Preoperative Dexamethasone as an adjunct to increase the success rate of pneumatic reduction for primary idiopathic intussusception in children: A pilot Study

Preoperative Dexamethasone as an adjunct to increase the success rate of pneumatic reduction for primary idiopathic intussusception in children: A pilot Study | 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 Preoperative Dexamethasone as an adjunct to increase the success rate of pneumatic reduction for primary idiopathic intussusception in children: A pilot Study Mahmoud Tarek, Ahmed Abdelnabi, Gamal Eltagy, Aly Shalaby This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-6184394/v1 This work is licensed under a CC BY 4.0 License Status: Posted Version 1 posted You are reading this latest preprint version Abstract Purpose Intussusception is a common cause of intestinal obstruction in children. Cases presenting early can be managed non-surgically by hydrostatic or pneumatic reduction. Dexamethasone is a long rapidly acting corticosteroid with anti-inflammatory effects. In this pilot study we aimed to evaluate the feasibility of recruiting and randomizing children with intussusception, administer two different doses of Dexamethasone, record outcomes and aid in the power calculation for a formal randomized trial. Methods Patients diagnosed with intussusception and presenting with early symptoms were recruited and underwent up to 3 trials of pneumatic reduction if the first and second trials were unsuccessfull. Dexamethasone was given once before the first trial only. Patients were randomized to two groups: high and low-dose Dexamethasone. Results The study involved 68 patients from January 2023 to December 2023, 34 patients in group (A) and 34 in group (B). Across all trials, a total of 58 patients (85.3%) avoided surgery. The first trial had the best success rate of 77.9%, rates dropped signifiantly in trials 2 and 3. There was no statistical difference between groups A and B. Conclusion Recruitment, randomization and data collection were all feasible. Results seem to suggest a promising role for Dexamethasone in the primary reduction of intussusception which would translate in a decreased need for surgery. A randomized trial is recommended. Infant Bowel obstruction Intestinal obstruction Steroids Africa Figures Figure 1 Figure 2 INTRODUCTION Intussusception is a common cause of bowel obstruction in infants and young children, with an incidence of 74 per 10,000 worldwide in the first year of age [ 1 ]. It involves one segment invaginating the intestine into a distal segment, causing venous and lymphatic congestion, bowel edema, and ultimately ischemia and perforation [ 2 ]. Ileocolic intussusceptions are the most common site of pediatric intussusceptions. Primary (idiopathic) intussusceptions occur without a leading point due to hypertrophied Peyer's patches [ 3 ], while secondary intussusceptions have a defined leading point due to various causes [ 4 ]. The main causes of secondary intussusception are Meckel's diverticulum, bowel duplication cysts, polyps, ectopic pancreatic tissue, and other systemic diseases such as cystic fibrosis [ 5 ]. Most common symptoms are abdominal pain, vomiting, red currant jelly stool, pallor, and lethargy [ 6 ]. Diagnosis is based on the Brighton Collaboration intussusception working group criteria [ 7 ]. Treatment options can be non-surgical or surgical, with hydrostatic and pneumatic reduction methods being the most common non-surgical methods [ 8 – 10 ]. Air enemas are more effective than hydrostatic enemas [ 8 ]. Under fluoroscopy or ultrasonography, the colon is compressed while being monitored for air reflux into the terminal ileum and the disappearance of the mass at the ileocecal valve. Carbon dioxide can be used to replace air [ 11 ]. Surgery is in the form of open reduction of the mass via laparotomy, or laparoscopically-guided reduction. Occasionally bowel resection with stoma formation or anastomosis may be required [ 12 , 13 ]. Non-surgical treatment for intussusception is preferred due to lower morbidity and cost. If the first enema attempt is unsuccessful, it is recommended to perform a repeat enema in all cases unless there is a specific clinical justification not to do so. If the second enema is unsuccessful, it may be reasonable to attempt the procedure for a third time. The appropriate time interval between enemas varies between 30 minutes to several hours, depending on the situation. Delayed repeat enemas have significantly decreased the need for surgical intervention [ 10 ]. The duration of symptoms directly impacts the success rate of enema reduction, with longer symptoms beyond 24 hours reducing the likelihood of successful enema reduction. Delays in treatment are typically 48 hours, but some suggest as little as 24 or 72 hours [ 14 ]. Non-surgical reduction failures range from 46–94% and can be caused by factors such as duration of symptoms, emesis, bloody stool, and poor ultrasound prognosis signs [ 15 ]. Other factors such as age, dehydration, small bowel obstruction, and recurrent intussusception may also affect reduction success [ 10 ]. Cortisol has potent anti-inflammatory effects, can stabilize lysozyme membranes and decrease capillary permeability, which prevents the loss of plasma protein into tissues [ 16 ]. Dexamethasone, a synthetic glucocorticoid, has been used to treat asthma, allergic reactions, arthritis, and autoimmune diseases and acts through the blockade of two pathways of inflammation: vasodilation and immune cell migration [ 17 ]. It is administered over a range of doses ranging from 0.2mg/kg up to 1mg/kg. Given the underlying pathology in primary intussusception, it is postulated that using an anti-inflammatory agent will increase the chances of success of the non-surgical option. Thus, this pilot study aims to evaluate the feasibility of recruiting and randomizing children with intussusception, administer two different doses of Dexamethasone, record outcomes and aid in the power calculation for a formal randomized trial. Whereas Dexamethasone has been studied to reduce recurrence of intussusception [ 18 , 19 ], this study is exploring its use in the primary management stage. PATIENTS AND METHODS This is a pilot study on children diagnosed with intussusception admitted to a tertiary specialized pediatric hospital. Inclusion criteria comprised ages from 3 months to 3 years and an onset of symptoms less than 72 hours. Excluded were cases older than 3 years, delayed presentation beyond 72 hours or cases with signs of severe shock or suspected bowel ischemia. Methodology in details: Data were collected for all patients regarding demographics, symptoms and their duration, number of trials of pneumatic reduction, success of pneumatic reduction, need for laparotomy, side effects of steroids and incidence of complications. The cohort was further randomized to two different doses of Dexamethasone (see below) based on simple randomization without any restrictions. The mechanism to implement randomization was sequentially numbered containers. One of the authors (AAN) supervised enrollment and randomization. Dexamethasone: The dexamethasone was given via IV route one hour before the first trial of pneumatic reduction and was not repeated on any subsequent trials. After resuscitation and standard pre-operative labs, the cases were subdivided into two groups: Group A: dexamethasone at low dose 0.2 mg/kg; Group B: dexamethasone at high dose 0.5-1 mg/kg. Pneumatic reduction: In theatre, the child is placed in a supine position, near the edge of the operating table. A Foley catheter size 20Fr is then inserted in the anus. The catheter balloon is insufflated by 35ml air. Under fluoroscopic guidance, the catheter is then insufflated with air at a pressure of 80–120 mmHg. A maximum of 3 trials are allowed, with a one-hour interval between every trial. Successful reduction was defined as a release of the intussusception mass with a visible gush of air into the proximal bowel loops. In query cases, an ultrasound scan is used to confirm the success of the pneumatic reduction. Failure of pneumatic reduction resulted in a transfer to theatre for surgical management. Cases with a successful pneumatic reduction were allowed to feed ad lib and were discharged home the following day. Cases needing surgery followed a standard post-operative recovery pathway. Statistical methods: Collected data was entered and coded on Microsoft Excel 2016®, then analyzed using ICM® SPSS v25. Chi-squared or Fisher’s exact tests were used to compare qualitative variables between the 2 groups. The conformity of the distribution of the studied variables to the normal distribution was checked (Shapiro-Wilk test). Based on the results obtained, a decision was made to use the appropriate statistical test. Either independent-t test or Mann Whitney U test was used to detect statistically- significant difference between 2 groups for quantitative variables. Data are presented in figures. RESULTS From June 2022 to November 2023, 120 children presented to our center with intussusception. Of these, 68 matched the inclusion criteria. Randomization resulted in the following groups: group A, 34 patients receiving low dose dexamethasone and group B, 34 patients receiving high dose dexamethasone. The cohort was made up of 45 (66.2%) males and 23 (33.8%) females, with a male to female ratio 1.9 to 1. Thes ages had a mean of 0.9 (range 4 to 18 months). Weights averaged 8.7 kg (range 5 to 11 kg). (Table 1) . In study group A, 24 patients (70.6%) experienced symptoms such as abdominal pain, vomiting, colic, and abdominal distention. Additionally, 10 cases (29.4%) had red currant jelly stool. Similarly, in group B, 24 patients (70.6%) had the same early symptoms. Among them, 10 cases (29.4%) had red currant jelly stool. A mass was felt during examination in more than 75% of patients in each of the 2 study groups (Table 1) . Table (1) Demographic data and pre-operative clinical picture of intussusception cases Group A (low dose) (N = 34) Group B (high dose) (N = 34) Male: N (%) 21(61.8) 24(70.6) Female: N (%) 13(38.2) 10(29.4) Age: Mean (SD) 0.9(0.8) 1(0.6) Weight in Kg: Mean (SD) 8.7(2.1) 9.6(2.9) Presenting Symptoms N (%) Red currant jelly stool (late) 10(29.4) 10(29.4) Abdominal pain and colics (early) 22(64.7) 23(67.6) Abdominal distension (early) 2(5.9) 1(2.9) Mass felt during examination 25(75.8) 27(79.4) Out of all the reduction trials, a total of 58 (85.3%) patients achieved complete success. Fifty three patients (77.9%) patients were successfully reduced in the first trial, 4 (5.9%) in the second trial and 1 (1.5%) in the third trial. Pneumatic reduction success was 82.3% (28/34) in group A and 88.2% (30/34) in group B. ( Fig. 1 ) The first trial was successful in 26/34 (76.4%) in Group A, and in 27/34 (79.4%) in Group B. The second trial success rate was 2/34 (5.8%) in both groups A and B. None of the patients from group A and 1 (2.9%) from group B had a successful third trial. There was no statistically significant difference between the group taking low dose or high dose dexamethasone in any of the trials (P-value = 0.49). ( Fig. 2 ) A total of 10 (14.7%) cases needed surgical intervention after failed 3 trials of pneumatic reduction: 6 in group A and 4 in group B (Fig. 2 ). In group A, 3 (50%) patients underwent laparoscopic-assisted simple reduction, 1 (16.7%) laparoscopic to open simple reduction, 1 (16.7%) open simple reduction and 1 (16.7%) had resection anastomosis for gangrenous, non-viable bowel. In group B, 1 (25%) patient underwent-laparoscopic assisted simple reduction, 2 (50%) open simple reduction and 1 (25%) had resection anastomosis for gangrenous, non-viable bowel. DISCUSSION This study was conducted to explore the role of Dexamethasone in improving the success rate of pneumatic reduction in primary pediatric intussusception. There is an abundance of literature on the management of pediatric intussusception. The management is split between non-surgical and surgical. The former uses either air or hydrostatic enemas to reduce the mass. The latter is opted for in cases which have a failed non-surgical approach, in instances where there is a risk of bowel compromise, or in older children where the pathology may preclude an enema reduction [ 19 , 20 ]. A repeat enema is advised as it appears to improve the reduction success rate [ 21 ]. The rationale behind this study is that the use of steroids can reduce tissue edema and decrease the thickness of the bowel wall, thereby facilitating the process of pneumatic reduction in intussusception [ 17 ]. We added a further dimension to test the effect of low and high doses on the outcome. We also tested a simple randomization without any restrictions given the clear distinction between the two treatment groups. One of the authors (AAN) supervised the process which was simple and time-saving in a busy tertiary center. This method yielded the two trial groups. The male to female ratio was 1.9:1, in concordance with other published results [ 22 , 23 ]. In this study, most cases presented with early symptoms of abdominal pain, colic and vomiting. Symptoms of feeding intolerance, irritability, or lethargy were less frequently reported, in keeping with published literature [ 24 ]. In our surgical center, pneumatic reduction is our intervention of choice since it gained popularity in the 1980s as a safe, fast, and effective treatment method [ 25 ]. Air enemas have proven to be more effective than hydrostatic enemas [ 8 ]. In 2015, an extensive meta-analysis showed that under fluoroscopic guidance, air has a higher success rate than liquid enema (air 82.7%, liquid 69.6%). This is attributed to the inherent air compressibility that allows it to sweep between the intussuscipiens and the intussusceptum, leading to easier and faster reduction [ 8 ]. In 2020, a systematic review and meta-analysis confirmed this (air 81%, liquid 67%) and reported an even higher success rate of US-guided air versus liquid enema (air 93%, liquid 82%) [ 26 ]. In our study, pneumatic reduction has shown a success rate of 85.2% in a total of 3 attempts with a 60-minute time interval between attempts. This finding is on the higher spectrum of success rates reported in the literature, which