u0026thinsp;\u0026lt;\u0026thinsp;0.05 were statistically significant. SPSS Statistics for Windows, version 25.0, is used to conduct all statistical analyses (SPSS 25.0).\u003c/p\u003e \u003c/div\u003e"},{"header":"Results","content":"\u003cp\u003eFrom May 2017 to April 2021, a total of 531 intussusception cases were collected. All patients met the inclusion criteria. 32 cases of recurrent intussusceptions occurring during the same hospitalization were classified as duplicates and excluded. Ultimately, a total of 499 patients who visited our hospital, were enrolled in this study (Fig. \u003cspan\u003e1\u003c/span\u003e.). According to the usage of different hydrostatic pressures, the patients were separated into two groups: Group A (247 patients) and Group B (252 patients). Of the 499 patients, 484 patients were successfully reduced by hydrostatic enema, while 15 cases required surgical intervention Additionally, 72 patients experienced recurrence after the initial enema reduction (39 in group A and 33 in group B).\u003c/p\u003e\n\u003cdiv id=\"Sec7\"\u003e\n \u003ch2\u003e表 1\u003c/h2\u003e\n \u003cdiv\u003e\n \u003ctable id=\"Tab1\" border=\"1\"\u003e\n \u003ccaption language=\"En\"\u003e\n \u003cdiv\u003eTable 1\u003c/div\u003e\n \u003cdiv\u003e\n \u003cp\u003eBaseline characteristics of the study population.\u003c/p\u003e\n \u003c/div\u003e\n \u003c/caption\u003e\n \u003ccolgroup cols=\"5\"\u003e\u003c/colgroup\u003e\n \u003cthead\u003e\n \u003ctr\u003e\n \u003cth align=\"left\" rowspan=\"2\"\u003e\n \u003cp\u003eVariable\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003eAll\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003eGroup A\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003eGroup B\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\" rowspan=\"2\"\u003e\n \u003cp\u003eP-Value\u003c/p\u003e\n \u003c/th\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003eN\u0026thinsp;=\u0026thinsp;499\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003eN\u0026thinsp;=\u0026thinsp;247\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003eN\u0026thinsp;=\u0026thinsp;252\u003c/p\u003e\n \u003c/th\u003e\n \u003c/tr\u003e\n \u003c/thead\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eSex\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\" rowspan=\"3\"\u003e\n \u003cp\u003e0.936\u003csup\u003ea\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eFemale, n (%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e187(37.5)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e93(37.7)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e94(37.3)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eMale, n (%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e312(62.5)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e154(62.3)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e158(62.7)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eAge, m, median (IQR)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e21(11.0,34.0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e21(10.0,33.0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e21.0(11.0,34.00)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.385\u003csup\u003eb\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eBody weight, Kg, median (IQR)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e11.00(9.00,13.50)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e10.5(9.00,13.5)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e11.0(9.50,13.38)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.360\u003csup\u003eb\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eDOS,h, median (IQR)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e12.00(7,24)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e12(6,24)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e13(8,24)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.755\u003csup\u003eb\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eSymptoms n (%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eParoxysmal crying\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e220(44.10)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e69(27.9)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e151(59.9)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eVomiting\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e231(46.3)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e92(37.2)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e139(55.2)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eBloody stool\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e108(21.6)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e47(19.0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e61(24.2)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.160\u003csup\u003ea\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eAbdominal pain\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e207(41.5)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e123(49.80)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e84(33.3)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eAbdominal mass\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e490(98.2)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e243(98.4)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e247(98.0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eLocation of the mass n (%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.042\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eRight lower quadrant\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e6(1.2)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0(0.00)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e6(2.4)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eRight upper quadrant\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e489(98.2)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e246(99.6)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e243(96.8)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eLeft upper quadrant\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e3(0.6)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e1(0.4)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e2(0.8)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eLeft lower quadrant\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0 (0.00)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0 (0.00)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0 (0.00)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eDiameter, mm, median (IQR)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e31(28,33)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e30(28,33)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e31(29,33)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.135\u003csup\u003eb\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eThe types of Intussusceptions,\u003c/p\u003e\n \u003cp\u003en(%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.257\u003csup\u003ea\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eIleocolic\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e487(97.6)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e243(98.4)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e244(96.80)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" rowspan=\"2\"\u003e\n \u003cp\u003e--2\u003ca href=\"#Fn1\" id=\"#FNLinkFn1\"\u003e\u003c/a\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eIleo-ileal\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e12(2.4)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e4(1.6)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e8(3.2)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n \u003c/table\u003e\n \u003c/div\u003e\n \u003cp\u003e[2] a: The P value was calculated by means of Chi-square test or Fisher\u0026rsquo;s exact test\u0026nbsp;\u003c/p\u003e\n \u003cp\u003eb: The P value was calculated by means of Mann\u0026ndash;Whitney U-test.