ORIGINAL ARTICLE
A Case Series of Adult Intussusception Managed Laparoscopically Sze Li Siow, MBBS, MRCS, MS and Hans Alexander Mahendran, MD, MS
Objective: Adult intussusception is rare, representing only 1% to 5% of bowel obstructions. This is a case series of 8 patients who presented with intestinal obstruction secondary to intussusception managed laparoscopically at our institution.
January 2010 to December 2012. Data reviewed were type and location of intussusceptions, clinical presentation, preoperative radiologic findings, operative techniques, postoperative outcomes, length of hospital stay, and follow-up.
Methods: Eight cases of adult intussusceptions were treated laparoscopically at our institution between January 2010 and December 2012. The presentation, diagnosis, management strategy, and pathology involved were reviewed.
Operative Procedure
Results: Three patients presented with small-bowel obstruction, whereas 4 had recurrent bouts of abdominal pain and 1 had persisting diarrhea. Computed tomography scan was performed in all but 1 of our patients and was accurate in diagnosing in all instances. Laparoscopy and resection of the intussusceptions was completed successfully in all patients. There were no intraoperative and postoperative complications. Four patients underwent laparoscopyassisted small-bowel resection; 3 patients underwent right hemicolectomy and 1 had anterior resection. All patients recovered uneventfully. Conclusions: Laparoscopic management of adult intussusception is safe and feasible. Further, diagnostic laparoscopy is useful when the diagnosis is uncertain despite computed tomography scan imaging. Key Words: adult intussusception, enteric intussusceptions, colonic intussusceptions, laparoscopy, therapy
(Surg Laparosc Endosc Percutan Tech 2014;24:327–331)
I
ntussusception occurs when there is telescoping of a proximal segment of intestine and its mesentery (intussusceptum) into the distal segment (intussuscipiens). It occurs rarely in adults, accounting for 5% of all intussusceptions diagnosed.1 Unlike intussusception in the pediatric population, adult intussusception is usually associated with a pathologic lead point often necessitating surgical resection. There is increasing evidence supporting the feasibility and safety of laparoscopy in the management of this rare clinical entity.
MATERIALS AND METHODS Study Population This study reviewed 8 adult patients (above 18 y of age) who were diagnosed with intussusception and had laparoscopic treatment at Sarawak General Hospital from Received for publication May 23, 2013; accepted August 27, 2013. From the Department of Surgery, Sarawak General Hospital, Kuching, Sarawak, Malaysia. The authors declare no conflicts of interest. Reprints: Sze L. Siow, MBBS, MRCS, MS, Department of Surgery, Sarawak General Hospital, Jalan Hospital, 93584, Kuching, Sarawak, Malaysia (e-mail: [email protected]). Copyright r 2014 by Lippincott Williams & Wilkins
Surg Laparosc Endosc Percutan Tech
The operative approach depended on the types of intussusceptions. The following describes our techniques and approaches to both enteric and colonic intussusceptions.
Enteric Intussusceptions The surgery was performed under general anesthesia with the patient supine. The surgeon and the camera surgeon stood on the left side of the patient with the monitor placed opposite to them. Nasogastric tube and urinary catheter were routinely inserted. Antibiotic prophylaxis (intravenous cefoperazone 1 g and intravenous metronidazole 500 mg) was administered to all patients. An 11- or 12mm Xcel camera port was inserted at the left flank at the level of the umbilicus under direct telescopic visualization, and two 5-mm working trocars were placed at the left hypochondrium and left iliac fossa. An additional 5-mm trocar was placed according to the need of the surgery as a retraction port. Laparoscopic exploration was performed using a 30degree 10-mm laparoscope, with the patient placed in the Trendelenburg position. Examination of the small bowels was performed using an atraumatic grasper, starting from the collapsed, nondilated loop and moving proximally toward the intussusception, using a “hand-to-hand” or “hand-over-hand” running of bowel technique. Initial reduction was attempted briefly for all cases of enteric intussusceptions as there were no signs of bowel ischemia. The atraumatic grasper was applied transversely across the whole length of the bowel diameter proximal to the apex of the intussusceptum, while another atraumatic grasper was applied on the distal bowel. The force was applied to both the graspers using the traction-countertraction technique. Care was taken not to perforate the bowels during manipulation, and reduction was attempted only in nonischemic bowel. If the intracorporeal reduction was unsuccessful, then extracorporeal reduction was performed. The intussusception can be delivered through a minilaparotomy incision (3 to 4 cm) in the periumbilical region or a small transverse skin crease incision (3 to 4 cm) over the site of the pathology. The bowel was then resected extracorporeally, and the anastomosis was performed using either hand-sewn or linear cutter techniques. Laparoscopy-assisted right hemicolectomy was performed for 2 patients with enteric intussusception, both being ileocolic intussusceptions. One patient had intussusception secondary to typhoid colitis (Fig. 1), whereas the other had
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FIGURE 1. Ileocolic intussusception secondary to typhoid colitis.
an ileal polyp. Both patients were placed in the Trendelenburg position with the right side up. The surgeon and the camera surgeon stood to the left of the patient. During the initial laparoscopic assessment, both intussusceptums lay in the ascending colon, with the distal ileum noted to be invaginated into the ascending colon. However, in both cases, neither the small bowel nor the colon was grossly distended. Hence, attempt was made to reduce it, using a combination of “distal pushing against the intussusception/milking” and “traction-countertraction” techniques.
