Adult Cecoanal Intussusception Caused by Cecum Cancer: Report of a Case

We report a case of cecoanal intussusception caused by cecum cancer in a 29-year-old woman. The patient presented to our hospital with a mass protruding from the anus. We manually pushed the mass back into the rectum and performed a gastrograffin enema, which showed a cup-shaped filling defect in the rectum. The defect was moved back to oral side with the pressure of the enema, revealing a tumor originating in the cecum. Colonoscopy showed a protrusion, 5 × 3 cm in size, in the cecum. Laparotomy confirmed that the tumor originated at the bottom of the appendix in the cecum. We performed partial resection of the cecum containing the tumor and appendix. The pathological finding was submucosal adenocarcinoma in adenoma. Cecoanal intussusception is extremely rare and, to our knowledge, this adult case represents the first report documented in the world scientific literature.     

Adult ileoileal intussusception induced by an ileal lipoma diagnosed preoperatively: report of a case and review of the literature

We herein report a case of adult ileoileal intussusception induced by an ileal lipoma. A 68-year-old woman with a history of small intestinal tumors was admitted to our hospital with severe, colicky lower abdominal pain, similar to episodes experienced in the past. A barium meal enema at the initial admission demonstrated a small intestinal tumor in the ileum 30 cm proximal to the ileocecal valve. Abdominal ultrasound sonography and computed tomography showed a sausage-shaped mass presenting as a target sign in the right lower abdomen, suggestive of intussusception. There was also a round mass of fat attenuation representing a lipoma, which was considered the lead point of the intussusception. The patient underwent emergency surgery and partial resection of the ileum, including the ileal tumor, following reduction of the intussusception. The resected specimen contained a round tumor measuring 1.5 × 1.5 × 1.4 cm, which was diagnosed histopathologically as an intestinal lipoma. The patient made a satisfactory recovery and was discharged on postoperative day 10. The clinical characteristics of previously reported lipomas with intussusception are also discussed, including the relationships between the tumor size and symptoms or location.     

Manual laparoscopy-assisted intraoperative reduction for adult ileocolic intussusception with ileal adenoma: A case report

IntroductionAdult intussusception is a rare condition with a pathological lead point. Intraoperative reduction of adult intussusception can eliminate the need for extensive or invasive resection. We safely performed a manual laparoscopy-assisted intraoperative reduction that allowed functional preservation of tissue.Presentation of caseA 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 thickening and invagination into the ascending colon on computed tomography. Emergency laparoscopic surgery was chosen to treat the ileocolic intussusception. First, the right colon was mobilized. Second, the ileocecal region was pulled through a 4-cm right pararectus incision. Third, the edge of the intussusceptum was gently manipulated back upstream without tearing. After reduction, a soft mass was recognized on palpation at the lead point, located 10 cm proximal to the ileocecal valve. Ileocecal resection was performed, and a laterally spreading tumor was observed in the resected specimen. The histological diagnosis was high-grade tubular adenoma. The postoperative course was uneventful.DiscussionAdult 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.ConclusionManual laparoscopy-assisted intraoperative reduction with a minilaparotomy was safely performed, which eliminated the need for extensive or invasive resection.     

Laparoscopic appendectomy for appendiceal intussusception assisted by colonoscopy: A case report

IntroductionAppendiceal intussusception sometimes results from appendiceal cancer. Ileocecal resection instead of appendectomy is often chosen as a treatment as it is technically difficult to resect the appendix alone without causing dissemination of appendiceal cells to the abdominal cavity. Herein, we present the first report of a case in which appendiceal intussusception was treated by resection of the appendix alone via simultaneous colonoscopy and laparoscopy.Presentation of caseA 40-year-old man underwent laparoscopic appendectomy for appendiceal intussusception. Since a neoplastic cause could not be completely ruled out, we planned to carry out oncologically safe appendectomy that would not expose the tumor to the abdominal cavity. The resection was performed in the lumen of the cecum rather than in the abdominal cavity to prevent dissemination of appendiceal cells to the peritoneal cavity during surgery. Histopathologic examination revealed chronic inflammation of the appendix but no malignancy. The postoperative course was uneventful.DiscussionHere, we present a case in which laparoscopic resection of the mesoappendix and colonoscopy-assisted resection of the appendix were performed in combination in a patient with appendiceal intussusception. When the possibility of malignancy is low, this maneuver may prevent patients from undergoing ileocecal resection with lymph node dissection as it prevents exposure of the abdominal cavity to the tumor.ConclusionSimultaneous performance of laparoscopy and intraoperative colonoscopy is feasible and, from an oncological viewpoint, may be preferable when the cause of appendiceal intussusception is unknown or malignancy is not suspected.     