\u003c/p\u003e\n \u003cp\u003eAbbreviation: IQR, interquartile range, DOS, duration of symptoms.\u0026nbsp;\u003c/p\u003e\n \u003cdiv\u003e\n \u003ctable id=\"Tab2\" border=\"1\"\u003e\n \u003ccaption language=\"En\"\u003e\n \u003cdiv\u003eTable 2\u003c/div\u003e\n \u003cdiv\u003e\n \u003cp\u003eEvaluation of patients in the two groups.\u003c/p\u003e\n \u003c/div\u003e\n \u003c/caption\u003e\n \u003ccolgroup cols=\"5\"\u003e\u003c/colgroup\u003e\n \u003cthead\u003e\n \u003ctr\u003e\n \u003cth align=\"left\"\u003e\u0026nbsp;\u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003eAll,\u003c/p\u003e\n \u003cp\u003en (%)\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003eGroup A,\u003c/p\u003e\n \u003cp\u003en (%)\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003eGroup B\u003c/p\u003e\n \u003cp\u003en (%)\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003eP-Value\u003c/p\u003e\n \u003c/th\u003e\n \u003c/tr\u003e\n \u003c/thead\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eSuccess rate\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e484(97.0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e24(99.2)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e23(94.8)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.004\u003csup\u003ea\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eEnema time\u003c/p\u003e\n \u003cp\u003eMin, Median (IQR)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e10(5,15)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e5(4,7)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e15(10,16)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003csup\u003eb\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eNumber of enema attempts\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\" rowspan=\"4\"\u003e\n \u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003csup\u003ea\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e357(71.7)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e224(90.7)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e134(53.2)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e103(20.7)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e12(4.9)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e91(36.1)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e3\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e38(7.6)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e11(4.5)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e27(10.7)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eWBC counts\u0026times;109 ,Median(IQR)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e10.65\u003c/p\u003e\n \u003cp\u003e(8.33,13.4)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e10.24\u003c/p\u003e\n \u003cp\u003e(8.09,12.82)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e11.01\u003c/p\u003e\n \u003cp\u003e(8.69,13.92)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.015\u003csup\u003eb\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eCRP,mg/dl, Median (IQR)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e5.85(2.31,11.30)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e6.0\u003c/p\u003e\n \u003cp\u003e(2.59,10.53)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e5.60\u003c/p\u003e\n \u003cp\u003e(2.2, 11.74)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.829\u003csup\u003eb\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eFever\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e16(3.2)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e6(2.4)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e10(4.0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.329\u003csup\u003ea\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eHospital stay, d, Median(IQR)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e2(2,3)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e2(2,3)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e2(2,2)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003csup\u003eb\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003ePerforation\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0 (0.00)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0 (0.00)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0 (0.00)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0\u003csup\u003ea\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n \u003c/table\u003e\n \u003c/div\u003e\n \u003cp\u003eThe characteristics of the patients at baseline were similar in the two trial groups (Table \u003cspan\u003e1\u003c/span\u003e). The median age was 21.00 months (IQR,11.00 to 34.00). The average weight was 11.00 kg (IQR,9.00 to 13.50). The duration of symptoms was 12.00 hours (IQR, 7.00 to 24.00). There were no significant differences between the two groups in terms of gender (P\u0026thinsp;=\u0026thinsp;0.936), age (P\u0026thinsp;=\u0026thinsp;0.385), body weight (P\u0026thinsp;=\u0026thinsp;0.360), or duration of symptoms (0.755). The contrasting outcomes of the two groups are shown in Table \u003cspan\u003e2\u003c/span\u003e. The overall success reduction rate was 97.00%, with Group A showing a significantly superior success rate of hydrostatic reduction (99.20%) compared to Group B (94.8%) (p\u0026thinsp;=\u0026thinsp;0.004). The enema time in Group A was 5 minutes (IQR, 4 to 7), while in Group B was 15 minutes (IQR, 10 to 16). The process in Group A took less time than in Group B, and the difference was statistically significant (P\u0026thinsp;\u0026lt;\u0026thinsp;0.001). In both groups, the median length of stay in hospital was two days. The median of White blood cells counts was 10.24 \u0026times; 10⁹/L (IQR,8.09 to 12.82)in Group A versus 11.01\u0026times; 10⁹/L (IQR, 8.69 to 13.92) in Group B, and the difference was statistically significant (P\u0026thinsp;=\u0026thinsp;0.015).The median C-reactive protein was 6.0mg/dl (IQR, 2.59 to 10.53༉in Group A versus 5.60mg/dl (IQR, 2.2 to 11.74) in Group B with no significant difference(P\u0026thinsp;=\u0026thinsp;0.829). There was no statistical difference between the two groups in the proportion of patients who developed fever during their hospitalization (P\u0026thinsp;=\u0026thinsp;0.329). No perforation or intestinal necrosis was found in those patients who were successfully reduced by hydrostatic enema.