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 ¤ Case Report
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UNUSUAL CASE
Year : 2020  |  Volume : 16  |  Issue : 1  |  Page : 87-89
 

Ileocolic invagination in adults: A totally minimally invasive endoscopic and laparoscopic staged approach


1 Department of General Surgery, Poliambulanza Foundation Hospital, Brescia, Italy
2 Department of General Surgery, University of Genoa, San Martino Hospital, Genova, Italy
3 Department of Radiology, Poliambulanza Foundation Hospital, Brescia, Italy
4 Department of Digestive Endoscopy Unit, Poliambulanza Foundation Hospital, Brescia, Italy

Date of Submission26-Oct-2018
Date of Acceptance23-Nov-2018
Date of Web Publication20-Dec-2019

Correspondence Address:
Elio Treppiedi
Department of General Surgery, Poliambulanza Foundation Hospital, Brescia 25124
Italy
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/jmas.JMAS_279_18

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 ¤ Abstract 

Adult intussusception of the bowel is a rare clinical entity, and its management remains debated. The timing of treatment is not yet standardised, and no guidelines exist. We report a case of an 83-year-old woman presenting to the emergency department of our hospital with a history of increasing abdominal pain in the right iliac fossa. A contrast-enhanced computed tomography scan showed the presence of a large ileocolic intussusception with evidence of the terminal ileus invaginated within the right colon and the ileocolic vessels dragged and trapped into the intussusception. A colonoscopy confirmed the ileocolic invagination with a large right colonic lesion as leading point, and a partial pneumatic (carbon dioxide) and hydrostatic reduction was achieved. Subsequent laparoscopic right colectomy was performed according to oncological principles. A totally minimally invasive approach of this rare condition has been achieved but the literature lacks about the correct management of this entity.


Keywords: Ileocolic invagination, intestinal intussusception, intestinal invagination


How to cite this article:
Treppiedi E, Cocchi L, Zimmitti G, Manzoni A, Seletti V, Bizzotto A, Spada C, Garatti M, Rosso E. Ileocolic invagination in adults: A totally minimally invasive endoscopic and laparoscopic staged approach. J Min Access Surg 2020;16:87-9

How to cite this URL:
Treppiedi E, Cocchi L, Zimmitti G, Manzoni A, Seletti V, Bizzotto A, Spada C, Garatti M, Rosso E. Ileocolic invagination in adults: A totally minimally invasive endoscopic and laparoscopic staged approach. J Min Access Surg [serial online] 2020 [cited 2020 Sep 24];16:87-9. Available from: http://www.journalofmas.com/text.asp?2020/16/1/87/252464



 ¤ Introduction Top


Adult intussusception (AI) of the bowel is an uncommon clinical entity, and its management remains controversial. Ileocolic invagination is frequently associated with the presence of a neoplastic lesion acting as a lead point for intussusception. However, given the lack of data from the literature, the optimal management strategy of this scenario remains unclear.


 ¤ Case Report Top


An 83-year-old woman presented to the Emergency Department with a 6-month history of recurrent and progressively severe abdominal pain, along with constipation, vomiting and unintentional 5-kg weight loss. Her medical history was notable for deep venous thrombosis and pulmonary embolism, osteoporosis, polymyalgia rheumatic and autoimmune thyroiditis. The clinical examination revealed normal primary vital signs, abdominal distension and a palpable mass in the right iliac fossa without signs of peritonitis. Blood tests were normal. A computed tomography (CT) scan with intravenous contrast demonstrated a large ileocolic invagination associated with diffuse colon and small bowel wall thickening and initial evidence of vascular congestion without signs of bowel obstruction [Figure 1]. Hydration and antibiotic prophylaxis were started. Colonoscopy was performed, and an endoscopic reduction of the intussusception through carbon dioxide and water insufflations was obtained; ischaemic injury of the surrounding mucosa was noticed. After the reduction, a large villous lesion of the right colon was revealed with irregular pit pattern highly suggestive of malignancy. The patient underwent an explorative laparoscopy that showed a complete resolution of the ileocolic invagination and right colectomy was performed adhering to oncological criteria [Figure 2]. The postoperative course was uneventful, and the patient was discharged after 8 days. The final pathologic examination revealed a moderately differentiated adenocarcinoma pT3 N1a (1/27).
Figure 1: Computed tomography scan; irregular bowel wall thickening with ileal invagination with ileocolic vascular axis and reactive lymph nodes within the invagination

