About the Journal | Editorial Board | Instructions to Contributors | Submission & Review | Advertise with Us | Subscribe to E- Alerts
Sitemap | Feedback
Advanced search
Journal of Case Reports
A Rare Case of Adult Intussusception Treated by Laparoscopic Assisted Surgery
Subhash Khanna, Chaitra N Khanna, Nilotpal Deka, Supriya Choudhury
From the Department of Minimal Access Surgery, SWAGAT Endo-laparoscopic Surgical Research Institute, Guwahati, Assam, India
Corresponding Author:
Dr. Chaitra N Khanna
Email: chaitrank@yahoo.co.in
Received: 12-OCT-2014 Accepted: 27-NOV-2014 Published Online: 20-DEC-2014
DOI: http://dx.doi.org/10.17659/01.2014.0126
Abstract
Adult intussusception is a rare condition and, unlike in children where most cases are idiopathic, usually has an identifiable etiology. Often the leading point to adult intussusception is a benign or malignant bowel tumor. Surgical resection of the involved bowel is regarded as the treatment of choice in adult intussusception. We present a case of laparoscopic-assisted small bowel resection in the treatment of adult ileo-ileal intussusception caused by a small submucosal lipoma.
Keywords : Intussusception, Small Intestine, Laparoscopy, Lipoma, Ileum, Humans.
6go6ckt5b8|3000F7576AC3|Tab_Articles|Fulltext|0xf1ff5800060000005f03000001000500
6go6ckt5b5idvals|404
6go6ckt5b5|2000F757Tab_Articles|Fulltext
Introduction

Intussusception is defined as the invagination of one segment of the gastrointestinal tract and its mesentery (intussusceptum) into the lumen of an adjacent distal segment of the gastrointestinal tract (intussuscipiens). Sliding within the bowel is propelled by intestinal peristalsis and may lead to intestinal obstruction and ischemia [1]. Incidence-wise, intussusceptions are almost exclusively seen in the paediatric population. Adult intussusception is a rare condition which can occur in any site of gastrointestinal tract from stomach to rectum. It represents only about 5% of all intussusceptions and causes 1-5% of all cases of intestinal obstructions [2-4]. Unlike children where most cases are idiopathic, intussusception in adults has an identifiable etiology in 80-90% of cases [1]. Intussusception in adults usually has a leading point. Benign or malignant tumors such as lipoma, submucosal fibroma, gastrointestinal stromal tumor, Meckel’s diverticulum, and adenocarcinoma can be a leading point of intussusceptions [5].

Diagnosis of adult intussusception is difficult secondary to the variable symptoms that can be acute, intermittent, or chronic. Computed tomography has proven to be a valuable diagnostic tool, with an accuracy rate of 78%. In adults, surgery is the recommended treatment considering the high rate of malignant lesions associated with this process [6].

Case Report

A 54 years old female presented to us with the complaint of intermittent pain abdomen for the past 2 months. Pain increased with food intake and reduced with rest and medications. Patient also complained of vomiting occasionally after food intake. On examination, her general condition was fair, vitals were stable, systemic examination was normal with no palpable lump on per abdomen examination.

Investigations revealed her routine blood examination to be within normal limits. She was receiving treatment for hypothyroidism; TSH levels were normal when she came to us. An ultrasound abdomen was done which showed fatty pancreas with no other significant findings. However, contrast-enhanced CT scan abdomen revealed an ileo-ileal intussusception having an intraluminal benign-looking mass, 3.4x2.2 cm, within the apex of the intussusceptum, along with twisting of the mesentery.

The patient was planned for a laparoscopic assisted ileal resection. Necessary pre-operative investigations and preparation was done, and surgery undertaken. Under general anaesthesia, patient was put in supine position. The surgeon stood on the left of the patient. The scrub nurse stood to the right of the patient. The monitor was situated towards the foot end of the patient, opposite to the surgeon. A Stryker high definition camera with a xenon light source was used. Infraumbilical vertical incision was made for around 11 mm. The first trocar was inserted by modified Hassan’s technique, followed by carbon dioxide insufflation. Two other ports were made and diagnostic laparoscopy was done.