\u003c/p\u003e\n \u003cp\u003eTable \u003cspan\u003e4\u003c/span\u003e shows the analysis of the failure cases of enema reduction. The ileoileocolic intussusception (53.33%) was the most common type. Among the 15 surgical patients, 60%(9/15) cases had idiopathic intussusception and 6/15 (40%) patients had a pathological lead point (3 Meckel\u0026apos;s diverticulum, 2 intestinal polyp, 1 Peutz-Jeghers\u0026apos;s syndrome). 26.67% (4/15) patients had intestinal necrosis and underwent intestinal resection (1 in Group A and 3 in Group B). 53.33% (8/15)patients performed simple surgical reduction, including 1 in Group A and 7 in Group B. All 15 patients were finally discharged and recovered well after operation. No recurrence occurred in the 15 patients after surgical reduction.\u003c/p\u003e\n \u003cp\u003eTable \u003cspan\u003e5\u003c/span\u003e presents a comparison of recurrent intussusceptions between the two groups. The overall recurrence rate of intussusception within 48 hours after the initial hydrostatic enema reduction was 7.34%, while the recurrence rate beyond 48 hours was 6.97%. Although the recurrence rates within 48 hours and beyond 48 hours in Group A (8.85%, 6.15%, respectively) were higher than those in Group B (7.75%, 5.90%, respectively), there was no significant difference between the two groups (P\u0026thinsp;=\u0026thinsp;0.514). All recurrent patients were discharged after successful reduction with the same pressure enema as the initial. If there are more than three recurrences, abdominal magnetic resonance imaging (MRI) and ectopic gastric mucosal imaging (ECT) are recommended to identify a pathologic lead point. In a stratified analysis of patients with bloody stools in the two groups, we found that the success rate was significantly higher in Group A (95.70%) than in Group B (83.6%) (P\u0026thinsp;=\u0026thinsp;0.047).\u003c/p\u003e\n \u003cp\u003eThe follow-up period for all patients lasted 6 months, during which there were no reports of adverse outcomes or deaths, as confirmed through both outpatient follow-up and telephone contact.\u003c/p\u003e\n\u003c/div\u003e"},{"header":"Discussion","content":"\u003cp\u003eIn this retrospective cohort study, the use of 130mmHg hydrostatic pressure during the ultrasound-guided saline enema reduction led to a significantly higher successful reduction rate in Group A than in Group B. During the four years of study, a total of 531 intussusception cases in 499 patients were collected, the overall success reduction rate was 97.00%, which was consistent with the literatures reported by Bai et al[\u003cspan class=\"CitationRef\"\u003e9\u003c/span\u003e] and Xie et al[\u003cspan class=\"CitationRef\"\u003e11\u003c/span\u003e]. In our subgroup study, Group A achieved a higher reduction success rate (99.2%) by increasing the enema pressure (130 mmHg), which was significantly higher than that of (94.8%) in Group B (110 mmHg), with a statistically significant difference (P\u0026thinsp;=\u0026thinsp;0.004). Additionally, by increasing the pressure up to 130 mmHg, it also reduced the enema time. The median enema time for reduction in Group A was 5mins (IQR,4to7), which was significantly superior to that in Group B(P\u0026thinsp;\u0026lt;\u0026thinsp;0.001). Meanwhile, successful reduction on the first attempt occurred in 90.7% (224/247) of patients in Group A, comparing with only 53.0% (133/251) in group B, and the difference between the two groups was statistically significant (P\u0026thinsp;\u0026lt;\u0026thinsp;0.001).\u003c/p\u003e\n\u003cp\u003eProlonged symptoms of intussusception have been linked to intestinal edema, ischemic necrosis, and a higher risk of perforation [\u003cspan class=\"CitationRef\"\u003e20\u003c/span\u003e, \u003cspan class=\"CitationRef\"\u003e21\u003c/span\u003e]. Therefore, increasing pressure can rapidly alleviate the child\u0026apos;s symptoms by resetting the intussusception, leading to a reduction in adverse events.\u003c/p\u003e\n\u003cp\u003eThese results may be attributed to our enhancement of the success rate by increasing hydrostatic pressure. The primary analysis in our study was performed according to the Bernoulli\u0026rsquo;s equation principle, which stated that the higher the height of the water column, the higher the enema pressure. Given a relatively stable isotonic saline flow rate, we solely focused on the fluid height difference that corresponds to pressure magnitude, as discussed in the literature by Liu et al. [\u003cspan class=\"CitationRef\"\u003e23\u003c/span\u003e] and Kanglie et al. [\u003cspan class=\"CitationRef\"\u003e19\u003c/span\u003e], who indicated the relationship between bag height and hydrostatic pressure. Moreover, a previous study by Zambuto et al. [\u003cspan class=\"CitationRef\"\u003e7\u003c/span\u003e] showed that the pressure exerted on the intestinal wall was more uniform during hydrostatic enema than during pneumatic enema.\u003c/p\u003e\n\u003cp\u003eThe explanation that greater pressure facilitates more successful reduction can also be supported by the enema procedure. When intussusception passes through the ileocecal valve, it often becomes more challenging and requires greater hydrostatic pressure. Liu et al[\u003cspan class=\"CitationRef\"\u003e13\u003c/span\u003e] also documented that the patient was more likely to be successfully reduced at a time when a Valsalva maneuver was induced by the patient\u0026rsquo;s crying or mounting, and also documented a significant increase in intra-intestinal pressure when the Valsalva maneuver was induced. Also for the patient in Group B who failed to be reduced, our operative exploration confirmed this, with only a small portion of the ileocecal portion of the intussusception remaining to be reduced. In Group A, a 5-year-old boy who failed to reset was an ileocolic intussusception with multiple enlarged lymph nodes inside the intussusception, which made the intussusceptum significantly larger and could not pass through the ileocecal valve. In addition, it has been reported in the literatures [\u003cspan class=\"CitationRef\"\u003e14\u003c/span\u003e\u0026ndash;\u003cspan class=\"CitationRef\"\u003e16\u003c/span\u003e] that the pressure in the intestinal lumen can reach up to 200 mmHg.\u003c/p\u003e\n\u003cp\u003eWe hypothesize that the perforation after hydrostatic enema is not directly related to the hydrostatic pressure, but is link to the gangrene of the small intestine in the intussusceptum. Therefore, increasing the pressure to 130 mmHg is relatively safe. Currently, the literature suggests that the perforation rate of pneumatic and hydrostatic enema reduction was similar, with both having a perforation rate of approximately 0.8% [\u003cspan class=\"CitationRef\"\u003e27\u003c/span\u003e]. In addition, our study observed no occurrence of adverse events. Furthermore, patients who were successfully treated and discharged also did not experience any adverse events during the follow-up period. It is worth noting that C-reactive protein levels, as discussed in a previous study by Sproston et al [\u003cspan class=\"CitationRef\"\u003e28\u003c/span\u003e], can serve as a reliable indicator for assessing the severity of disease in relation to injury, infection, and inflammatory responses.