range between 53.2% and 62.5% [ 20 ]. The success rate is inversely related to the number of attempts and there is a suggestion that there may be little to no benefit after a 4th attempt [ 20 ]. There are no studies that specifically examine the optimal timing between reduction attempts. The highest success rate of repeated enemas (82.3% =19/23 attempts) was reported in a study using a 45–60-minute interval between enemas [ 27 ]. Dexamethasone was chosen as it is a potent, rapid, and long-acting steroid. It acts through the blockade of two pathways of inflammation: vasodilation and immune cell migration. It crosses the host cell membrane and binds to glucocorticoid receptors present in the cell cytoplasm, which initiates a series of immune cell responses that lead to pro-inflammatory suppression cytokines IL-1, IL-2, IL-6, IL-8, TNF, and IFN-γ through a decrease in gene transcription [ 19 ]. Dexamethasone has a low therapeutic dose and can be used safely with less risks of common steroid induced adverse effects [ 28 ]. Dexamethasone has been therefore advocated to reduce the lymphoid hyperplasia often associated with intussusception, and subsequently reported (albeit low quality evidence) as useful in reducing recurrence rates [ 19 , 28 ]. To the best of our knowledge its use has not been scrutinized for its effect on enema reduction rates. In the current study, dexamethasone was given intravenously with resuscitation 1 hour before the first pneumatic reduction trial. Of interest, the success rate of 2nd and 3rd pneumatic reduction trials dropped dramatically compared to the 1st trial. We would like to highlight that the dexamethasone was not administered repeatedly with each trial rather given only once during the initial resuscitation. Whether this reflects an inherent difficulty in intussusception mass reduction or a need for repeated dosage remains to be determined. It appears that low and high dose dexamethasone have the same successful effect on reduction suggesting that a low dose may be sufficient. To the best of our knowledge this is the first report looking into dose-effect in the literature. No complications from the use of hydrocortisone were encountered during the study in the form of hypertension or electrolyte imbalance as all cases were monitored on an intermediate care unit from the moment of admission until they improved and started oral feeding. A complete blood picture, coagulation profile and electrolytes were also drawn before any intervention, and no difference was noticed between study groups in the post intervention period. Cases which have a failed enema reduction will require some form of surgical intervention. Currently there is no strong evidence to identify superiority of laparoscopic vs. open surgery regarding recurrence rates or complications [ 13 , 29 ]. However, an initial laparoscopic approach should be considered given the known benefits of minimally invasive surgery such as smaller scars, lesser pain and shorter length of stay [ 30 , 31 ]. Cases that needed laparotomy for simple reduction or resection anastomosis in both groups were followed up closely. Children who had received a pre-enema dose of dexamethasone did not develop any complications such as delayed wound healing. CONCLUSION This pilot study set out to evaluate the feasibility of recruiting and randomizing children with intussusception, administer two different doses of Dexamethasone, record outcomes and aid in the power calculation for a formal randomized trial. We encountered a high flow of patients in our tertiary center and had no issues with the sequential numbering for randomization. Blinding and dosing of Dexamethasone was straight-forward. A structured data-collection sheet is now available to reflect study-relevant data such as symptoms and their duration. Although the cohort in this study is small (68 cases) it has been suggested that anywhere between 12 and 50 cases are representative for similar pilots [ 32 ]. The results are clearly encouraging enough to set up a formal RCT on this topic. Declarations The authors declare no conflict of interest. No funding was received for this study. Ethics approval granted for this study. CONFLICT OF INTEREST: Authors declare no conflict of interest is present. ETHICAL CONIDERATION: Ethical approval was obtained from the institutional review board at the armed forces college of medicine. A written informed consent was obtained after proper orientation for study subjects regarding the objectives of the study. Participation was voluntary, only those who agreed were included and the participant may discontinue participation at any time. Strict confidentiality and privacy were maintained throughout the process of data collection, entry and analysis as declaration of Helsinki. FUNDING: None. Authors’ contribution: AS, MT: instigated study, data interpretation, literature search, drafting manuscript, tables and figures. 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Epub 2018 Jul 23 Kelley-Quon LI, Arthur LG, Williams RF, Goldin AB, Peter SD, Beres AL, Hu YY, Renaud EJ, Ricca R, Slidell MB, Taylor A (2021) Management of intussusception in children: a systematic review. J Pediatr Surg 56(3):587–596 Schukfeh N, Kuebler JF, Dingemann J, Ure BM (2020) Thirty Years of Minimally Invasive Surgery in Children: Analysis of Meta-Analyses. Eur J Pediatr Surg 30(5):420–428. 10.1055/s-0039-1687901 Epub 2019 Apr 23. PMID: 31013537 Corley A, Marsh N, Keogh S (2024) Methodological progress note: Pilot randomized controlled trials. J Hosp Med 19(9):821–826. 10.1002/jhm.13376 Epub 2024 Apr 24. PMID: 38655805 Additional Declarations No competing interests reported. Cite Share Download PDF Status: Posted Version 1 posted You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. 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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-6184394","acceptedTermsAndConditions":true,"allowDirectSubmit":true,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":429477805,"identity":"e6cb4cda-367d-4770-8075-ef5f1e36535e","order_by":0,"name":"Mahmoud Tarek","email":"","orcid":"","institution":"Cairo University Specialized Pediatric Hospital","correspondingAuthor":false,"prefix":"","firstName":"Mahmoud","middleName":"","lastName":"Tarek","suffix":""},{"id":429477809,"identity":"c4c1d057-426c-4a77-b082-68fc9cd2ba59","order_by":1,"name":"Ahmed Abdelnabi","email":"","orcid":"","institution":"Armed Forces College of Medicine (AFCM)","correspondingAuthor":false,"prefix":"","firstName":"Ahmed","middleName":"","lastName":"Abdelnabi","suffix":""},{"id":429477810,"identity":"b51a98bb-a6cb-4f7e-9e39-adc79b290f03","order_by":2,"name":"Gamal Eltagy","email":"","orcid":"","institution":"Cairo University Specialized Pediatric Hospital","correspondingAuthor":false,"prefix":"","firstName":"Gamal","middleName":"","lastName":"Eltagy","suffix":""},{"id":429477811,"identity":"2fad05a2-7afa-4213-946b-945d579a7e12","order_by":3,"name":"Aly Shalaby","email":"data:image/png;base64,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","orcid":"","institution":"Cairo University Specialized Pediatric