Laparoscopic "radical appendectomy" is an effective alternative to endoscopic removal of cecal polyps

BACKGROUND: The endoscopic removal of cecal polyps can be complicated by hemorrhage, perforation, or incomplete resection. Laparoscopic radical appendectomy represents a safe alternative for the definitive resection and accurate pathologic evaluation of selected cecal polyps. METHODS: Patients with cecal cap polyps not involving the ileocecal valve were candidates for laparoscopic radical appendectomy. Intraoperative colonoscopy and resection of the appendix and cecum to the level of the ileocecal valve were accomplished via three midline ports. For each patient, histologic evaluation by frozen section ruled out malignancy and ensured complete resection. RESULTS: Five patients, four of whom had significant medical comorbidities, presented with large adenomatous polyps contained within the cecum. Each polyp was determined to be unresectable endoscopically; therefore, a laparoscopic radical appendectomy was performed. One patient with cirrhosis also underwent intraoperative liver ultrasonography and biopsies, which contributed to the longest operative time and hospital stay. The histologic diagnosis by frozen section was benign for each patient. The mean operative time was 95 minutes, and the mean length of hospital stay was 1.8 days. No postoperative complications were observed during a mean follow-up of 6 months. CONCLUSION: Laparoscopic "radical appendectomy" is an effective treatment for selected cecal adenomatous polyps. Our ability to resect the polyps completely and avoid a standard right hemicolectomy supports this approach.     

Laparoscopic surgery for colon cancer with intestinal malrotation in adults: Two case reports and review of literatures in Japan

IntroductionIntestinal malrotation is a congenital anomaly, and its occurrence in adults is rare. Colon cancer with intestinal malrotation is far more rare. We herein report two cases of colon cancer with intestinal malrotation treated with laparoscopic surgery and reviewed the literatures in Japan.Presentation of casesCase 1 involved a 78-year-old man. Abdominal enhanced computed tomography (CT) showed that the tumor was located in the sigmoid colon. Intraoperatively, the cecum and ascending colon were located along the midline and the small intestine occupied the right side of the abdomen. The tumor was located in the cecum, and the patient was diagnosed with cecal cancer with intestinal malrotation. We performed laparoscopy-assisted ileocecal resection. Case 2 involved a 81-year-old man. Colonoscopy revealed a laterally spreading tumor in the cecum. Intraoperatively, the position of the small intestine and the ascending colon was similar to case 1, and Ladd’s band was found in front of the duodenum. Thus, we diagnosed the patient with a laterally spreading cecal tumor with intestinal malrotation and performed laparoscopy-assisted ileocecal resection.DiscussionA review of the literature revealed 49 cases of colon cancer with intestinal malrotation and laparoscopic surgery performed at 30.6%. If laparoscopic mesenteric excision for colon cancer with intestinal malrotation is unsafe because of the abnormalities of the artery, mesenteric excision should be performed outside the body.ConclusionIf the intestinal malrotation is diagnosed preoperatively, 3D-CT angiography should be used to reveal the vascular anatomic anomalies for safe performance of laparoscopic surgery.     

Single-Incision Laparoscopic Surgery for Colon Cancer in Patient with Situs Inversus Totalis: Report of a Case

A preliminary experience with single-incision laparoscopic colectomy for colon cancer with situs inversus totalis (SIT) is reported. An 87-year-old man was admitted because of a fecal occult blood. A colonoscopy revealed cecal cancer. An air-barium and a computed tomography contrast enema showed the right-sided descending colon and the left-sided ascending colon and cecum. The surgical procedures were as follows: First, a Lap protector was inserted through a 2.5-cm transumbilical incision. Three 5-mm ports were placed in the Lap protector. We successfully performed ileocolectomy with lymph node dissection by using a single-incision laparoscopic approach without any technical problems. The operative time was 125 min, and blood loss was negligible. Postoperative follow-up did not reveal any umbilical wound complications and recurrences.     

Hydrostatic reduction of intussusceptions caused by lead points

It is generally accepted that an intussusception caused by a lead point will not be reduced by hydrostatic barium enema. This was reported several years ago, and has continued to be a consistent finding, prompting us to attempt hydrostatic barium enema reductions of recurrent intussusceptions in infants and children and also in older children with a first intussusception. However, in the last 9 years we have treated five children whose ileocolic intussusceptions were caused by lead points but which were reduced by hydrostatic barium enema. The histories and physical examinations were not any different than those of the average pediatric patient with an intussusception. The ileocolic intussusceptions diagnosed by barium enema were reduced with adequate reflux of barium into the terminal ileum. However, a residual and persistent filling defect in the colon or ileocecal area made laparotomy mandatory. In all five cases, a lead point was found and resected. This experience has suggested to us that a residual intraluminal filling defect in the barium column following what appears to be adequate flooding of the terminal ileum should be interpreted as a lead point, and an indication for a laparotomy.     

Cystic lymphangioma of the cecum with ileocecal intussusception: Case report.

A rare case of cystic lymphangioma of the cecum presenting as a leading point for ileocecal intussusception is described. Local resection is recommended.     

Ileocecal intussusception in an adult: the laparoscopic approach.