Colonic Intussusceptions The patient was placed in a modified lithotomy position. The surgeons stood to the left of the patient in case of colocolic intussusception and to the right of the patient in case of sigmoidorectal intussusception (Fig. 2). Laparoscopy-assisted extended right hemicolectomy was performed for colocolic intussusception due to a villous adenoma of the proximal transverse colon. The positioning of the patient and surgical team was similar to that of right hemicolectomy for ileocolic intussusceptions. In this patient, we failed at the attempt of reduction and proceeded
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with en bloc extended right hemicolectomy. The challenges of performing en bloc resection included the following: first, the anatomy of the blood supply to the colon was distorted and the colon was invaginated along with a considerable length of bowel into the intussuscipiens, making the dissection to isolate the vessels difficult. Second, the normal loose areolar tissue plane between the colon and the posterior peritoneum was replaced by edematous thickened tissue, making the separation of the plane difficult. Nevertheless, the surgery conformed to the oncologic principles, achieving the control of vessels in the early phase of dissection, followed by medial to lateral approach and retroperitoneal tunneling. At the end of the surgery, the specimens were delivered through a small transverse skin incision, with extracorporeal stapled anastomoses performed. In the patient with sigmoidorectal intussusception, we attempted a laparoscopic approach as we are familiar performing laparoscopic resection for colorectal carcinoma. The abdomen was approached using the trocar position meant for a standard laparoscopic anterior resection. The intraoperative findings were that the sigmoid colon carcinoma had telescoped into the rectum, forming a mass in the rectum. The inferior mesenteric artery was invaginated into the intussuscipiens. We attempted reduction as the intussusceptum had descended into the mid-rectum but we were unsuccessful. Laparoscopic low anterior resection was performed in the normal manner with en bloc resection of the intussuscepted colon. The conventional medial to lateral dissection behind the sigmoid mesocolon was difficult because of the limited space caused by the intussusception and compounded by the edematous sigmoid mesocolon. Instead, the division of the lateral attachment of sigmoid and descending colon was performed first before returning to medial to lateral dissection. The use of the nylon tape to lift the sigmoid colon had further exposed the window between the mesocolon and Toldt fascia. It was then that the origin of inferior mesenteric artery was identified, doubly clipped proximally with hemolock, and divided. The mesenteric vein was identified at the level of the inferior border of the pancreas, clipped with hemolock, and divided. Rectal mobilization began with division of the peritoneum on the right and then left, followed by posterior rectal dissection along the avascular plane of Heald and anteriorly in front of the Denonvillers fascia. Rectal transection was performed using an endostapler at a level much lower than what was anticipated for sigmoid colon carcinoma because of the prolapsing of sigmoid carcinoma into the mid-rectum. Hence, a diverting loop ileostomy was performed at the end of the surgery as there was concern regarding tissue edema jeopardizing the anastomosis and also because it is the standard procedure in our unit when low anterior resection is performed. Histopathologic examination revealed a 50 35 mm in diameter by 10 mm in depth moderately differentiated adenocarcinoma with a TNM staging of T3N0M0. The patient made an uncomplicated recovery and was discharged home 4 days after surgery and referred for adjuvant chemotherapy.
RESULTS FIGURE 2. Sigmoidorectal intussusceptions secondary to sigmoid adenocarcinoma.
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Laparoscopic surgery was performed successfully in all 8 patients with no conversions. The summary of the patients’ demographic, clinical presentation, types r
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Adult Intussusception Managed Laparoscopically
TABLE 1. Summary of Patients’ Demographic Data, Clinical Presentation, Surgical Treatment, and Pathology
No.
Age (y)
1
25
2
Sex
Clinical Presentation
Type of Intussusception
Male
Surgical Treatment
Pathology
56
Chronic Ileocolic symptoms Female Acute symptoms Sigmoidorectal
Laparoscopy-assisted right hemicolectomy Laparoscopy-assisted low anterior resection and covering ileostomy
3
74
Male
4
63
Female Acute symptoms Colocolic
5
55
Male
6
25
7
24
8
78
Laparoscopy-assisted resection Laparoscopy-assisted hemicolectomy Laparoscopy-assisted resection Laparoscopy-assisted resection Laparoscopy-assisted hemicolectomy Laparoscopy-assisted resection
Acute symptoms Ileoileal
Chronic Jejunojejunal symptoms Male Acute symptoms Jejunojejunal (Fig. 3) Female Chronic Ileocolic symptoms Male Subacute Ileoileal (2 sites) symptoms
small-bowel
Suggestive of typhoid colitis Moderately differentiated adenocarcinoma of sigmoid colon, T3N0M0 Nodular lymphoid hyperplasia
extended right Villous adenoma of transverse colon small-bowel small-bowel right small-bowel
Non-Hodgkin diffuse large B-cell lymphoma Benign polyp Hyperplastic Peyer patches of terminal ileum Bifocal intestinal neuroendocrine carcinoma
“Acute symptoms” indicates symptoms 14 days.
