International Journal of Surgery Case Reports
International Journal of Surgery Case Reports
International Journal of Surgery Case Reports
a r t i c l e i n f o a b s t r a c t
Article history: INTRODUCTION: Adult intussusception is a rare condition with a pathological lead point. Intraoperative
Received 11 March 2017 reduction of adult intussusception can eliminate the need for extensive or invasive resection. We safely
Received in revised form 2 May 2017 performed a manual laparoscopy-assisted intraoperative reduction that allowed functional preservation
Accepted 6 May 2017
of tissue.
Available online 15 May 2017
PRESENTATION OF CASE: A 70-year-old woman with dull right lumbar pain at regular intervals and right
lower quadrant abdominal tenderness was admitted to our hospital. The ileum exhibited enhanced wall
Keywords:
thickening and invagination into the ascending colon on computed tomography. Emergency laparoscopic
Case report
Adult intussusception
surgery was chosen to treat the ileocolic intussusception. First, the right colon was mobilized. Second, the
Laparoscopy ileocecal region was pulled through a 4-cm right pararectus incision. Third, the edge of the intussuscep-
Intraoperative reduction tum was gently manipulated back upstream without tearing. After reduction, a soft mass was recognized
Ileal adenoma on palpation at the lead point, located 10 cm proximal to the ileocecal valve. Ileocecal resection was per-
formed, and a laterally spreading tumor was observed in the resected specimen. The histological diagnosis
was high-grade tubular adenoma. The postoperative course was uneventful.
DISCUSSION: Adult intussusception has a pathological lead point, and curative treatment generally
includes resection of the lesion. Complete or partial intraoperative reduction can avoid or shorten bowel
resection and allow functional preservation of the tissue.
CONCLUSION: Manual laparoscopy-assisted intraoperative reduction with a minilaparotomy was safely
performed, which eliminated the need for extensive or invasive resection.
© 2017 The Author(s). Published by Elsevier Ltd on behalf of IJS Publishing Group Ltd. This is an open
access article under the CC BY-NC-ND license (http://creativecommons.org/licenses/by-nc-nd/4.0/).
Adult intussusception is rare, has a pathological lead point [1,2] A 70-year-old woman with dull right lumbar pain at regular
and is diagnosed by specific imaging findings [3]. Surgical inter- intervals walked into Emergency room. She had experienced the
vention is required to resect the lesion. Intraoperative reduction same lumbar pain approximately one year previously, melena two
of intussusception in adults can avoid or shorten bowel resection days previously and intermittent right lumbar pain every three
and allow functional preservation of the tissue [4]. Laparoscopy hours for one day. She received oral medication for dyslipidemia.
is also an effective and minimally invasive technique for patients A physical examination revealed right lower quadrant abdominal
with intussusception. We report a case of ileocolic intussusception tenderness. Ileocolic intussusception with enhanced wall thicken-
in an adult with a laterally spreading tumor (LST) in the ileum that ing at the forward part of the ileum was observed with enhanced
illustrates the benefits and safety of the laparoscopic approach and computed tomography (CT) (Fig. 1). An emergency laparoscopic
manual reduction operation was performed to treat the ileocolic intussusception with
an unknown pathological lead point. Under general anesthesia and
spine position, first, a 20-mm skin incision was made at the umbili-
cus, a 12-mm trocar was inserted, and pneumoperitoneum was
established. Then, three 5-mm trocars were inserted into the mid-
dle lower abdomen and the bilateral lower quadrant. The ileocecal
region was covered by the omentum and was adherent to the
∗ Corresponding author. abdominal wall, but it was freed easily via sharp and blunt dissec-
®
E-mail addresses: naoki0403@kuwanacmc.or.jp (N. Takahashi), tion using Harmonic ACE + (Ethicon). The ileocolic intussusception
generalpeople0719@gmail.com (K. Narita), r-sato@kuwanacmc.or.jp (R. Sato), was visible, and no ischemic changes were observed. Mobilization
hidero@kuwanacmc.or.jp (H. Suzuki), machishi-s@kuwanacmc.or.jp (H. Machishi), of the right colon was performed, a 4-cm right pararectal incision
okadas77@kuwanacmc.or.jp (Y. Okada).
http://dx.doi.org/10.1016/j.ijscr.2017.05.010
2210-2612/© 2017 The Author(s). Published by Elsevier Ltd on behalf of IJS Publishing Group Ltd. This is an open access article under the CC BY-NC-ND license (http://
creativecommons.org/licenses/by-nc-nd/4.0/).