Hospital","correspondingAuthor":true,"prefix":"","firstName":"Aly","middleName":"","lastName":"Shalaby","suffix":""}],"badges":[],"createdAt":"2025-03-08 13:38:22","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-6184394/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-6184394/v1","draftVersion":[],"editorialEvents":[],"editorialNote":"","failedWorkflow":false,"files":[{"id":78735023,"identity":"8e472463-2d7f-4ae0-9d0a-76693dd091ce","added_by":"auto","created_at":"2025-03-18 08:07:18","extension":"jpeg","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":150598,"visible":true,"origin":"","legend":"\u003cp\u003eSuccess rates of pneumatic reduction across all trial attempts\u003c/p\u003e","description":"","filename":"floatimage16.jpeg","url":"https://assets-eu.researchsquare.com/files/rs-6184394/v1/a361416f721eda04a105aaab.jpeg"},{"id":78734325,"identity":"4d27315e-b985-4e0c-80bb-96de98518bed","added_by":"auto","created_at":"2025-03-18 07:59:18","extension":"jpeg","order_by":2,"title":"Figure 2","display":"","copyAsset":false,"role":"figure","size":135165,"visible":true,"origin":"","legend":"\u003cp\u003eDetails of Dexamethasone groups A and B\u003c/p\u003e","description":"","filename":"floatimage26.jpeg","url":"https://assets-eu.researchsquare.com/files/rs-6184394/v1/cf2eef6f402604bcee1578cc.jpeg"},{"id":79566845,"identity":"04e1f174-3a42-4a73-a6f1-6f90d000ea1a","added_by":"auto","created_at":"2025-03-31 09:38:56","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":819412,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-6184394/v1/5e932a96-e6fa-41fc-b84b-1d2da5145c8e.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"Preoperative Dexamethasone as an adjunct to increase the success rate of pneumatic reduction for primary idiopathic intussusception in children: A pilot Study","fulltext":[{"header":"INTRODUCTION","content":"\u003cp\u003eIntussusception is a common cause of bowel obstruction in infants and young children, with an incidence of 74 per 10,000 worldwide in the first year of age [\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e]. It involves one segment invaginating the intestine into a distal segment, causing venous and lymphatic congestion, bowel edema, and ultimately ischemia and perforation [\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e]. Ileocolic intussusceptions are the most common site of pediatric intussusceptions. Primary (idiopathic) intussusceptions occur without a leading point due to hypertrophied Peyer's patches [\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e], while secondary intussusceptions have a defined leading point due to various causes [\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e]. The main causes of secondary intussusception are Meckel's diverticulum, bowel duplication cysts, polyps, ectopic pancreatic tissue, and other systemic diseases such as cystic fibrosis [\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eMost common symptoms are abdominal pain, vomiting, red currant jelly stool, pallor, and lethargy [\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e]. Diagnosis is based on the Brighton Collaboration intussusception working group criteria [\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eTreatment options can be non-surgical or surgical, with hydrostatic and pneumatic reduction methods being the most common non-surgical methods [\u003cspan additionalcitationids=\"CR9\" citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e]. Air enemas are more effective than hydrostatic enemas [\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e]. Under fluoroscopy or ultrasonography, the colon is compressed while being monitored for air reflux into the terminal ileum and the disappearance of the mass at the ileocecal valve. Carbon dioxide can be used to replace air [\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e]. Surgery is in the form of open reduction of the mass via laparotomy, or laparoscopically-guided reduction. Occasionally bowel resection with stoma formation or anastomosis may be required [\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e, \u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eNon-surgical treatment for intussusception is preferred due to lower morbidity and cost. If the first enema attempt is unsuccessful, it is recommended to perform a repeat enema in all cases unless there is a specific clinical justification not to do so. If the second enema is unsuccessful, it may be reasonable to attempt the procedure for a third time. The appropriate time interval between enemas varies between 30 minutes to several hours, depending on the situation. Delayed repeat enemas have significantly decreased the need for surgical intervention [\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eThe duration of symptoms directly impacts the success rate of enema reduction, with longer symptoms beyond 24 hours reducing the likelihood of successful enema reduction. Delays in treatment are typically 48 hours, but some suggest as little as 24 or 72 hours [\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e]. Non-surgical reduction failures range from 46\u0026ndash;94% and can be caused by factors such as duration of symptoms, emesis, bloody stool, and poor ultrasound prognosis signs [\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e]. Other factors such as age, dehydration, small bowel obstruction, and recurrent intussusception may also affect reduction success [\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eCortisol has potent anti-inflammatory effects, can stabilize lysozyme membranes and decrease capillary permeability, which prevents the loss of plasma protein into tissues [\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e]. Dexamethasone, a synthetic glucocorticoid, has been used to treat asthma, allergic reactions, arthritis, and autoimmune diseases and acts through the blockade of two pathways of inflammation: vasodilation and immune cell migration [\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e]. It is administered over a range of doses ranging from 0.2mg/kg up to 1mg/kg.\u003c/p\u003e \u003cp\u003eGiven the underlying pathology in primary intussusception, it is postulated that using an anti-inflammatory agent will increase the chances of success of the non-surgical option. Thus, this pilot study aims to evaluate the feasibility of recruiting and randomizing children with intussusception, administer two different doses of Dexamethasone, record outcomes and aid in the power calculation for a formal randomized trial.\u003c/p\u003e \u003cp\u003eWhereas Dexamethasone has been studied to reduce recurrence of intussusception [\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e, \u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e], this study is exploring its use in the primary management stage.\u003c/p\u003e"},{"header":"PATIENTS AND METHODS","content":"\u003cp\u003eThis is a pilot study on children diagnosed with intussusception admitted to a tertiary specialized pediatric hospital. Inclusion criteria comprised ages from 3 months to 3 years and an onset of symptoms less than 72 hours. Excluded were cases older than 3 years, delayed presentation beyond 72 hours or cases with signs of severe shock or suspected bowel ischemia.