of intussusception and operation, and pathologic data are illustrated in Table 1. Overall, there were 5 men and 3 women, with a mean age of 50 (range, 24 to 78) years. Computed tomography (CT) scan of the abdomen and pelvis was performed for 7 patients, except for 1 patient who was misdiagnosed to have perforated appendicitis and was diagnosed intraoperatively through diagnostic laparoscopy. Patients were classified into enteric or colonic intussusceptions on the basis of the site of the lead point, which was examined at the end of the surgery. An intussusception was considered enteric if the pathologic lead point was located in the jejunum or ileum (jejunojejunal, ileoileal, and ileocolic intussusceptions) and colonic if the lead point was located in the colon only (colocolonic and sigmoidorectal intussusceptions) (Fig. 3). Intracorporeal reduction was possible for 2 patients with enteric intussusceptions and none for colonic intussusceptions. However, extracorporeal reduction was performed for the rest of the enteric intussusceptions to minimize the extent of resection. Surgery was technically more difficult in colonic than enteric intussusceptions when the intussusceptions could not be reduced intracorporeally. Of these, 2 patients had right hemicolectomy, 1 had extended right hemicolectomy, 1 had low anterior resection, and 4 had laparoscopy-assisted small-bowel resection. None of the patients had any complications such as bleeding, wound infection, anastomotic leak, or visceral organ injuries. In 1 patient with ileoileal intussusception, we unexpectedly identified another ileoileal intussusception at the more proximal bowel during the delivery of the distal intussusception through the wound. All patients had an uneventful postoperative recovery. The mean operating time and postoperative stay were 105 (range, 60 to 240) minutes and 3.9 (range, 3 to 5) days, respectively. Histopathologic examination showed a malignant lead point in 3 of 8 patients (37.5%; Table 1). At a mean follow-up of 24.2 (range, 4 to 44) months, 1 patient with multiple ileoileal intussusceptions secondary to neuroendocrine tumors had developed peritoneal recurrence 6 months after surgery. r
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DISCUSSION In our previous study involving 14 cases of adult intussusceptions, treated in 4 major hospitals in Sarawak over 5 years, 93% of the intussusceptions were noted to be associated with a pathologic lead point.2 Malignancy accounted for 50% of adult intussusceptions, with majority of colonic intussusceptions proven to be malignant, in contrast to enteric intussusceptions, only one third of which were proven to be malignant.2 In our current single institution study of a small cohort, we found a lowered incidence of malignancy, in 3 of 8 patients (37.5%) with intussusceptions. The clinical presentation of adult intussusception is variable with nonspecific symptoms and signs. Most patients had chronic symptoms and most of them had symptoms suggestive of intestinal obstruction.1,3,4 It accounts for 1% to 5% of all intestinal obstructions in adults.1,5 All of the 8 adult patients in our series presented with clinical features of intestinal obstruction. However, half of them had acute symptoms. The exact mechanisms of intussusceptions remain uncertain. An alteration of normal peristaltic activity of the
FIGURE 3. Jejunojejunal intussusception secondary to benign polyp.
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bowel has been postulated as the etiology in adult intussusceptions. Possible mechanisms can include both primary (idiopathic) and secondary. Several secondary mechanisms have been postulated and included either the presence of an intraluminal mass acting as a lead point resulting in invagination of the involved wall during normal peristalsis1,4 or a functional disturbance without bowel wall abnormality.6,7 This can be caused by diseases such as celiac disease,6 Crohn disease,7 acquired immunodeficiency syndrome,1,8 and previous abdominal surgery. The most common locations for intussusception are at the interface between the mobile and fixed or retroperitoneal segments of the bowels, such as the ileocecal region, and in areas of adhesions9 or prior inflammations10 that cause bowel fixation, allowing the proximal bowel to telescope into the distal bowel lumen. The classification of intussusceptions is tailored to the anatomic location of the lead point. It is classified as enteric when the lead point is located in the small bowel and colonic when the lead point is in the colon. Enteric intussusceptions include jejunojejunal, ileoileal, and ileocolic intussusceptions, whereas colonic intussusceptions include ileocecal-colic, colocolonic, sigmoidorectal, and appendicocecal intussusceptions. In the west and developed countries, enteric intussusceptions form the most common type.11–13 We have made a similar observation here in Sarawak, Malaysia. However, the same could not be said of the central and Western Africa, where they reported that their most common variety is the cecal-colic type.14,15 The variability and nonspecific nature of the clinical presentation makes it challenging to establish a correct clinical diagnosis. Preoperative diagnosis is best achieved with abdominal CT,1,4 which we strongly recommend to be performed as part of preliminary investigation of intestinal obstruction or any acute abdomen. The CT features of intussusceptions are virtually pathognomonic and include a target or doughnut signs on transverse view, and pseudokidney or sausage signs on longitudinal view.16 Other supporting evidence includes presence of fat within the mass, which represents the intussuscepted mesenteric fat, and mesenteric vessels entering the involved loops.16 The role of CT is not only limited to diagnosis alone, but also facilitates laparoscopic approach in all cases, especially in acute presentations, when laparotomy is usually indicated. The feasibility and safety of laparoscopy in diagnosis and treatment of adult intussusceptions have been documented in several studies.9,17,18 Our study further supports the use of laparoscopy in management of adult intussusceptions with no morbidity and zero mortality. In adult intussusceptions, the proximal bowel loops are usually of normal caliber and are occasionally dilated, making it feasible to manipulate with a certain degree of force.16 As such, we recommend a gentle attempt at reduction for all cases of intussusceptions provided that there is no evidence of bowel ischemia or edema. However, appropriate judgment and caution should be exercised and use of undue force should be limited. The roles of laparoscopy in small-bowel intussusceptions differ from those of colonic intussusceptions. The focus is on localization of the pathology and its delivery through a planned transverse incision or minilaparotomy.18,19 This technique has become our procedure of choice when dealing with small-bowel diseases. We believe that an extracorporeal rather than intracorporeal resection and anastomosis should be attempted as any length of small-bowel intussusceptions could be exteriorized through a 3 to 4 cm skin crease