\u003c/p\u003e\n\u003cp\u003eWe examined the CRP of patients in both groups separately after enema reduction, and the median CRP was 6.0mg/dl (IQR,2.59to 10.53) in Group A and 5.60 mg/dl (IQR,2.2to11.74) in Group B. The values were low in both groups and did not differ substantially between the two groups(P\u0026thinsp;=\u0026thinsp;0.829). In addition, Additionally, both groups of patients who underwent successful enema reduction did not exhibit any symptoms of peritonitis upon abdominal examination. The median white blood cell (WBC) counts in Group A was 10.24\u0026times;109 (IQR 8.09 to 12.82), which was slightly lower than the median WBC counts in Group B of 11.01\u0026times;109 (IQR, 8.690 to 13.92), and although the difference in WBC counts between the two groups was statistically significant (P\u0026thinsp;\u0026lt;\u0026thinsp;0.001), the clinical difference was small and insignificant. The incidence of fever after enema reduction was not statistically significant between the two groups (P\u0026thinsp;=\u0026thinsp;0.329). As a result, we did not find any evidence to suggest that the use of enemas increased the risk of abdominal infection. Therefore, we do not recommend the use of prophylactic antibiotics given the low probability of fever and the lack of evidence showing a bacterial infection resulting from the insignificant increase in WBC counts and CRP after the use of enemas. Our findings are consistent with previous studies [29\u0026ndash;31].\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eTable 3 Evaluation of patients with bloody stool\u003c/strong\u003e\u003c/p\u003e\n\u003ctable border=\"1\" cellspacing=\"0\" cellpadding=\"0\" width=\"654\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd width=\"30.627871362940276%\" valign=\"top\"\u003e\n \u003cp\u003eVariable\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"15.46707503828484%\" valign=\"top\"\u003e\n \u003cp\u003eAll, n%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"18.83614088820827%\" valign=\"top\"\u003e\n \u003cp\u003eGroup A, n%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"18.83614088820827%\" valign=\"top\"\u003e\n \u003cp\u003eGroup B, n%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"16.232771822358345%\" valign=\"top\"\u003e\n \u003cp\u003eP-Value\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"30.627871362940276%\" valign=\"top\"\u003e\n \u003cp\u003eSuccess rate\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"15.46707503828484%\" valign=\"top\"\u003e\n \u003cp\u003e96(88.9)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"18.83614088820827%\" valign=\"top\"\u003e\n \u003cp\u003e45(95.7)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"18.83614088820827%\" valign=\"top\"\u003e\n \u003cp\u003e51(83.6)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"16.232771822358345%\" valign=\"top\"\u003e\n \u003cp\u003e0.047\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"30.627871362940276%\" valign=\"top\"\u003e\n \u003cp\u003eEnema time\u003c/p\u003e\n \u003cp\u003emin, Median(IQR)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"15.46707503828484%\"\u003e\n \u003cp\u003e11(5,19)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"18.83614088820827%\"\u003e\n \u003cp\u003e5(5,12)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"18.83614088820827%\"\u003e\n \u003cp\u003e15(10,27.5)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"16.232771822358345%\"\u003e\n \u003cp\u003e\u0026lt;0.001\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"30.627871362940276%\" valign=\"top\"\u003e\n \u003cp\u003eNumber of enema attempts\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"15.46707503828484%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"18.83614088820827%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"18.83614088820827%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"16.232771822358345%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"30.627871362940276%\" valign=\"top\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"15.46707503828484%\" valign=\"top\"\u003e\n \u003cp\u003e60(55.6)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"18.83614088820827%\" valign=\"top\"\u003e\n \u003cp\u003e36(76.6)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"18.83614088820827%\" valign=\"top\"\u003e\n \u003cp\u003e24(39.3)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"16.232771822358345%\" rowspan=\"3\"\u003e\n \u003cp\u003e\u0026lt;0.001\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"36.56307129798903%\" valign=\"top\"\u003e\n \u003cp\u003e2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"18.46435100548446%\" valign=\"top\"\u003e\n \u003cp\u003e27(25.0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"22.486288848263253%\" valign=\"top\"\u003e\n \u003cp\u003e5(10.6)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"22.486288848263253%\" valign=\"top\"\u003e\n \u003cp\u003e22(36.1)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"36.56307129798903%\" valign=\"top\"\u003e\n \u003cp\u003e3\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"18.46435100548446%\" valign=\"top\"\u003e\n \u003cp\u003e21(19.4)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"22.486288848263253%\" valign=\"top\"\u003e\n \u003cp\u003e6(12.8)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"22.486288848263253%\" valign=\"top\"\u003e\n \u003cp\u003e15(24.6)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cdiv class=\"gridtable\"\u003e\n \u003cdiv align=\"left\" class=\"colspec\"\u003e\u003cbr\u003e\u003c/div\u003e\n \u003cp\u003e\u003cstrong\u003eTable 4 Analysis of the failure cases of enema reduction in the two groups\u003c/strong\u003e\u003c/p\u003e\n \u003ctable border=\"1\" cellspacing=\"0\" cellpadding=\"0\" width=\"656\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd width=\"34.75609756097561%\" valign=\"top\"\u003e\n \u003cp\u003eVariable\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"17.98780487804878%\" valign=\"top\"\u003e\n \u003cp\u003eAll, (n, %)\u003c/p\u003e\n \u003cp\u003eN=15\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"22.408536585365855%\" valign=\"top\"\u003e\n \u003cp\u003eGroup A, (n, %)\u003c/p\u003e\n \u003cp\u003eN=2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"24.847560975609756%\" valign=\"top\"\u003e\n \u003cp\u003eGroup B, (n, %)\u003c/p\u003e\n \u003cp\u003eN=13\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"34.75609756097561%\" valign=\"top\"\u003e\n \u003cp\u003eThe types of Intussusceptions\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"17.98780487804878%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"22.408536585365855%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"24.847560975609756%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"34.75609756097561%\" valign=\"top\"\u003e\n \u003cp\u003eIleocolic\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"17.98780487804878%\" valign=\"top\"\u003e\n \u003cp\u003e7（46.67）\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"22.408536585365855%\" valign=\"top\"\u003e\n \u003cp\u003e1（50.00）\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"24.847560975609756%\" valign=\"top\"\u003e\n \u003cp\u003e6（46.15）\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"34.75609756097561%\" valign=\"top\"\u003e\n \u003cp\u003eIleo-ileocolic\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"17.98780487804878%\" valign=\"top\"\u003e\n \u003cp\u003e8(53.33)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"22.408536585365855%\" valign=\"top\"\u003e\n \u003cp\u003e1（50.00）\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"24.847560975609756%\" valign=\"top\"\u003e\n \u003cp\u003e7（53.85）\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"34.75609756097561%\" valign=\"top\"\u003e\n \u003cp\u003eEtiology\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"17.98780487804878%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"22.408536585365855%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"24.847560975609756%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"34.75609756097561%\" valign=\"top\"\u003e\n \u003cp\u003eIdiopathic\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"17.98780487804878%\" valign=\"top\"\u003e\n \u003cp\u003e9（60.00）\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"22.408536585365855%\" valign=\"top\"\u003e\n \u003cp\u003e2（100.00）\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"24.847560975609756%\" valign=\"top\"\u003e\n \u003cp\u003e7（53.85）\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"34.75609756097561%\" valign=\"top\"\u003e\n \u003cp\u003eSecondary\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"17.98780487804878%\" valign=\"top\"\u003e\n \u003cp\u003e6（40.00）\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"22.408536585365855%\" valign=\"top\"\u003e\n \u003cp\u003e0（0）\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"24.847560975609756%\" valign=\"top\"\u003e\n \u003cp\u003e6（46.15）\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"34.75609756097561%\" valign=\"top\"\u003e\n \u003cp\u003eThe method of operation\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"17.98780487804878%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"22.408536585365855%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"24.847560975609756%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"34.75609756097561%\" valign=\"top\"\u003e\n \u003cp\u003eSimple reduction\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"17.98780487804878%\" valign=\"top\"\u003e\n \u003cp\u003e8\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"22.408536585365855%\" valign=\"top\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"24.847560975609756%\" valign=\"top\"\u003e\n \u003cp\u003e7\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"34.75609756097561%\" valign=\"top\"\u003e\n \u003cp\u003eResection due to Intestinal necrosis\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"17.98780487804878%\" valign=\"top\"\u003e\n \u003cp\u003e4\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"22.408536585365855%\" valign=\"top\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"24.847560975609756%\" valign=\"top\"\u003e\n \u003cp\u003e3\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"34.75609756097561%\" valign=\"top\"\u003e\n \u003cp\u003ePathologic lead point\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"17.98780487804878%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"22.408536585365855%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"24.847560975609756%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"34.75609756097561%\" valign=\"top\"\u003e\n \u003cp\u003eMeckel\u0026rsquo;s diverticulum\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"17.98780487804878%\" valign=\"top\"\u003e\n \u003cp\u003e3\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"22.408536585365855%\" valign=\"top\"\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"24.847560975609756%\" valign=\"top\"\u003e\n \u003cp\u003e3\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"34.75609756097561%\" valign=\"top\"\u003e\n \u003cp\u003eIntestinal polyp\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"17.98780487804878%\" valign=\"top\"\u003e\n \u003cp\u003e2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"22.408536585365855%\" valign=\"top\"\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"24.847560975609756%\" valign=\"top\"\u003e\n \u003cp\u003e2\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"34.75609756097561%\" valign=\"top\"\u003e\n \u003cp\u003ePeutz-Jeghers syndrome\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"17.98780487804878%\" valign=\"top\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"22.408536585365855%\" valign=\"top\"\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"24.847560975609756%\" valign=\"top\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n \u003c/table\u003e\n \u003cdiv align=\"left\" class=\"colspec\"\u003e\u003cbr\u003e\u003c/div\u003e\n \u003cp\u003e\u003cstrong\u003eTable 5 Comparison of intussusception recurrence between the two groups.\u003c/strong\u003e\u003c/p\u003e\n \u003ctable border=\"1\" cellspacing=\"0\" cellpadding=\"0\" width=\"661\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd width=\"23.378582202111613%\" rowspan=\"2\" valign=\"top\"\u003e\n \u003cp\u003eVariable[3]\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"19.155354449472096%\" valign=\"top\"\u003e\n \u003cp\u003eAl, n%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"19.155354449472096%\" valign=\"top\"\u003e\n \u003cp\u003eGroup A, n%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"19.155354449472096%\" valign=\"top\"\u003e\n \u003cp\u003eGroup B, n%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"19.155354449472096%\" rowspan=\"2\" valign=\"top\"\u003e\n \u003cp\u003eP-Value\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"33.333333333333336%\" valign=\"top\"\u003e\n \u003cp\u003eN=72\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"33.333333333333336%\" valign=\"top\"\u003e\n \u003cp\u003eN=39\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"33.333333333333336%\" valign=\"top\"\u003e\n \u003cp\u003eN=33\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"23.378582202111613%\" valign=\"top\"\u003e\n \u003cp\u003eRecurrence after first enema\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"19.155354449472096%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"19.155354449472096%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"19.155354449472096%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"19.155354449472096%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"23.378582202111613%\" valign=\"top\"\u003e\n \u003cp\u003eEarly recurrence\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"19.155354449472096%\" valign=\"top\"\u003e\n \u003cp\u003e40（8.02）\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"19.155354449472096%\" valign=\"top\"\u003e\n \u003cp\u003e23（9.39）\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"19.155354449472096%\" valign=\"top\"\u003e\n \u003cp\u003e17（7.11）\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"19.155354449472096%\" rowspan=\"2\"\u003e\n \u003cp\u003e0.526\u003csup\u003ea\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"28.917910447761194%\" valign=\"top\"\u003e\n \u003cp\u003eLate recurrence\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"23.69402985074627%\" valign=\"top\"\u003e\n \u003cp\u003e32（6.41）\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"23.69402985074627%\" valign=\"top\"\u003e\n \u003cp\u003e16（6.53）\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"23.69402985074627%\" valign=\"top\"\u003e\n \u003cp\u003e16（6.69）\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n \u003c/table\u003e\u003cbr\u003e\u003cbr\u003e\n \u003ctable border=\"1\" cellspacing=\"0\" cellpadding=\"0\" width=\"661\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd width=\"23.378582202111613%\" valign=\"top\"\u003e\n \u003cp\u003eNumbers of\u003c/p\u003e\n \u003cp\u003eRecurrence\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"19.155354449472096%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"19.155354449472096%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"19.155354449472096%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"19.155354449472096%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"23.378582202111613%\" valign=\"top\"\u003e\n \u003cp\u003e1 time\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"19.155354449472096%\" valign=\"top\"\u003e\n \u003cp\u003e56（77.8）\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"19.155354449472096%\" valign=\"top\"\u003e\n \u003cp\u003e38（97.4）\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"19.155354449472096%\" valign=\"top\"\u003e\n \u003cp\u003e18（54.5）\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"19.155354449472096%\" rowspan=\"2\"\u003e\n \u003cp\u003e\u0026lt;0.001\u003csup\u003ea\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"28.917910447761194%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026ge;2 times\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"23.69402985074627%\" valign=\"top\"\u003e\n \u003cp\u003e16（22.2）\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"23.69402985074627%\" valign=\"top\"\u003e\n \u003cp\u003e1（2.6）\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"23.69402985074627%\" valign=\"top\"\u003e\n \u003cp\u003e1（45.5）\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n \u003c/table\u003e\n \u003cdiv id=\"ftn1\"\u003e\n \u003cp\u003e[3] a: The P value was calculated by means of Chi-square test or Fisher\u0026rsquo;s exact test\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;Children with ileoileal intussusceptions are at a greater risk for loss of intestinal viability than other types of intussusception [\u003cspan class=\"CitationRef\"\u003e17\u003c/span\u003e], so higher enema pressure and shorter enema duration may minimize the risk of necrosis in this portion of the small intestine. Ultrasound can identify small intestinal intussusception and indicate whether there a decrease in blood flow signal in intussusception[\u003cspan class=\"CitationRef\"\u003e18\u003c/span\u003e]. In our study, due to the higher enema pressure in Group A, 3/4 of ileo-ileocolic intussusceptions were successfully reduced, while only 1/8 of ileo-ileocolic intussusceptions in Group B was reduced. In our study, we also observed a case of a 4-year-old girl with an ileo-ileocolic intussusception in Group A, who failed the enema reduction. During the course of enema reduction, the intussusceptum passed through the ileocecal valve, but the small bowel intussusception remained, and the intra-operative investigation further confirmed that the inserted small intestine had been necrotic. It had been reported in the literature[\u003cspan class=\"CitationRef\"\u003e19\u003c/span\u003e] bloody stool was considered as a risk factor for failure of hydrostatic reduction of intussusception. Thus, we performed a subgroup analysis on the cases of bloody intussusception (Table \u003cspan class=\"InternalRef\"\u003e3\u003c/span\u003e), and demonstrated that increasing the pressure led to a higher success rate of enema reduction(95.7% vs 83.6%, P\u0026thinsp;=\u0026thinsp;0.047), and the enema time and enema attempts are significantly superior than those in the lower pressure group (both differences P\u0026thinsp;\u0026lt;\u0026thinsp;0.001).\u003c/p\u003e\n \u003c/div\u003e\n\u003c/div\u003e\n\u003cp\u003eApproximately 6% of childhood intussuceptions have pathologic lead points (PLP), such as a Meckel\u0026rsquo;s diverticulum, enteric duplication cyst, polyp or lymphoma. As to the issue of pathological lead points, it is not a contraindication to enema reduction in our study. The literature reported a relationship between pathological lead points and recurrence of intussusception[\u003cspan class=\"CitationRef\"\u003e20\u003c/span\u003e], but not a definite relationship with successful reduction. We deem that even a PLP exists, enema reduction should still be attempted. Early reduction will help to avoid the aggravation of edema and even ischemic necrosis caused by intestinal wall and mesenteric compression. Moreover, after successful reduction, we can choose more minimally invasive methods to treat the PLP, such as colonoscopy or laparoscopy, thus minimizing trauma to patients. In Group A, one patient with Meckel\u0026rsquo;s diverticulum was found during enema reduction. Laparoscopic treatment was performed after successful reduction. Delayed surgical treatment is conducive to reducing intestinal edema and reducing the risk of postoperative anastomotic leakage.\u003c/p\u003e\n\u003cp\u003eWe believe that a symptom duration of more than 48 hours should not be considered a contraindication to enema reduction. However, as time went on, the intestinal edema becomes more pronounced, making enema reduction more challenging. Despite this, Lim et al [35] found no correlation between symptom duration and reduction failure. Therefore, we still recommend attempting enema reduction. In Group A, 17 cases with symptom onset exceeding 72 hours were successfully reduced by enema, while in Group B, 6 out of 8 cases with onset time over 72 hours were successful, and 2 cases failed. Furthermore, no instances of intestinal necrosis were discovered during surgical exploration. The failure rate of enema reduction was positively correlated with the duration of symptoms, which is consistent with that reported by Yao et al [\u003cspan class=\"CitationRef\"\u003e17\u003c/span\u003e].\u003c/p\u003e\n\u003cp\u003eRecurrence after enema is a common event after non-surgical treatment of intussusception. The overall recurrence rate for recurrent intussusception following successful nonoperative reduction is approximately 10.0% [\u003cspan class=\"CitationRef\"\u003e21\u003c/span\u003e]. Early recurrence of intussusception within 48 hours after reduction is more common [\u003cspan class=\"CitationRef\"\u003e22\u003c/span\u003e]. In our study, the overall recurrence rate in the first 48 hours post successful reduction was 7.34% and the recurrence rate more than 48 hours after successful enema reduction was 6.97%, which was close to the recurrence rate reported in a meta-analysis by Gray et al [\u003cspan class=\"CitationRef\"\u003e21\u003c/span\u003e]. Furthermore, recurrence rates were similar in both groups, with no statistically significant differences, and neither group reported any additional morbidity or mortality. Importantly, none of the patients with recurrent intussusception had an adverse outcome. The treatment of recurrent intussusception should be the same as