CASE REPORT – OPEN ACCESS
N. Takahashi et al. / International Journal of Surgery Case Reports 36 (2017) 116–118 117
Fig. 3. The edge of the intussusceptum was gently manipulated back upstream.
Fig. 1. Ileocolic intussusception with enhanced wall thickening at the forward part
of the ileum was observed on enhanced CT images.
our case, the patient had dull lumbar pain, abdominal tenderness
Fig. 2. The ileocecal region was pulled through a right pararectus incision. and a bowel-within-a-bowel appearance of the right colon with
enhanced wall thickening. An emergency operation was required
for the ileocolic intussusception with its unknown pathological
was made, and the ileocecal region was pulled through the incision lead point. The lead point was an LST, which exhibited enhanced
(Fig. 2). The edge of the intussusceptum was gently manipulated wall thickening at the forward part of the ileum on preoperative
back upstream (Fig. 3). After reduction, no ischemic region was enhanced CT images.
observed, and a soft mass was found on palpation at the lead point, The surgical treatment for adult intussusception is generally
located 10 cm proximal to the ileocecal valve. Ileocecal resection resection of the lesion [1,7]. The most common etiology is malig-
was performed. An LST measuring 2.6 × 5.0 cm was observed in the nancy [1]. The condition can recur if the pathological lead point is
resected specimen, and the histological diagnosis was high-grade not excised [8]. Alternatively, reduction can be performed, which
tubular adenoma (Fig. 4). The postoperative course was uneventful. can avoid extensive and invasive resection [7]. We successfully per-
The patient was discharged on the eighth day. formed a manual intraoperative reduction. A soft mass was noted
on palpation at the lead point of the ileum. Therefore, ileocecal
3. Discussion resection was performed, avoiding extensive resection.
Laparoscopy is a beneficial and minimally invasive technique
Adult intussusception is rare and has a pathological lead point for patients with intussusception. Two cases of successful com-
[1,2]. The most common underlying lesions of adult intussuscep- plete intraoperative reduction were found among twenty-two case
tion are adenocarcinoma and lymphoma [5], but a case without reports of adult intussusception published in English-language
a pathological lead point has been reported [6,7]. The specific CT journals retrieved in a PubMed search using the keywords “adult
finding is the appearance of a bowel within a bowel, exhibiting a intussusception,” “ileocecal” or “ileocolic and laparoscopic.” In
target-like pattern, reniform pattern, or sausage-shaped pattern. A 2004, Yamaguchi et al. reported the first successful case of laparo-
pathological lead point can usually be found on CT images, but the scopic intraoperative reduction for ileocecal intussusception, using
distinct anatomic features of the lead mass may be difficult to dis- gauze sponge sticks to compress the distal colon [9]. Yang et al.
tinguish because of the presence of edema and inflammation [3]. In reported a patient with intestinal malignant lymphoma with
CASE REPORT – OPEN ACCESS
118 N. Takahashi et al. / International Journal of Surgery Case Reports 36 (2017) 116–118
Table 1
Cases in which intraoperative reduction was attempted.
Author Age/Sex Lead point Intraoperative reduction Reducting Extent of reduction Operation Histology
method
S Yamaguchi 32/M Transverse colon Laparoscopy Push Complete Lap-ICR Appendix mucocele
N Marsden 69/F Transverse colon Laparoscopy Pull Partial Lap-RH Cecal carcinoma
FA Alvarez 47/F Ascending colon Minilaparotomy Pull Partial Lap-SBR (hand assisted) Metastatic melanoma of ileum
WI Corey 47/F Ascending colon Minilaparotomy ND Not succsesfully Lap-ICR Appendix endometrioma
Jia-Hui Chen 36/M Ascending colon Laparoscopy ND Not succsesfully Lap-RH (single port) Ileal lipoma
TW Yang 31/M Ascending colon Laparoscopy Pull Complete Lap-appe Intestinal lymphoma
Our case 70/F Ascending colon Minilaparotomy Push Complete Lap-ICR Ileal adenoma
Lap-ICR: laparoscopic ileocecal resection, Lap-RH: laparoscopic right hemicolectomy, Lap-SBR: laparoscopic small bowel resection, Lap-appe: laparoscopic appendectomy.
Open Access
This article is published Open Access at sciencedirect.com. It is distributed under the IJSCR Supplemental terms and conditions, which
permits unrestricted non commercial use, distribution, and reproduction in any medium, provided the original authors and source are
credited.