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incision, thus avoiding formal laparotomy and its associated complications. Exteriorization of the small bowels allows manual reduction to be attempted extracorporeally, in the event of failed intracorporeal reduction. The use of wound protector is important when exteriorizing bowels for extracorporeal resection and anastomosis as to prevent possible dissemination of cancer cells to the wound. In our series, complete intracorporeal reduction could only be achieved in 2 patients of enteric intussusceptions and none in colonic intussusceptions. The logical explanations would be that the adult intussusception is of a chronic nature, associated with some degrees of bowel and mesenteric edema. The size of the lead point and dense adhesions around the intussuscepted mass are other factors that render the reduction of the intussusceptum difficult. Further, it appears that small-bowel intussusceptions have a better success rate in laparoscopic reduction than their colonic counterparts.20,21 These are the considerations that need to be taken into account when performing laparoscopic intracorporeal reduction. En bloc resection should be performed for patients suspected to have primary carcinoma. The proponent of this concept subscribe to the principles that attempted reduction may lead to intraluminal seeding or venous embolization of malignant cells.22 However, the theory lacks supportive evidence as clinical cases are scarce. In this respect, some authors have proposed for cautious use of reduction if en bloc resection entails extensive surgeries, such as abdominoperitoneal resection, which may compromise the patient’s quality of life,22,23 or extensive smallbowel resection, which may result in short-bowel syndrome. In the event of sigmoidorectal intussusceptions, there have been reports on combined approach of pulling the proximal colon above the intussusception and pushing the invaginated distal end from the anus with a lubricated sponge-onstick.9,23,24 One author described the use of the circular stapler body through the anus to push the intussusceptions up while simultaneously reducing it using a grasper.25 We concur with the latter opinion in judicious use of reduction in certain circumstances such as when reduction will facilitate the surgery and when the quality of patient’s life may be affected as a result of extensive surgery, but we must be cautious against excessive manipulation during reduction, which may result in perforation and dissemination of malignant cells. In all circumstances, we should adopt the oncologic principles when performing resection for all colonic intussusceptions in view of the risks for malignancy. We conclude that laparoscopic resection of both enteric and colonic adult intussusceptions is safe and feasible. The accurate diagnosis with CT abdomen before surgery is paramount to the safe undertaking of laparoscopic approaches. Although dealing with enteric intussusceptions did not require a great deal of laparoscopic technical expertise, the same could not be said of colonic intussusceptions. The surgeons performing the surgery must have already acquired advanced laparoscopic skills in performing elective laparoscopic colectomy. As for the role of operative reduction, we advocate attempting with caution for all intussusceptions in the absence of bowel ischemia. ACKNOWLEDGMENT The authors thank the Director General of Health, Malaysia, for permission to publish this paper. r
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REFERENCES 1. Begos DG, Sandor A, Modlin IM. The diagnosis and management of adult intussusception. Am J Surg. 1997;173: 88–94. 2. Siow SL, Chea CH, Hashimah AR, et al. Adult intussusception: 5-year experience in Sarawak. Med J Malaysia. 2011;66:199–201. 3. Goh BK, Quah HM, Chow PK, et al. Predictive factors of malignancy in adults with intussusceptions. World J Surg. 2006;30:1300–1304. 4. Azar T, Berger DL. Adult intussusception. Ann Surg. 1997;226:134–138. 5. Ellis H. Special Forms of Intestinal Obstruction in Schwartz Maingot Abdominal Operations. Englewood Cliffs, NJ: Prentice-Hall; 1990:905–906. 6. Cohen MD, Lintott DJ. Transient small bowel intussusceptions in adult celiac disease. Clin Radiol. 1978;29:529–534. 7. Knowles MC, Fishman EK, Kuhlman JE, et al. Transient intussusception in Crohn disease: CT evaluation. Radiology. 1989;170(pt 1):814. 8. Visvanathan R, Nichols TT, Reznek RH. Acquired immune deficiency syndrome-related intussusceptions in adults. Br J Surg. 1997;84:1539–1540. 9. Alonso V, Targarona EM, Bendahan GE, et al. Laparoscopic treatment for intussusception of the small intestine in the adult. Surg Laparosc Endosc Percutan Tech. 2003;13:394–396. 10. Kokoska ER, Nadig DE, Kokoska MS, et al. Colo-colonic intussusceptions in an adult: an unusual presentation of perforated diverticulitis. Tech Coloproctol. 2000;4:115–117. 11. Zubaidi A, Al-Saif F, Silverman R. Adult intussusceptions: a retrospective review. Dis Colon Rectum. 2006;49:1546–1551. 12. Wang LT, Wu CC, Yu JC, et al. Clinical entity and treatment strategies for adult intussusceptions: 20 years’ experience. Dis Colon Rectum. 2007;50:1941–1949. 13. Yakan S, Caliskan C, Makay O, et al. Intussusception in adults: clinical characteristics, diagnosis and operative strategies. World J Gastroenterol. 2009;15:1985–1989.