The patient was found to have an ileo-ileal intussusception, about 10 cms from the ileo-caecal junction. The involved bowel was dilated, but there was no evidence of bowel ischemia or perforation. Laparoscopic intracorporeal reduction with blunt graspers was performed cautiously.

An intraluminal lump could be felt within the reduced segment. We palpated the remaining small bowel to the terminal ileum using laparoscopic bowel graspers. No other masses or abnormalities were detected. Later, a 5 cm extension of the vertical incision was made along the infraumbilical port site, through which the small bowel segment was exteriorized. Through an incision on the convex surface of the exteriorized bowel, the suspected intraluminal benign-looking soft-to-firm mass of roughly 2.5x3.5 cm was visualised. A decision to resect the mass was taken. A margin of 3 cm of uninvolved bowel was resected along with the mass on either side. An end-to-end anastomosis was created by the hand-sewn method. The anastomosed ileum was placed back into the peritoneal cavity. The extensional incision site was closed. A drain was inserted near the anastomosis site in the pelvic cavity. The total operation time was 120 minutes.

Patient recovery was adequate. Post-operative period was uneventful. Patient was discharged on the 7th post-operative day. Histopathological report confirmed the presence of a submucosal lipoma with no evidence of malignancy.




Discussion

Intussusception in adults is an infrequent problem. Nevertheless, it is a challenging condition that requires the surgeon to understand its epidemiology, anomalous clinical presentation and treatment options. A strong pillar towards correct management is having a high index of suspicion. The continuously increasing variety of possible aetiological lesions, evidenced by the high case report numbers, means we can never be sure of the pathology for the next case till after surgery.

Diagnosis can be puzzling because of non-specific and often subacute symptoms with no out right pathognomonic clinical signs. The classic triad of crampy abdominal pain, bloody (‘currant jelly’) stool and a palpable mass of acute intussusception in paediatric presentation is rare [7]. The predominant symptoms are those associated with some form of bowel obstruction and most times still described non-specifically. These are abdominal pain and distension, nausea, vomiting, gastrointestinal bleeding, constipation and changes in bowel habits. The clinical features also have an association with the underlying pathological lesion’s nature and site, and the presence or absence of a lead point. A transient non-obstructing intussusception without a lead point is frequently idiopathic and, in the past, has been described as occasionally spontaneously resolving without any specific treatment. Contrastingly, intussusception with an organic lesion as the lead point usually presents as a bowel obstruction, acute, persistent or relapsing. Patients with benign enteric lesions have been said to have a higher frequency of nausea, vomiting and abdominal pain. Those with colonic malignancies tend to present more with bloody or melena stools. The mean duration of symptoms appears not to be of clinically practicable value, considering the variation in symptomatology.

Imaging studies in adult intussusceptions may give variable findings. Matching the clinical presentation and imaging characteristics to make a preoperative diagnosis is challenging. Over the years, numerous radiological signs have been described.

Abdominal computed tomography (CT) is currently considered as the most sensitive radiological method to confirm intussusception, with a reported diagnostic accuracy ranging from 58% to 100% [7]. The characteristic features include a heterogeneous ‘target’ or ‘sausage-shaped’ soft-tissue mass with a layering effect.  Mesenteric vessels within the bowel lumen are also typical. A CT scan may define the location and nature of the mass, its relationship to surrounding tissues and may contribute to staging of a tumour for a suspected malignant cause. It facilitates distinguishing between intussusception without a lead point from that with a lead point.

Flexible endoscopy of the lower gastrointestinal tract is very valuable in evaluating the cases of intussusception presenting with subacute or chronic large bowel obstruction. Its main benefits are confirmation of the intussusception, its localisation, demonstration of the underlying organic lesion serving as a lead point and possible treatment [7]. Snare polypectomy has been used to treat polypoid causes, though it is considered unsafe for chronic intussusception considering the background of chronic tissue ischaemia and possible necrosis of the intussuscepted bowel segment’s wall. However, it has limited use for large lead points such as ‘giant’ lipomas. Colonoscopy has been successfully used to reduce intussusceptions.