\u003c/p\u003e \u003cdiv id=\"Sec3\" class=\"Section2\"\u003e \u003ch2\u003eMethodology in details:\u003c/h2\u003e \u003cp\u003eData were collected for all patients regarding demographics, symptoms and their duration, number of trials of pneumatic reduction, success of pneumatic reduction, need for laparotomy, side effects of steroids and incidence of complications.\u003c/p\u003e \u003cp\u003eThe cohort was further randomized to two different doses of Dexamethasone (see below) based on simple randomization without any restrictions. The mechanism to implement randomization was sequentially numbered containers. One of the authors (AAN) supervised enrollment and randomization.\u003c/p\u003e \u003c/div\u003e\n\u003ch3\u003eDexamethasone:\u003c/h3\u003e\n\u003cp\u003eThe dexamethasone was given via IV route one hour before the first trial of pneumatic reduction and was not repeated on any subsequent trials. After resuscitation and standard pre-operative labs, the cases were subdivided into two groups: Group A: dexamethasone at low dose 0.2 mg/kg;\u003c/p\u003e \u003cp\u003eGroup B: dexamethasone at high dose 0.5-1 mg/kg.\u003c/p\u003e\n\u003ch3\u003ePneumatic reduction:\u003c/h3\u003e\n\u003cp\u003eIn theatre, the child is placed in a supine position, near the edge of the operating table. A Foley catheter size 20Fr is then inserted in the anus. The catheter balloon is insufflated by 35ml air. Under fluoroscopic guidance, the catheter is then insufflated with air at a pressure of 80\u0026ndash;120 mmHg. A maximum of 3 trials are allowed, with a one-hour interval between every trial. Successful reduction was defined as a release of the intussusception mass with a visible gush of air into the proximal bowel loops. In query cases, an ultrasound scan is used to confirm the success of the pneumatic reduction. Failure of pneumatic reduction resulted in a transfer to theatre for surgical management.\u003c/p\u003e \u003cp\u003eCases with a successful pneumatic reduction were allowed to feed ad lib and were discharged home the following day. Cases needing surgery followed a standard post-operative recovery pathway.\u003c/p\u003e\n\u003ch3\u003eStatistical methods:\u003c/h3\u003e\n\u003cp\u003eCollected data was entered and coded on Microsoft Excel 2016\u0026reg;, then analyzed using ICM\u0026reg; SPSS v25. Chi-squared or Fisher\u0026rsquo;s exact tests were used to compare qualitative variables between the 2 groups. The conformity of the distribution of the studied variables to the normal distribution was checked (Shapiro-Wilk test). Based on the results obtained, a decision was made to use the appropriate statistical test. Either independent-t test or Mann Whitney U test was used to detect statistically- significant difference between 2 groups for quantitative variables. Data are presented in figures.\u003c/p\u003e"},{"header":"RESULTS","content":"\u003cp\u003eFrom June 2022 to November 2023, 120 children presented to our center with intussusception. Of these, 68 matched the inclusion criteria. Randomization resulted in the following groups: group A, 34 patients receiving low dose dexamethasone and group B, 34 patients receiving high dose dexamethasone.\u003c/p\u003e \u003cp\u003eThe cohort was made up of 45 (66.2%) males and 23 (33.8%) females, with a male to female ratio 1.9 to 1. Thes ages had a mean of 0.9 (range 4 to 18 months). Weights averaged 8.7 kg (range 5 to 11 kg). \u003cb\u003e(Table\u0026nbsp;1)\u003c/b\u003e.\u003c/p\u003e \u003cp\u003eIn study group A, 24 patients (70.6%) experienced symptoms such as abdominal pain, vomiting, colic, and abdominal distention. Additionally, 10 cases (29.4%) had red currant jelly stool. Similarly, in group B, 24 patients (70.6%) had the same early symptoms. Among them, 10 cases (29.4%) had red currant jelly stool. A mass was felt during examination in more than 75% of patients in each of the 2 study groups \u003cb\u003e(Table\u0026nbsp;1)\u003c/b\u003e.\u003c/p\u003e \u003cp\u003e \u003cspan type=\"BoldUnderline\" class=\"BoldUnderline\" name=\"Emphasis\"\u003eTable\u0026nbsp;(1)\u003c/span\u003e Demographic data and pre-operative clinical picture of intussusception cases\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"No\" id=\"Taba\" border=\"1\"\u003e \u003ccolgroup cols=\"4\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colspan=\"2\" nameend=\"c2\" namest=\"c1\"\u003e\u0026nbsp;\u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eGroup A \u003c/p\u003e \u003cp\u003e(low dose)\u003c/p\u003e \u003cp\u003e(N\u0026thinsp;=\u0026thinsp;34)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003eGroup B \u003c/p\u003e \u003cp\u003e(high dose)\u003c/p\u003e \u003cp\u003e(N\u0026thinsp;=\u0026thinsp;34)\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c2\" namest=\"c1\"\u003e \u003cp\u003e\u003cb\u003eMale: N (%)\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e21(61.8)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e24(70.6)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c2\" namest=\"c1\"\u003e \u003cp\u003e\u003cb\u003eFemale: N (%)\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e13(38.2)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e10(29.4)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c2\" namest=\"c1\"\u003e \u003cp\u003e\u003cb\u003eAge: Mean (SD)\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0.9(0.8)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e1(0.6)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c2\" namest=\"c1\"\u003e \u003cp\u003e\u003cb\u003eWeight in Kg: Mean (SD)\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e8.7(2.1)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e9.6(2.9)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"3\" rowspan=\"4\"\u003e \u003cp\u003e\u003cb\u003ePresenting Symptoms\u003c/b\u003e\u003c/p\u003e \u003cp\u003e\u003cb\u003eN (%)\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u003cb\u003eRed currant jelly stool (late)\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e10(29.4)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e10(29.4)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u003cb\u003eAbdominal pain and colics (early)\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e22(64.7)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e23(67.6)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u003cb\u003eAbdominal distension (early)\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e2(5.9)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e1(2.9)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u003cb\u003eMass felt during examination\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e25(75.8)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e27(79.4)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003eOut of all the reduction trials, a total of 58 (85.3%) patients achieved complete success. Fifty three patients (77.9%) patients were successfully reduced in the first trial, 4 (5.9%) in the second trial and 1 (1.5%) in the third trial. Pneumatic reduction success was 82.3% (28/34) in group A and 88.2% (30/34) in group B. \u003cb\u003e(\u003c/b\u003eFig.