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14. VanderKolk WE, Snyder CA, Figg DM. Cecal-colic adult intussusceptions as a cause of intestinal obstruction in Central Africa. World J Surg. 1996;20:341–344. 15. Cole GJ. A review of 436 cases of intestinal obstruction in Ibadan. Gut. 1965;6:151–162. 16. Gayer G, Zissin R, Apter S, et al. Pictorial review: adult intussusception—a CT diagnosis. Br J Radiol. 2002;75: 185–190. 17. Ouyang EC, Stockwell D, Carr-Locke DL. Ileocolonic intussusceptions. MedGenMed. 2005;7:15. 18. Palanivelu C, Rangarajan M, Senthilkumar R, et al. Minimal access surgery for adult intussusception with subacute intestinal obstruction: a single center’s decade-long experience. Surg Laparosc Endosc Percutan Tech. 2007;17:487–491. 19. Barussaud M, Regenet N, Briennon X, et al. Clinical spectrum and surgical approach of adult intussusceptions: a multicentric study. Int J Colorectal Dis. 2006;21:834–839. 20. El-Sherif OF. Laparoscopy in the management of an adult case of small bowel intussusceptions. Surg Laparosc Endosc. 1998; 8:21–25. 21. Cunningham JD, Vine AJ, Karch L, et al. The role of laparoscopy in the management of intussusception in the Peutz-Jeghers syndrome: case report and review of the literature. Surg Laparosc Endosc. 1998;8:17–20. 22. Nagorney DM, Sarr MG, McIlrath DC. Surgical management of intussusception in the adult. Ann Surg. 1981;193:230–236. 23. Kim BS, Kang KH, Park HC, et al. Laparoscopic colectomy of colonic intussusceptions in adults. J Korean Surg Soc. 2012;83:397–402. 24. Park KJ, Choi HJ, Kim SH, et al. Sigmoidorectal intussusception of adenoma of sigmoid colon treated by laparoscopic anterior resection after sponge-on-stick-assisted manual reduction. World J Gastroenterol. 2006;12:146–149. 25. Lee SY, Park WC, Lee JK, et al. Laparoscopic treatment of adult sigmoidorectal intussusception caused by a mucinous adenocarcinoma of the sigmoid colon: a case report. J Korean Soc Coloproctol. 2011;27:44–49.
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A Case Series of Adult Intussusception Managed Laparoscopically Sze Li Siow, MBBS, MRCS, MS and Hans Alexander Mahendran, MD, MS
Objective: Adult intussusception is rare, representing only 1% to 5% of bowel obstructions. This is a case series of 8 patients who presented with intestinal obstruction secondary to intussusception managed laparoscopically at our institution.
January 2010 to December 2012. Data reviewed were type and location of intussusceptions, clinical presentation, preoperative radiologic findings, operative techniques, postoperative outcomes, length of hospital stay, and follow-up.
Methods: Eight cases of adult intussusceptions were treated laparoscopically at our institution between January 2010 and December 2012. The presentation, diagnosis, management strategy, and pathology involved were reviewed.
Operative Procedure
Results: Three patients presented with small-bowel obstruction, whereas 4 had recurrent bouts of abdominal pain and 1 had persisting diarrhea. Computed tomography scan was performed in all but 1 of our patients and was accurate in diagnosing in all instances. Laparoscopy and resection of the intussusceptions was completed successfully in all patients. There were no intraoperative and postoperative complications. Four patients underwent laparoscopyassisted small-bowel resection; 3 patients underwent right hemicolectomy and 1 had anterior resection. All patients recovered uneventfully. Conclusions: Laparoscopic management of adult intussusception is safe and feasible. Further, diagnostic laparoscopy is useful when the diagnosis is uncertain despite computed tomography scan imaging. Key Words: adult intussusception, enteric intussusceptions, colonic intussusceptions, laparoscopy, therapy
(Surg Laparosc Endosc Percutan Tech 2014;24:327–331)
I
ntussusception occurs when there is telescoping of a proximal segment of intestine and its mesentery (intussusceptum) into the distal segment (intussuscipiens). It occurs rarely in adults, accounting for 5% of all intussusceptions diagnosed.1 Unlike intussusception in the pediatric population, adult intussusception is usually associated with a pathologic lead point often necessitating surgical resection. There is increasing evidence supporting the feasibility and safety of laparoscopy in the management of this rare clinical entity.
MATERIALS AND METHODS Study Population This study reviewed 8 adult patients (above 18 y of age) who were diagnosed with intussusception and had laparoscopic treatment at Sarawak General Hospital from Received for publication May 23, 2013; accepted August 27, 2013. From the Department of Surgery, Sarawak General Hospital, Kuching, Sarawak, Malaysia. The authors declare no conflicts of interest. Reprints: Sze L. Siow, MBBS, MRCS, MS, Department of Surgery, Sarawak General Hospital, Jalan Hospital, 93584, Kuching, Sarawak, Malaysia (e-mail: [email protected]). Copyright r 2014 by Lippincott Williams & Wilkins
Surg Laparosc Endosc Percutan Tech
The operative approach depended on the types of intussusceptions. The following describes our techniques and approaches to both enteric and colonic intussusceptions.