Surgical resection of the involved bowel is regarded as the treatment of choice in adult intussusception, because most cases involve a leading point containing a potential malignancy [5]. Although “en-bloc” resection without reduction of the involved bowel has been recommended to avoid bowel perforation and seeding of potential cancer cells to other sites, with adequate and successful reduction and accurate diagnosis to rule out the possibility of malignancy, surgeons can minimize the range of resected bowel.

Recently, minimally invasive techniques have been applied to the treatment of small bowel obstructions, specifically to the diagnosis and treatment of adult intussusception. Both laparoscopic and laparoscopic-assisted small bowel and colonic resections have been reported for both benign and malignant disease [5-10]. Our case highlights diagnostic laparoscopy and laparoscopic-assisted bowel resection as a potential and feasible tool in the treatment of small bowel intussusception. The ability to confirm diagnosis and plan targeted small incisions for treatment make laparoscopy a viable treatment option in patients suspected of having intussusceptions.


References
  1. Paskauskas S, Pavalkis D. Adult Intussusception. Current Concepts in Colonic Disorders 2012; Dr. Godfrey Lule (Ed.), ISBN: 978-953-307-957-8, InTech, Available from: http://www.intechopen.com/books/current-concepts-in-colonic-disorders/adult-intussusception. Accessed on October 12, 2014.
  2. Agha FP. Intussusception in adults.  Am J Roentgenol. 1986;146:527-531.
  3. Eisen LK, Cunningham JD, Aufses AH Jr. Intussusception in adults: institutional review. J Am Coll Surg. 1999;188:390-395.
  4. Begos DG, Sandor A, Modlin IM. The diagnosis and management of adult intussusception. Am J Surg. 1997;173(2):88-94.
  5. Kang SI, Kang J, Kim MJ, Kim I, Lee J, Lee KL, Sohn S. Laparoscopic-Assisted Resection of Jejunojejunal Intussusception Caused by a Juvenile Polyp in an Adult. Case Reports in Surgery; Volume 2014, Article ID 856765,
  6. Stewart D, Hughes M, Hope WW.  Laparoscopic-assisted small bowel resection for treatment of adult small bowel intussusception: a Case Report. Cases Journal. 2008;1:432.
  7. Ongom PA, Kijjambu SC. Adult intussusception: a continuously unveiling clinical complex illustrating both acute (emergency) and chronic disease management. OA Emergency Medicine. 2013;1(1):3.
  8. M Solazzo, CS, Puccio F. Laparoscopic Surgery for Adult Bowel Intussusception: Report Of A Case. The Internet Journal of Surgery. 2004; Volume 6 Number 2.
  9. Ishibashi Y, Yamamoto S, Yamada Y, Fujita S, Akasu T, Moriya Y. Laparoscopic resection for malignant lymphoma of the ileum causing ileocecal intussusception. Surg Laparosc Endosc Percutan Tech. 2007;17(5):444-446.
  10. Lin MW, Chen KH, Lin HF, Chen HA, Wu JM, Huang SH. Laparoscopy-assisted resection of ileoileal intussusception caused by intestinal lipoma. J Laparoendosc Adv Surg Tech A. 2007;17(6):789-792.
Article Options
FULL TEXT
ABSTRACT
PDF
PRINTER FRIENDLY VERSION
Search PubMed for
Search Google Scholar for
Article Statistics
CITE THIS ARTICLE
Khanna S, Khanna CN, Deka N, Choudhury SA Rare Case of Adult Intussusception Treated by Laparoscopic Assisted Surgery.JCR 2014;4:495-499
CITE THIS URL
Khanna S, Khanna CN, Deka N, Choudhury SA Rare Case of Adult Intussusception Treated by Laparoscopic Assisted Surgery.JCR [serial online] 2014[cited 2024 Mar 19];4:495-499. Available from: http://www.casereports.in/articles/4/2/A-Rare-Case-of-Adult-Intussusception-Treated-by-Laparoscopic-Assisted-Surgery.html
Bookmark and Share