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Figure 2: Endoscopic partial reduction of the intussusception with evidence of ischaemic damage of the mucosa and intraoperative findings at laparoscopy

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 ¤ Discussion Top


Due to its rarity, only case reports or small case series are available about the treatment of AI. In contrast to the paediatric counterpart, AI is rarely idiopathic being caused in 90% of cases by a benign or malignant lesion. In particular, colonic and ileocolic invagination is strongly associated with malignant lesions, mainly adenocarcinomas.[1] Nevertheless, with the increasing use of abdominal CT scans in clinical practice, incidental finding of transient, asymptomatic intussusception is more frequently encountered. Clinical presentation is widely variable, and symptoms are often nonspecific, most of the time related to the presence of concomitant bowel obstruction. The classic triad 'abdominal mass, tenderness and bloody jelly stools' is rarely observed in adults unlike in children. However, abdominal pain, constipation, intermittent obstruction episodes or vomiting are common findings. CT is the most sensitive and accurate diagnostic tool, and it is accepted as the gold standard to confirm clinical suspicion.[2] It also provides additional crucial information about the mesenteric vascular axis, the length and diameter of invagination and the presence of lesions acting as a lead point.

The treatment of ileocolic invagination in adult is not standardised. There is broad consensus in the literature on the need for surgery considering the high percentage of failure of conservative management and the strong correlation between intussusception and malignancy.[1],[3] In this paper, we present our experience of a minimally invasive approach with endoscopic resolution of intussusception and subsequent laparoscopic oncological resection. However, the role of preoperative reduction of invagination in this scenario has not yet been clarified. Some authors advise against a preoperative attempt at endoscopic reduction due to a theoretical risk of seeding or perforation.[4] On the contrary, others authors advocate that an endoscopic approach with total or partial reduction of the invagination could avoid an extended bowel sacrifice.[5] In our experience, a complete reduction of the invagination led us to an anatomical colonic resection without the necessity of major intestinal sacrifice with an identification of the surgical landmarks to perform a standard right laparoscopic colectomy. On the contrary, without endoscopic reduction, the risk of major ileal resection is elevated. An intraoperative laparoscopic attempt of manual reduction of the invagination could be performed but no data are available about this approach and we thought that it could be a challenging procedure with a persistent risk of ileal major resection.

In our opinion, this mininvasive staged treatment is a safe technique, allowing a correct oncologic surgery in case of neoplastic underlying pathology, with a benefit in terms of conservative surgical resection outweighing the theoretical risks of perforation or seeding.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

 
 ¤ References Top

1.
Wang LT, Wu CC, Yu JC, Hsiao CW, Hsu CC, Jao SW, et al. Clinical entity and treatment strategies for adult intussusceptions: 20 years' experience. Dis Colon Rectum 2007;50:1941-9.  Back to cited text no. 1
    
2.
Kim YH, Blake MA, Harisinghani MG, Archer-Arroyo K, Hahn PF, Pitman MB, et al. Adult intestinal intussusception: CT appearances and identification of a causative lead point. Radiographics 2006;26:733-44.  Back to cited text no. 2
    
3.
Marinis A, Yiallourou A, Samanides L, Dafnios N, Anastasopoulos G, Vassiliou I, et al. Intussusception of the bowel in adults: A review. World J Gastroenterol 2009;15:407-11.  Back to cited text no. 3
    
4.
Zubaidi A, Al-Saif F, Silverman R. Adult intussusception: A retrospective review. Dis Colon Rectum 2006;49:1546-51.  Back to cited text no. 4
    
5.
Honjo H, Mike M, Kusanagi H, Kano N. Adult intussusception: A retrospective review. World J Surg 2015;39:134-8.  Back to cited text no. 5
    


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