the initial treatment [\u003cspan class=\"CitationRef\"\u003e23\u003c/span\u003e]. Furthermore, some previous studies [\u003cspan class=\"CitationRef\"\u003e24\u003c/span\u003e, \u003cspan class=\"CitationRef\"\u003e25\u003c/span\u003e] had shown that discharge from the hospital after a successful enema reduction did not increase adverse events. More interestingly, in our study, it was found that most of the intussusceptions in group A recurred once (97.4%), which was statistically significant compared with group B(P\u0026thinsp;\u0026lt;\u0026thinsp;0.001). The reason may be that the enema time is short and the compression and expansion effect on ileocecal valve is light. As early recurrence is relatively concentrated within 48 hours after enema reduction, we recommend that patients should be admitted to hospital for observation after reduction. Another reason is that some patients are already combined with dehydration and electrolyte disorders at the time of admission, then hospitalization can further improve prognosis and reduce complications. According to the literatures reported [\u003cspan class=\"CitationRef\"\u003e26\u003c/span\u003e, \u003cspan class=\"CitationRef\"\u003e27\u003c/span\u003e], pathological lead points may lead to recurrence. Therefore, in our institution, abdominal magnetic resonance imaging (MRI) scans and ectopic gastric mucosal imaging (ECT) were recommended to detect the presence of pathological lead points that may have been missed by ultrasound if a patient had more than three recurrences. This is similar to the approach reported by Hutchason et al [\u003cspan class=\"CitationRef\"\u003e28\u003c/span\u003e].\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eLimitation\u003c/strong\u003e:\u003c/p\u003e\n\u003cp\u003eOur study has several limitations that should be acknowledged. First, it is a retrospective study rather than a randomized controlled trial (RCT), which may lead to potential selective bias and lower quality of evidence. However, in terms of patient selection, we have limited enema reduction handled by the three senior residents to reduce the difference in experience. Another limitation is that the experience of sonographers involved in this study varied, and we cannot rule out the possibility that some patients may have had some unrecognized PLP.\u003c/p\u003e"},{"header":"Conclusion","content":"\u003cp\u003eIn conclusion, our retrospective study suggests that increasing enema pressure up to 130 mmHg (175 cm) in ultrasound-guided saline enema for hydrostatic reduction of childhood intussusception is viable, safe and effective. Furthermore, the success rate of this approach is higher and there are no increased complications. Ultrasound-guided hydrostatic enema therapy is considered one of the ideal methods for the nonsurgical treatment of childhood intussusception. However, to establish its wider clinical use, multicenter randomized controlled studies are necessary to provide robust evidence.\u003c/p\u003e \u003cp\u003e \u003cb\u003eFinancial support statement\u003c/b\u003e: This study was supported from Startup Fund for scientific research, Fujian Medical University;(Grant number: 2021QH1263)\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eFinancial support statement:\u0026nbsp;\u003c/strong\u003eThis study was supported from Startup Fund for scientific research, Fujian Medical University;(Grant number: 2021QH1263)\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCompliance with ethical standards\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConflict of interest\u003c/strong\u003e The authors declare that they have no conflict of interest.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eEthical approval\u003c/strong\u003e For this type of study formal consent is not required.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eInformed consent\u003c/strong\u003e Informed consent was obtained from all individual participants included in the study.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\n\u003cli\u003eGuo JZ, Ma XY, Zhou QH: Results of air pressure enema reduction of intussusception: 6,396 cases in 13 years. \u003cem\u003eJ Pediatr Surg \u003c/em\u003e1986, 21(12):1201-1203.http://doi.org/10.1016/0022-3468(86)90040-0.\u003c/li\u003e\n\u003cli\u003eTang XB, Zhao JY, Bai YZ: Status survey on enema reduction of paediatric intussusception in china. \u003cem\u003eJ Int Med Res \u003c/em\u003e2019, 47(2):859-866.http://doi.org/10.1177/0300060518814120.\u003c/li\u003e\n\u003cli\u003eStein-Wexler R, O\u0026apos;connor R, Daldrup-Link H, Wootton-Gorges SL: Current methods for reducing intussusception: Survey results. \u003cem\u003ePediatr Radiol \u003c/em\u003e2015, 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intussusception. \u003cem\u003eFront Pharmacol \u003c/em\u003e2019, 10:43.http://doi.org/10.3389/fphar.2019.00043.\u003c/li\u003e\n\u003cli\u003ePensabene, L.: Colonic manometry in children with defecatory disorders role in diagnosis and management. \u003cem\u003eThe American Journal of Gastroenterology \u003c/em\u003e2003, 98(5):1052-1057.http://doi.org/10.1016/s0002-9270(03)00130-8.\u003c/li\u003e\n\u003cli\u003eGiorgio V, Borrelli O, Smith VV, Rampling D, Koglmeier J, Shah N, Thapar N, Curry J, Lindley KJ: High-resolution colonic manometry accurately predicts colonic neuromuscular pathological phenotype in pediatric slow transit constipation. \u003cem\u003eNeurogastroenterol Motil \u003c/em\u003e2013, 25(1):70-78 e78-79.http://doi.org/10.1111/nmo.12016.\u003c/li\u003e\n\u003cli\u003eDinning PG, Benninga MA, Southwell BR, Scott SM: Paediatric and adult colonic manometry: A tool to help unravel the pathophysiology of constipation. \u003cem\u003eWorld J Gastroenterol \u003c/em\u003e2010, 16(41):5162-5172.http://doi.org/10.3748/wjg.v16.i41.5162.\u003c/li\u003e\n\u003cli\u003eYao XM, Chen ZL, Shen DL, Zhou QS, Huang SS, Cai ZR, Tong YL, Wang M, Ren Y, Lai XH, Chen XM: Risk factors for pediatric intussusception complicated by loss of intestine viability in china from june 2009 to may 2014: A retrospective study. \u003cem\u003ePediatr Surg Int \u003c/em\u003e2015, 31(2):163-166.http://doi.org/10.1007/s00383-014-3653-0.\u003c/li\u003e\n\u003cli\u003eZhang M, Zhou X, Hu Q, Jin L: Accurately distinguishing pediatric ileocolic intussusception from small-bowel intussusception using ultrasonography. \u003cem\u003eJ Pediatr Surg \u003c/em\u003e2021, 56(4):721-726.http://doi.org/10.1016/j.jpedsurg.2020.06.014.\u003c/li\u003e\n\u003cli\u003eXiaolong X, Yang W, Qi W, Yiyang Z, Bo X: Risk factors for failure of hydrostatic reduction of intussusception in pediatric patients: A retrospective study. \u003cem\u003eMedicine (Baltimore) \u003c/em\u003e2019, 98(1):e13826.http://doi.org/10.1097/MD.0000000000013826.\u003c/li\u003e\n\u003cli\u003eShen G, Zhang C, Li J, Zhang J, Liu Y, Guan Z, Hu Q: Risk factors for short-term recurrent intussusception and reduction failure after ultrasound-guided saline enema. \u003cem\u003ePediatr Surg Int \u003c/em\u003e2018, 34(11):1225-1231.http://doi.org/10.1007/s00383-018-4340-3.\u003c/li\u003e\n\u003cli\u003eGray MP, Li SH, Hoffmann RG, Gorelick MH: Recurrence rates after intussusception enema reduction: A meta-analysis. \u003cem\u003ePediatrics \u003c/em\u003e2014, 134(1):110-119.http://doi.org/10.1542/peds.2013-3102.