Enteric Intussusceptions The surgery was performed under general anesthesia with the patient supine. The surgeon and the camera surgeon stood on the left side of the patient with the monitor placed opposite to them. Nasogastric tube and urinary catheter were routinely inserted. Antibiotic prophylaxis (intravenous cefoperazone 1 g and intravenous metronidazole 500 mg) was administered to all patients. An 11- or 12mm Xcel camera port was inserted at the left flank at the level of the umbilicus under direct telescopic visualization, and two 5-mm working trocars were placed at the left hypochondrium and left iliac fossa. An additional 5-mm trocar was placed according to the need of the surgery as a retraction port. Laparoscopic exploration was performed using a 30degree 10-mm laparoscope, with the patient placed in the Trendelenburg position. Examination of the small bowels was performed using an atraumatic grasper, starting from the collapsed, nondilated loop and moving proximally toward the intussusception, using a “hand-to-hand” or “hand-over-hand” running of bowel technique. Initial reduction was attempted briefly for all cases of enteric intussusceptions as there were no signs of bowel ischemia. The atraumatic grasper was applied transversely across the whole length of the bowel diameter proximal to the apex of the intussusceptum, while another atraumatic grasper was applied on the distal bowel. The force was applied to both the graspers using the traction-countertraction technique. Care was taken not to perforate the bowels during manipulation, and reduction was attempted only in nonischemic bowel. If the intracorporeal reduction was unsuccessful, then extracorporeal reduction was performed. The intussusception can be delivered through a minilaparotomy incision (3 to 4 cm) in the periumbilical region or a small transverse skin crease incision (3 to 4 cm) over the site of the pathology. The bowel was then resected extracorporeally, and the anastomosis was performed using either hand-sewn or linear cutter techniques. Laparoscopy-assisted right hemicolectomy was performed for 2 patients with enteric intussusception, both being ileocolic intussusceptions. One patient had intussusception secondary to typhoid colitis (Fig. 1), whereas the other had
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FIGURE 1. Ileocolic intussusception secondary to typhoid colitis.
an ileal polyp. Both patients were placed in the Trendelenburg position with the right side up. The surgeon and the camera surgeon stood to the left of the patient. During the initial laparoscopic assessment, both intussusceptums lay in the ascending colon, with the distal ileum noted to be invaginated into the ascending colon. However, in both cases, neither the small bowel nor the colon was grossly distended. Hence, attempt was made to reduce it, using a combination of “distal pushing against the intussusception/milking” and “traction-countertraction” techniques.
Colonic Intussusceptions The patient was placed in a modified lithotomy position. The surgeons stood to the left of the patient in case of colocolic intussusception and to the right of the patient in case of sigmoidorectal intussusception (Fig. 2). Laparoscopy-assisted extended right hemicolectomy was performed for colocolic intussusception due to a villous adenoma of the proximal transverse colon. The positioning of the patient and surgical team was similar to that of right hemicolectomy for ileocolic intussusceptions. In this patient, we failed at the attempt of reduction and proceeded
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with en bloc extended right hemicolectomy. The challenges of performing en bloc resection included the following: first, the anatomy of the blood supply to the colon was distorted and the colon was invaginated along with a considerable length of bowel into the intussuscipiens, making the dissection to isolate the vessels difficult. Second, the normal loose areolar tissue plane between the colon and the posterior peritoneum was replaced by edematous thickened tissue, making the separation of the plane difficult. Nevertheless, the surgery conformed to the oncologic principles, achieving the control of vessels in the early phase of dissection, followed by medial to lateral approach and retroperitoneal tunneling. At the end of the surgery, the specimens were delivered through a small transverse skin incision, with extracorporeal stapled anastomoses performed. In the patient with sigmoidorectal intussusception, we attempted a laparoscopic approach as we are familiar performing laparoscopic resection for colorectal carcinoma. The abdomen was approached using the trocar position meant for a standard laparoscopic anterior resection. The intraoperative findings were that the sigmoid colon carcinoma had telescoped into the rectum, forming a mass in the rectum. The inferior mesenteric artery was invaginated into the intussuscipiens. We attempted reduction as the intussusceptum had descended into the mid-rectum but we were unsuccessful. Laparoscopic low anterior resection was performed in the normal manner with en bloc resection of the intussuscepted colon. The conventional medial to lateral dissection behind the sigmoid mesocolon was difficult because of the limited space caused by the intussusception and compounded by the edematous sigmoid mesocolon. Instead, the division of the lateral attachment of sigmoid and descending colon was performed first before returning to medial to lateral dissection. The use of the nylon tape to lift the sigmoid colon had further exposed the window between the mesocolon and Toldt fascia. It was then that the origin of inferior mesenteric artery was identified, doubly clipped proximally with hemolock, and divided. The mesenteric vein was identified at the level of the inferior border of the pancreas, clipped with hemolock, and divided. Rectal mobilization began with division of the peritoneum on the right and then left, followed by posterior rectal dissection along the avascular plane of Heald and anteriorly in front of the Denonvillers fascia. Rectal transection was performed using an endostapler at a level much lower than what was anticipated for sigmoid colon carcinoma because of the prolapsing of sigmoid carcinoma into the mid-rectum. Hence, a diverting loop ileostomy was performed at the end of the surgery as there was concern regarding tissue edema jeopardizing the anastomosis and also because it is the standard procedure in our unit when low anterior resection is performed. Histopathologic examination revealed a 50 35 mm in diameter by 10 mm in depth moderately differentiated adenocarcinoma with a TNM staging of T3N0M0. The patient made an uncomplicated recovery and was discharged home 4 days after surgery and referred for adjuvant chemotherapy.