\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003e\u003cb\u003e)\u003c/b\u003e\u003c/p\u003e \u003cp\u003eThe first trial was successful in 26/34 (76.4%) in Group A, and in 27/34 (79.4%) in Group B. The second trial success rate was 2/34 (5.8%) in both groups A and B. None of the patients from group A and 1 (2.9%) from group B had a successful third trial. There was no statistically significant difference between the group taking low dose or high dose dexamethasone in any of the trials (P-value\u0026thinsp;=\u0026thinsp;0.49). \u003cb\u003e(\u003c/b\u003eFig.\u0026nbsp;\u003cspan refid=\"Fig2\" class=\"InternalRef\"\u003e2\u003c/span\u003e\u003cb\u003e)\u003c/b\u003e\u003c/p\u003e \u003cp\u003eA total of 10 (14.7%) cases needed surgical intervention after failed 3 trials of pneumatic reduction: 6 in group A and 4 in group B (Fig.\u0026nbsp;\u003cspan refid=\"Fig2\" class=\"InternalRef\"\u003e2\u003c/span\u003e). In group A, 3 (50%) patients underwent laparoscopic-assisted simple reduction, 1 (16.7%) laparoscopic to open simple reduction, 1 (16.7%) open simple reduction and 1 (16.7%) had resection anastomosis for gangrenous, non-viable bowel. In group B, 1 (25%) patient underwent-laparoscopic assisted simple reduction, 2 (50%) open simple reduction and 1 (25%) had resection anastomosis for gangrenous, non-viable bowel.\u003c/p\u003e"},{"header":"DISCUSSION","content":"\u003cp\u003eThis study was conducted to explore the role of Dexamethasone in improving the success rate of pneumatic reduction in primary pediatric intussusception.\u003c/p\u003e \u003cp\u003eThere is an abundance of literature on the management of pediatric intussusception. The management is split between non-surgical and surgical. The former uses either air or hydrostatic enemas to reduce the mass. The latter is opted for in cases which have a failed non-surgical approach, in instances where there is a risk of bowel compromise, or in older children where the pathology may preclude an enema reduction [\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e, \u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e]. A repeat enema is advised as it appears to improve the reduction success rate [\u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eThe rationale behind this study is that the use of steroids can reduce tissue edema and decrease the thickness of the bowel wall, thereby facilitating the process of pneumatic reduction in intussusception [\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e]. We added a further dimension to test the effect of low and high doses on the outcome.\u003c/p\u003e \u003cp\u003eWe also tested a simple randomization without any restrictions given the clear distinction between the two treatment groups. One of the authors (AAN) supervised the process which was simple and time-saving in a busy tertiary center. This method yielded the two trial groups. The male to female ratio was 1.9:1, in concordance with other published results [\u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e, \u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eIn this study, most cases presented with early symptoms of abdominal pain, colic and vomiting. Symptoms of feeding intolerance, irritability, or lethargy were less frequently reported, in keeping with published literature [\u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eIn our surgical center, pneumatic reduction is our intervention of choice since it gained popularity in the 1980s as a safe, fast, and effective treatment method [\u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e]. Air enemas have proven to be more effective than hydrostatic enemas [\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e]. In 2015, an extensive meta-analysis showed that under fluoroscopic guidance, air has a higher success rate than liquid enema (air 82.7%, liquid 69.6%). This is attributed to the inherent air compressibility that allows it to sweep between the intussuscipiens and the intussusceptum, leading to easier and faster reduction [\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e]. In 2020, a systematic review and meta-analysis confirmed this (air 81%, liquid 67%) and reported an even higher success rate of US-guided air versus liquid enema (air 93%, liquid 82%) [\u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eIn our study, pneumatic reduction has shown a success rate of 85.2% in a total of 3 attempts with a 60-minute time interval between attempts. This finding is on the higher spectrum of success rates reported in the literature, which range between 53.2% and 62.5% [\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e]. The success rate is inversely related to the number of attempts and there is a suggestion that there may be little to no benefit after a 4th attempt [\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e]. There are no studies that specifically examine the optimal timing between reduction attempts. The highest success rate of repeated enemas (82.3% =19/23 attempts) was reported in a study using a 45\u0026ndash;60-minute interval between enemas [\u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e27\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eDexamethasone was chosen as it is a potent, rapid, and long-acting steroid. It acts through the blockade of two pathways of inflammation: vasodilation and immune cell migration. It crosses the host cell membrane and binds to glucocorticoid receptors present in the cell cytoplasm, which initiates a series of immune cell responses that lead to pro-inflammatory suppression cytokines IL-1, IL-2, IL-6, IL-8, TNF, and IFN-γ through a decrease in gene transcription [\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e]. Dexamethasone has a low therapeutic dose and can be used safely with less risks of common steroid induced adverse effects [\u003cspan citationid=\"CR28\" class=\"CitationRef\"\u003e28\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eDexamethasone has been therefore advocated to reduce the lymphoid hyperplasia often associated with intussusception, and subsequently reported (albeit low quality evidence) as useful in reducing recurrence rates [\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e, \u003cspan citationid=\"CR28\" class=\"CitationRef\"\u003e28\u003c/span\u003e]. To the best of our knowledge its use has not been scrutinized for its effect on enema reduction rates. In the current study, dexamethasone was given intravenously with resuscitation 1 hour before the first pneumatic reduction trial.\u003c/p\u003e \u003cp\u003eOf interest, the success rate of 2nd and 3rd pneumatic reduction trials dropped dramatically compared to the 1st trial. We would like to highlight that the dexamethasone was not administered repeatedly with each trial rather given only once during the initial resuscitation. Whether this reflects an inherent difficulty in intussusception mass reduction or a need for repeated dosage remains to be determined.