\u003c/li\u003e\n\u003cli\u003eFerrantella A, Quinn K, Parreco J, Quiroz HJ, Willobee BA, Ryon E, Thorson CM, Sola JE, Perez EA: Incidence of recurrent intussusception in young children: A nationwide readmissions analysis. \u003cem\u003eJ Pediatr Surg \u003c/em\u003e2020, 55(6):1023-1025.http://doi.org/10.1016/j.jpedsurg.2020.02.034.\u003c/li\u003e\n\u003cli\u003eCho MJ, Nam CW, Choi SH, Hwang EH: Management of recurrent ileocolic intussusception. \u003cem\u003eJ Pediatr Surg \u003c/em\u003e2020, 55(10):2150-2153.http://doi.org/10.1016/j.jpedsurg.2019.09.039.\u003c/li\u003e\n\u003cli\u003eRaval MV, Minneci PC, Deans KJ, Kurtovic KJ, Dietrich A, Bates DG, Rangel SJ, Moss RL, Kenney BD: Improving quality and efficiency for intussusception management after successful enema reduction. \u003cem\u003ePediatrics \u003c/em\u003e2015, 136(5):e1345-1352.http://doi.org/10.1542/peds.2014-3122.\u003c/li\u003e\n\u003cli\u003eBeres AL, Baird R, Fung E, Hsieh H, Abou-Khalil M, Ted Gerstle J: Comparative outcome analysis of the management of pediatric intussusception with or without surgical admission. \u003cem\u003eJ Pediatr Surg \u003c/em\u003e2014, 49(5):750-752.http://doi.org/10.1016/j.jpedsurg.2014.02.059.\u003c/li\u003e\n\u003cli\u003eGuo WL, Hu ZC, Tan YL, Sheng M, Wang J: Risk factors for recurrent intussusception in children: A retrospective cohort study. \u003cem\u003eBMJ Open \u003c/em\u003e2017, 7(11):e018604.http://doi.org/10.1136/bmjopen-2017-018604.\u003c/li\u003e\n\u003cli\u003eYe X, Tang R, Chen S, Lin Z, Zhu J: Risk factors for recurrent intussusception in children: A systematic review and meta-analysis. \u003cem\u003eFront Pediatr \u003c/em\u003e2019, 7:145.http://doi.org/10.3389/fped.2019.00145.\u003c/li\u003e\n\u003cli\u003eHutchason A, Sura A, Vettikattu N, Goodarzian F: Clinical management and recommendations for children with more than four episodes of recurrent intussusception following successful reduction of each: An institutional review. \u003cem\u003eClin Radiol \u003c/em\u003e2020, 75(11):864-867.http://doi.org/10.1016/j.crad.2020.08.009.\u003c/li\u003e\n\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":true,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"pediatric-surgery-international","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"pesi","sideBox":"Learn more about [Pediatric Surgery International](http://link.springer.com/journal/383)","snPcode":"383","submissionUrl":"https://submission.nature.com/new-submission/383/3","title":"Pediatric Surgery International","twitterHandle":"","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"em","reportingPortfolio":"Springer Hybrid","inReviewEnabled":true,"inReviewRevisionsEnabled":false},"keywords":"Intussusception, Hydrostatic Reduction Pressure, Ultrasound-Guided, Reduction Rate","lastPublishedDoi":"10.21203/rs.3.rs-4938928/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-4938928/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003ch2\u003ePurpose\u003c/h2\u003e \u003cp\u003eThe aim of this study is to analyze the effect of increasing enema pressure on enema outcomes.\u003c/p\u003e\u003ch2\u003eMethods\u003c/h2\u003e \u003cp\u003eWe conducted a retrospective study to compare the effect of increasing enema pressure on enema outcomes. The primary outcome was the success rate of reduction, while secondary outcomes included intestinal perforation and recurrence rate.\u003c/p\u003e\u003ch2\u003eResults\u003c/h2\u003e \u003cp\u003eFrom May 2017 to April 2021, a total of 531 intussusceptions in 499 patients (Group A 247 patients, Group B 252 patients) were collected. The overall success reduction rate was 97.00%. The success reduction rate in Group A was 99.20% (245/247) and 94.8% (239/252) in Group B (P\u0026thinsp;=\u0026thinsp;0.004). The overall recurrence rate within 48 hours after the initial enema reduction was 8.02%, and beyond 48 hours was 6.41%. The recurrence rates within 48 hours and beyond 48 hours were 9.39% and 6.53% in group A and 7.11% and 6.69% in group B, respectively (P\u0026thinsp;=\u0026thinsp;0.526). No complications were associated with the enema reduction procedure.\u003c/p\u003e\u003ch2\u003eConclusion\u003c/h2\u003e \u003cp\u003eOur study has shown that using a hydrostatic pressure of 130 mmHg for enema reduction is both effective and safe, with a higher success rate and no increased risk of complications.\u003c/p\u003e\u003ch2\u003eStudy type:\u003c/h2\u003e \u003cp\u003eRetrospective cohort study\u003c/p\u003e\u003ch2\u003eLevel of evidence:\u003c/h2\u003e \u003cp\u003eTherapeutic study, III\u003c/p\u003e","manuscriptTitle":"Short-Term Outcomes of Improving Hydrostatic Pressures on Reducing Intussusception in Children","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2024-10-14 11:53:41","doi":"10.21203/rs.3.rs-4938928/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"decision","content":"Revision requested","date":"2024-10-20T16:51:33+00:00","index":"","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2024-09-25T17:44:20+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"33863269505726979942299104834973213661","date":"2024-09-15T10:03:26+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"40707286349904128670191554212411376523","date":"2024-09-07T08:54:47+00:00","index":"hide","fulltext":""},{"type":"reviewersInvited","content":"","date":"2024-09-02T08:20:14+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2024-08-19T13:46:45+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2024-08-19T13:36:31+00:00","index":"","fulltext":""},{"type":"submitted","content":"Pediatric Surgery International","date":"2024-08-19T13:23:24+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"pediatric-surgery-international","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"pesi","sideBox":"Learn more about [Pediatric Surgery International](http://link.springer.com/journal/383)","snPcode":"383","submissionUrl":"https://submission.nature.com/new-submission/383/3","title":"Pediatric Surgery International","twitterHandle":"","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"em","reportingPortfolio":"Springer Hybrid","inReviewEnabled":true,"inReviewRevisionsEnabled":false}}],"origin":"","ownerIdentity":"fafd8988-00cf-4131-b019-a4ffd3fe3bc2","owner":[],"postedDate":"October 14th, 2024","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"published-in-journal","subjectAreas":[],"tags":[],"updatedAt":"2024-12-09T15:58:36+00:00","versionOfRecord":{"articleIdentity":"rs-4938928","link":"https://doi.org/10.1007/s00383-024-05919-2","journal":{"identity":"pediatric-surgery-international","isVorOnly":false,"title":"Pediatric Surgery International"},"publishedOn":"2024-12-08 15:56:51","publishedOnDateReadable":"December 8th, 2024"},"versionCreatedAt":"2024-10-14 11:53:41","video":"","vorDoi":"10.1007/s00383-024-05919-2","vorDoiUrl":"https://doi.org/10.1007/s00383-024-05919-2","workflowStages":[]},"version":"v1","identity":"rs-4938928","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-4938928","identity":"rs-4938928","version":["v1"]},"buildId":"qtupq5eGEP_6zYnWcrvyt","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}