RESULTS FIGURE 2. Sigmoidorectal intussusceptions secondary to sigmoid adenocarcinoma.
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Laparoscopic surgery was performed successfully in all 8 patients with no conversions. The summary of the patients’ demographic, clinical presentation, types r
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Adult Intussusception Managed Laparoscopically
TABLE 1. Summary of Patients’ Demographic Data, Clinical Presentation, Surgical Treatment, and Pathology
No.
Age (y)
1
25
2
Sex
Clinical Presentation
Type of Intussusception
Male
Surgical Treatment
Pathology
56
Chronic Ileocolic symptoms Female Acute symptoms Sigmoidorectal
Laparoscopy-assisted right hemicolectomy Laparoscopy-assisted low anterior resection and covering ileostomy
3
74
Male
4
63
Female Acute symptoms Colocolic
5
55
Male
6
25
7
24
8
78
Laparoscopy-assisted resection Laparoscopy-assisted hemicolectomy Laparoscopy-assisted resection Laparoscopy-assisted resection Laparoscopy-assisted hemicolectomy Laparoscopy-assisted resection
Acute symptoms Ileoileal
Chronic Jejunojejunal symptoms Male Acute symptoms Jejunojejunal (Fig. 3) Female Chronic Ileocolic symptoms Male Subacute Ileoileal (2 sites) symptoms
small-bowel
Suggestive of typhoid colitis Moderately differentiated adenocarcinoma of sigmoid colon, T3N0M0 Nodular lymphoid hyperplasia
extended right Villous adenoma of transverse colon small-bowel small-bowel right small-bowel
Non-Hodgkin diffuse large B-cell lymphoma Benign polyp Hyperplastic Peyer patches of terminal ileum Bifocal intestinal neuroendocrine carcinoma
“Acute symptoms” indicates symptoms 14 days.
of intussusception and operation, and pathologic data are illustrated in Table 1. Overall, there were 5 men and 3 women, with a mean age of 50 (range, 24 to 78) years. Computed tomography (CT) scan of the abdomen and pelvis was performed for 7 patients, except for 1 patient who was misdiagnosed to have perforated appendicitis and was diagnosed intraoperatively through diagnostic laparoscopy. Patients were classified into enteric or colonic intussusceptions on the basis of the site of the lead point, which was examined at the end of the surgery. An intussusception was considered enteric if the pathologic lead point was located in the jejunum or ileum (jejunojejunal, ileoileal, and ileocolic intussusceptions) and colonic if the lead point was located in the colon only (colocolonic and sigmoidorectal intussusceptions) (Fig. 3). Intracorporeal reduction was possible for 2 patients with enteric intussusceptions and none for colonic intussusceptions. However, extracorporeal reduction was performed for the rest of the enteric intussusceptions to minimize the extent of resection. Surgery was technically more difficult in colonic than enteric intussusceptions when the intussusceptions could not be reduced intracorporeally. Of these, 2 patients had right hemicolectomy, 1 had extended right hemicolectomy, 1 had low anterior resection, and 4 had laparoscopy-assisted small-bowel resection. None of the patients had any complications such as bleeding, wound infection, anastomotic leak, or visceral organ injuries. In 1 patient with ileoileal intussusception, we unexpectedly identified another ileoileal intussusception at the more proximal bowel during the delivery of the distal intussusception through the wound. All patients had an uneventful postoperative recovery. The mean operating time and postoperative stay were 105 (range, 60 to 240) minutes and 3.9 (range, 3 to 5) days, respectively. Histopathologic examination showed a malignant lead point in 3 of 8 patients (37.5%; Table 1). At a mean follow-up of 24.2 (range, 4 to 44) months, 1 patient with multiple ileoileal intussusceptions secondary to neuroendocrine tumors had developed peritoneal recurrence 6 months after surgery. r
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DISCUSSION In our previous study involving 14 cases of adult intussusceptions, treated in 4 major hospitals in Sarawak over 5 years, 93% of the intussusceptions were noted to be associated with a pathologic lead point.2 Malignancy accounted for 50% of adult intussusceptions, with majority of colonic intussusceptions proven to be malignant, in contrast to enteric intussusceptions, only one third of which were proven to be malignant.2 In our current single institution study of a small cohort, we found a lowered incidence of malignancy, in 3 of 8 patients (37.5%) with intussusceptions. The clinical presentation of adult intussusception is variable with nonspecific symptoms and signs. Most patients had chronic symptoms and most of them had symptoms suggestive of intestinal obstruction.1,3,4 It accounts for 1% to 5% of all intestinal obstructions in adults.1,5 All of the 8 adult patients in our series presented with clinical features of intestinal obstruction. However, half of them had acute symptoms. The exact mechanisms of intussusceptions remain uncertain. An alteration of normal peristaltic activity of the
FIGURE 3. Jejunojejunal intussusception secondary to benign polyp.