\u003c/p\u003e \u003cp\u003eIt appears that low and high dose dexamethasone have the same successful effect on reduction suggesting that a low dose may be sufficient. To the best of our knowledge this is the first report looking into dose-effect in the literature.\u003c/p\u003e \u003cp\u003e No complications from the use of hydrocortisone were encountered during the study in the form of hypertension or electrolyte imbalance as all cases were monitored on an intermediate care unit from the moment of admission until they improved and started oral feeding. A complete blood picture, coagulation profile and electrolytes were also drawn before any intervention, and no difference was noticed between study groups in the post intervention period.\u003c/p\u003e \u003cp\u003eCases which have a failed enema reduction will require some form of surgical intervention. Currently there is no strong evidence to identify superiority of laparoscopic vs. open surgery regarding recurrence rates or complications [\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e, \u003cspan citationid=\"CR29\" class=\"CitationRef\"\u003e29\u003c/span\u003e]. However, an initial laparoscopic approach should be considered given the known benefits of minimally invasive surgery such as smaller scars, lesser pain and shorter length of stay [\u003cspan citationid=\"CR30\" class=\"CitationRef\"\u003e30\u003c/span\u003e, \u003cspan citationid=\"CR31\" class=\"CitationRef\"\u003e31\u003c/span\u003e]. Cases that needed laparotomy for simple reduction or resection anastomosis in both groups were followed up closely. Children who had received a pre-enema dose of dexamethasone did not develop any complications such as delayed wound healing.\u003c/p\u003e"},{"header":"CONCLUSION","content":"\u003cp\u003eThis pilot study set out to evaluate the feasibility of recruiting and randomizing children with intussusception, administer two different doses of Dexamethasone, record outcomes and aid in the power calculation for a formal randomized trial. We encountered a high flow of patients in our tertiary center and had no issues with the sequential numbering for randomization. Blinding and dosing of Dexamethasone was straight-forward. A structured data-collection sheet is now available to reflect study-relevant data such as symptoms and their duration. Although the cohort in this study is small (68 cases) it has been suggested that anywhere between 12 and 50 cases are representative for similar pilots [\u003cspan citationid=\"CR32\" class=\"CitationRef\"\u003e32\u003c/span\u003e]. The results are clearly encouraging enough to set up a formal RCT on this topic.\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003eThe authors declare no conflict of interest.\u003c/p\u003e\n\u003cp\u003eNo funding was received for this study.\u003c/p\u003e\n\u003cp\u003eEthics approval granted for this study. \u003cspan lang=\"\"\u003e\u0026nbsp;\u0026nbsp;\u003c/span\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u003cu\u003eCONFLICT OF INTEREST:\u0026nbsp;\u003c/u\u003e\u003c/strong\u003eAuthors declare no conflict of interest is present.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u003cu\u003eETHICAL CONIDERATION:\u0026nbsp;\u003c/u\u003e\u003c/strong\u003eEthical approval was obtained from the institutional review board at the armed forces college of medicine. A written informed consent was obtained after proper orientation for study subjects regarding the objectives of the study. Participation was voluntary, only those who agreed were included and the participant may discontinue participation at any time. Strict confidentiality and privacy were maintained throughout the process of data collection, entry and analysis as declaration of Helsinki.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u003cu\u003eFUNDING:\u003c/u\u003e\u003c/strong\u003e None.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAuthors\u0026rsquo; contribution:\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eAS, MT: instigated study, data interpretation, literature search, drafting manuscript, tables and figures.\u003c/p\u003e\n\u003cp\u003eAA: data collection, data interpretation, drafting manuscript.\u003c/p\u003e\n\u003cp\u003eGE: drafting and critical revision of manuscript.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\u003cli\u003e\u003cspan\u003eGlover-Addy H, Ansong D, Enweronu-Laryea C, Tate JE, Amponsa-Achiano K, Sarkodie B, Mwenda JM, Diamenu S, Owusu SK, Nimako B, Mensah NK (2021) Epidemiology of intussusception in infants less than one year of age in Ghana, 2012\u0026ndash;2016. 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Dig Dis Sci 51(6):1047\u0026ndash;1048\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eDowson HM, Bong JJ, Lovell DP, Worthington TR, Karanjia ND, Rockall TA (2008) Reduced adhesion formation following laparoscopic versus open colorectal surgery. J Br Surg 95(7):909\u0026ndash;914\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eDeng S, Liu Z, Yang J, Zhang L, Shou T, Zhu J, He Y, Ma R, Li N, Xu G, Zhan S (2023) Diagnostic validation and development of an algorithm for identification of intussusception in children using electronic health records of Ningbo city in China. Expert Rev Vaccines 22(1):307\u0026ndash;314\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eSadigh G, Zou KH, Razavi SA, Khan R, Applegate KE (2015) Meta-analysis of air versus liquid enema for intussusception reduction in children. Am J Roentgenol 205(5):W542\u0026ndash;W549\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eDom\u0026iacute;nguez-Carral J, Puertas-Mart\u0026iacute;n V, Carreras-S\u0026aacute;ez I, Mara\u0026ntilde;a-P\u0026eacute;rez AI, Escobar-Delgado T, Garc\u0026iacute;a-Pe\u0026ntilde;as JJ Neurological symptoms in children with intussusception. InAnales de Pediatria (Barcelona, Spain: (2003) 2013 Oct 6 (Vol. 80, No. 5, pp. 293\u0026ndash;298)\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eRobson N, Beasley S (2014) Role of plain abdominal radiography in the initial investigation of suspected intussusception. J Paediatr Child Health 50(4):251\u0026ndash;252\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eBanapour P, Sydorak RM, Shaul D (2015) Surgical approach to intussusception in older children: influence of lead points. 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Therapeutics and Clinical Risk Management. 9:1231\u0026ndash;1237\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eLiu D, Ahmet A, Ward L, Krishnamoorthy P, Mandelcorn ED, Leigh R, Brown JP, Cohen A, Kim H (2013) A practical guide to the monitoring and management of the complications of systemic corticosteroid therapy. Allergy asthma Clin Immunol 9:1\u0026ndash;25\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eEsposito F, Ambrosio C, De Fronzo S, Panico MR, D\u0026rsquo;Aprano M, Giugliano AM, Noviello D, Oresta P (2015) Fluoroscopy-guided hydrostatic reduction of intussusception in infancy: role of pharmacological premedication. Radiol Med 120:549\u0026ndash;556\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eEfrati Y, Klin B, Kozer E, Abu-Kishk I (2017) The role of dexamethasone in decreasing early recurrence of acute intussusception in children: A retrospective study. J Pediatr Surg 52(7):1141\u0026ndash;1143\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eGluckman S, Karpelowsky J, Webster AC, McGee RG (2017) Management for intussusception in children. Cochrane Database Syst Rev 6(6):CD006476. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1002/14651858.CD006476.pub3\u003c/span\u003e\u003cspan address=\"10.1002/14651858.CD006476.pub3\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003ePMID: 28567798; PMCID: PMC6481850\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eKelley-Quon LI, Arthur LG, Williams RF, Goldin AB, St Peter SD, Beres AL, Hu YY, Renaud EJ, Ricca R, Slidell MB, Taylor A, Smith CA, Miniati D, Sola JE, Valusek P, Berman L, Raval MV, Gosain A, Dellinger MB, S\u0026oslash;mme S, Downard CD, McAteer JP, Kawaguchi A (2021) Management of intussusception in children: A systematic review. J Pediatr Surg 56(3):587\u0026ndash;596 Epub 2020 Oct 6. PMID: 33158508; PMCID: PMC7920908\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eIto Y, Kusakawa I, Murata Y, Ukiyama E, Kawase H, Kamagata S, Ueno S, Osamura T, Kubo M, Yoshida M (2012) Japanese guidelines for the management of intussusception in children, 2011. Pediatr Int 54(6):948\u0026ndash;958. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1111/j.1442-200X.2012.03622_1.x\u003c/span\u003e\u003cspan address=\"10.1111/j.1442-200X.2012.03622_1.x\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003eEpub 2012 Jul 2. PMID: 22748165\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eMehendale S, Kumar CG, Venkatasubramanian S, Prasanna T (2016) Intussusception in children aged less than five years. 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Practical Imaging Strategies for Intussusception in Children,2020 April: 215 (6): 1449\u0026ndash;1463 \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.2214/AJR.19.22445\u003c/span\u003e\u003cspan address=\"10.2214/AJR.19.22445\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eGorenstein A, Raucher A, Serour F, Witzling M, Katz R (1998) Intussusception in children: reduction with repeated, delayed air enema. Radiology 206(3):721\u0026ndash;724\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eRaja AS, Gajanthody S et al (2023) Role of Dexamethasone as an adjuvant in the treatment of intussusception: A prospective study. Med Res Archives [online] 11(4). \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.18103/mra. v11i4.3723)\u003c/span\u003e\u003cspan address=\"10.18103/mra. v11i4.3723)\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eLaparoendosc Adv Surg Tech J A (2018) The Laparoscopic Versus Open Approach for Reduction of Intussusception in Infants and Children: An Updated Institutional Experience Leo Andrew Benedict 1, Derrick Ha 2, Joseph Sujka 1, Justin A Sobrino 1, Tolulope A Oyetunji 1, Shawn D St Peter 1. 28(11):1412\u0026ndash;1415 Jason D Fraser 1. 10.1089/lap.2018.0268. Epub 2018 Jul 23\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eKelley-Quon LI, Arthur LG, Williams RF, Goldin AB, Peter SD, Beres AL, Hu YY, Renaud EJ, Ricca R, Slidell MB, Taylor A (2021) Management of intussusception in children: a systematic review. J Pediatr Surg 56(3):587\u0026ndash;596\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eSchukfeh N, Kuebler JF, Dingemann J, Ure BM (2020) Thirty Years of Minimally Invasive Surgery in Children: Analysis of Meta-Analyses. Eur J Pediatr Surg 30(5):420\u0026ndash;428. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1055/s-0039-1687901\u003c/span\u003e\u003cspan address=\"10.1055/s-0039-1687901\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003eEpub 2019 Apr 23. PMID: 31013537\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eCorley A, Marsh N, Keogh S (2024) Methodological progress note: Pilot randomized controlled trials. J Hosp Med 19(9):821\u0026ndash;826. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1002/jhm.13376\u003c/span\u003e\u003cspan address=\"10.1002/jhm.13376\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003eEpub 2024 Apr 24. PMID: 38655805\u003c/span\u003e\u003c/li\u003e\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":true,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true},"keywords":"Infant, Bowel obstruction, Intestinal obstruction, Steroids, Africa","lastPublishedDoi":"10.21203/rs.3.rs-6184394/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-6184394/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003ch2\u003ePurpose\u003c/h2\u003e \u003cp\u003eIntussusception is a common cause of intestinal obstruction in children. Cases presenting early can be managed non-surgically by hydrostatic or pneumatic reduction. Dexamethasone is a long rapidly acting corticosteroid with anti-inflammatory effects. In this pilot study we aimed to evaluate the feasibility of recruiting and randomizing children with intussusception, administer two different doses of Dexamethasone, record outcomes and aid in the power calculation for a formal randomized trial.\u003c/p\u003e\u003ch2\u003eMethods\u003c/h2\u003e \u003cp\u003ePatients diagnosed with intussusception and presenting with early symptoms were recruited and underwent up to 3 trials of pneumatic reduction if the first and second trials were unsuccessfull. Dexamethasone was given once before the first trial only. Patients were randomized to two groups: high and low-dose Dexamethasone.\u003c/p\u003e\u003ch2\u003eResults\u003c/h2\u003e \u003cp\u003eThe study involved 68 patients from January 2023 to December 2023, 34 patients in group (A) and 34 in group (B). Across all trials, a total of 58 patients (85.3%) avoided surgery. The first trial had the best success rate of 77.9%, rates dropped signifiantly in trials 2 and 3. There was no statistical difference between groups A and B.\u003c/p\u003e\u003ch2\u003eConclusion\u003c/h2\u003e \u003cp\u003eRecruitment, randomization and data collection were all feasible. Results seem to suggest a promising role for Dexamethasone in the primary reduction of intussusception which would translate in a decreased need for surgery. A randomized trial is recommended.\u003c/p\u003e","manuscriptTitle":"Preoperative Dexamethasone as an adjunct to increase the success rate of pneumatic reduction for primary idiopathic intussusception in children: A pilot Study","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2025-03-18 07:51:13","doi":"10.21203/rs.3.rs-6184394/v1","editorialEvents":[{"type":"communityComments","content":0}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"296277cb-ec02-4be4-80f5-9564cb8e4eef","owner":[],"postedDate":"March 18th, 2025","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"posted","subjectAreas":[],"tags":[],"updatedAt":"2025-03-31T09:38:46+00:00","versionOfRecord":[],"versionCreatedAt":"2025-03-18 07:51:13","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-6184394","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-6184394","identity":"rs-6184394","version":["v1"]},"buildId":"8U1c8b4HqxoKbykW_rLl7","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}