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bowel has been postulated as the etiology in adult intussusceptions. Possible mechanisms can include both primary (idiopathic) and secondary. Several secondary mechanisms have been postulated and included either the presence of an intraluminal mass acting as a lead point resulting in invagination of the involved wall during normal peristalsis1,4 or a functional disturbance without bowel wall abnormality.6,7 This can be caused by diseases such as celiac disease,6 Crohn disease,7 acquired immunodeficiency syndrome,1,8 and previous abdominal surgery. The most common locations for intussusception are at the interface between the mobile and fixed or retroperitoneal segments of the bowels, such as the ileocecal region, and in areas of adhesions9 or prior inflammations10 that cause bowel fixation, allowing the proximal bowel to telescope into the distal bowel lumen. The classification of intussusceptions is tailored to the anatomic location of the lead point. It is classified as enteric when the lead point is located in the small bowel and colonic when the lead point is in the colon. Enteric intussusceptions include jejunojejunal, ileoileal, and ileocolic intussusceptions, whereas colonic intussusceptions include ileocecal-colic, colocolonic, sigmoidorectal, and appendicocecal intussusceptions. In the west and developed countries, enteric intussusceptions form the most common type.11–13 We have made a similar observation here in Sarawak, Malaysia. However, the same could not be said of the central and Western Africa, where they reported that their most common variety is the cecal-colic type.14,15 The variability and nonspecific nature of the clinical presentation makes it challenging to establish a correct clinical diagnosis. Preoperative diagnosis is best achieved with abdominal CT,1,4 which we strongly recommend to be performed as part of preliminary investigation of intestinal obstruction or any acute abdomen. The CT features of intussusceptions are virtually pathognomonic and include a target or doughnut signs on transverse view, and pseudokidney or sausage signs on longitudinal view.16 Other supporting evidence includes presence of fat within the mass, which represents the intussuscepted mesenteric fat, and mesenteric vessels entering the involved loops.16 The role of CT is not only limited to diagnosis alone, but also facilitates laparoscopic approach in all cases, especially in acute presentations, when laparotomy is usually indicated. The feasibility and safety of laparoscopy in diagnosis and treatment of adult intussusceptions have been documented in several studies.9,17,18 Our study further supports the use of laparoscopy in management of adult intussusceptions with no morbidity and zero mortality. In adult intussusceptions, the proximal bowel loops are usually of normal caliber and are occasionally dilated, making it feasible to manipulate with a certain degree of force.16 As such, we recommend a gentle attempt at reduction for all cases of intussusceptions provided that there is no evidence of bowel ischemia or edema. However, appropriate judgment and caution should be exercised and use of undue force should be limited. The roles of laparoscopy in small-bowel intussusceptions differ from those of colonic intussusceptions. The focus is on localization of the pathology and its delivery through a planned transverse incision or minilaparotomy.18,19 This technique has become our procedure of choice when dealing with small-bowel diseases. We believe that an extracorporeal rather than intracorporeal resection and anastomosis should be attempted as any length of small-bowel intussusceptions could be exteriorized through a 3 to 4 cm skin crease
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incision, thus avoiding formal laparotomy and its associated complications. Exteriorization of the small bowels allows manual reduction to be attempted extracorporeally, in the event of failed intracorporeal reduction. The use of wound protector is important when exteriorizing bowels for extracorporeal resection and anastomosis as to prevent possible dissemination of cancer cells to the wound. In our series, complete intracorporeal reduction could only be achieved in 2 patients of enteric intussusceptions and none in colonic intussusceptions. The logical explanations would be that the adult intussusception is of a chronic nature, associated with some degrees of bowel and mesenteric edema. The size of the lead point and dense adhesions around the intussuscepted mass are other factors that render the reduction of the intussusceptum difficult. Further, it appears that small-bowel intussusceptions have a better success rate in laparoscopic reduction than their colonic counterparts.20,21 These are the considerations that need to be taken into account when performing laparoscopic intracorporeal reduction. En bloc resection should be performed for patients suspected to have primary carcinoma. The proponent of this concept subscribe to the principles that attempted reduction may lead to intraluminal seeding or venous embolization of malignant cells.22 However, the theory lacks supportive evidence as clinical cases are scarce. In this respect, some authors have proposed for cautious use of reduction if en bloc resection entails extensive surgeries, such as abdominoperitoneal resection, which may compromise the patient’s quality of life,22,23 or extensive smallbowel resection, which may result in short-bowel syndrome. In the event of sigmoidorectal intussusceptions, there have been reports on combined approach of pulling the proximal colon above the intussusception and pushing the invaginated distal end from the anus with a lubricated sponge-onstick.9,23,24 One author described the use of the circular stapler body through the anus to push the intussusceptions up while simultaneously reducing it using a grasper.25 We concur with the latter opinion in judicious use of reduction in certain circumstances such as when reduction will facilitate the surgery and when the quality of patient’s life may be affected as a result of extensive surgery, but we must be cautious against excessive manipulation during reduction, which may result in perforation and dissemination of malignant cells. In all circumstances, we should adopt the oncologic principles when performing resection for all colonic intussusceptions in view of the risks for malignancy. We conclude that laparoscopic resection of both enteric and colonic adult intussusceptions is safe and feasible. The accurate diagnosis with CT abdomen before surgery is paramount to the safe undertaking of laparoscopic approaches. Although dealing with enteric intussusceptions did not require a great deal of laparoscopic technical expertise, the same could not be said of colonic intussusceptions. The surgeons performing the surgery must have already acquired advanced laparoscopic skills in performing elective laparoscopic colectomy. As for the role of operative reduction, we advocate attempting with caution for all intussusceptions in the absence of bowel ischemia. ACKNOWLEDGMENT The authors thank the Director General of Health, Malaysia, for permission to publish this paper. r
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