Adult intussusception is uncommon and requires a surgical approach. Malignancy is associated with 31% (43/137) of small bowel intussusception and 70% (74/106) of large bowel intussusception. Computerized tomography (CT) findings are pathognomonic for this condition. Often, the patient presents with long-standing, nonspecific complaints. A 63-year-old man presented with sudden onset of abdominal pain. CT demonstrated colonic inflammation. A laparoscopic right hemicolectomy for ileocecal intussusception was performed. The pathology report revealed a lipoma of the cecum. The postoperative course was uneventful, and he was discharged the fifth postoperative day. Despite a high incidence of malignancy, colonic or ileocecal intussusception can be successfully treated by laparoscopic resection. Review of the literature and treatment options are discussed.     

Intussusception caused by a carcinoma of the cecum during pregnancy: Report of a case and review of the literature

A case of intussusception due to a carcinoma of the cecum during pregnancy is reported. A 27-year-old pregnant female was admitted to Shimodate Municipal Hospital because of abdominal pain, nausea and vomiting. Her abdomen was distended, and a relatively hard mass was palpable in the right hypochondrium. Following a diagnosis of intussusception by ultrasonography, a laparotomy was performed. The lesion causing the intussusception was found to be a carcinoma of the cecum, and thus a right hemicolectomy with lymph node dissection was carried out. Histological examination revealed that the tumor was a well-differentiated adenocarcinoma which had invaded the muscularis propria but was superficial to the subserosa. None of the lymph nodes were cancerous. The incidence of colonic cancer above the peritoneal reflection during pregnancy is very low. Only 24 cases have been previously reported; our patient is only the 25th case, as well as being the first case demonstrating Dukes' A. Due to the intussusception, ultrasonography was effective for diagnosis and the patient was able to undergo a curative operation at an earlier stage than other patients.     

Intussusception in the 1970s: Indications for operation

Eighty-one patients with proven intussusception were treated at the Cincinnati Children's Hospital from 1970–1974. One died. Seven of these had ileo-ileal intussusception, all treated surgically. Seventy-four had colonic components of their intussusceptions. In 58 of these patients (78%), reduction was attempted at barium enema, successfully in 32. Hydrostatic reduction was abandoned and the patient operated upon when the intussusception was not pushed out of the colon, when barium failed to reflux into several loops of ileum, or when there was a large persistent filling defect in the cecum or terminal ileum. Primary operation without barium enema was done in 16 patients. The appearance of intestinal obstruction by abdominal x-ray seemed to give the best warning about the complicated, incarcerated, or gangrenous intussusception. Primary operation is, therefore, advised for the patient with intussusception if there is x-ray evidence of intestinal obstruction. The age of the patient and the duration of his symptoms do not seem important in this regard, except as they correlate with peritonitis or obstruction. For the patient without peritonitis or intestinal obstruction, attempted reduction of the intussusception at barium enema seems safe and effective, regardless of the patient's age or duration of his symptoms.     

Intussusception: barium or air?

At The Hospital For Sick Children, the use of air has recently replaced the use of barium in the reduction of intussusceptions. The purpose of this study was to review the results from 200 consecutive patients with intussusceptions, 100 patients treated with barium enema and 100 patients treated with air enema. The groups were similar with regard to sex, average and median ages, and presenting symptoms and signs. Successful reduction was achieved in 75% of episodes of intussusception treated with barium enema and 76% treated with air enema. Failure of either modality showed a high association with the presence of either a lead point or an ileoileal or ileoileocolic intussusception. Among those cases of unsuccessful reduction, operation was performed in all 59 cases; resection in 30 cases, manual reduction in 19, and spontaneous reduction was found in 10. There were three perforations during attempted reduction with barium and two with air. All perforations were treated by resection and primary anastomosis. There were 18 recurrent intussusceptions following barium enema reduction and nine following air enema reduction. Therefore, with the lower absorption of x-rays by air and the relatively inert nature of air (compared with barium in the event of a perforation), we feel that air enema is the treatment of choice in the initial management of intussusception.     

Submucous large-bowel lipomas--presentation and management. An 18-year study.

Gastrointestinal lipomas are rare, but commonest in the colon and rectum, characteristically submucosal and seldom subserosal. An 18-year analysis revealed 17 cases of large-bowel lipoma, 13 presenting with colicky pain, abdominal discomfort, blood-stained feces or rectal bleeding and altered bowel habits and four asymptomatic. The 17 patients had totally 21 lipomas, all submucosal. No patients with multiple lipoma had evidence of lipoma at other sites. The ileocecal valve and cecum were most commonly affected, followed by the rectum, sigmoid colon and descending colon. Tumor size (largest diameter) was 0.5-10 cm, averaging 3.1 cm (3.5 cm in symptomatic, and 1.8 cm in asymptomatic patients). The primary diagnosis (with barium enema, colonoscopy and CT) was lipoma in only five cases, but CT gave the correct diagnosis in all three cases in which it was used. Two lipomas were found in surgical specimens from colorectal malignancy, while nine were misinterpreted as polyps and one as angiodysplasia. In symptomatic patients unnecessary colotomy or colonic resection may be avoidable by colonscopic removal of lipoma.     

小儿坏死性肠套叠外科治疗84例分析

目的 探讨小儿坏死性肠套叠的病因、诊断、低压空气灌肠复位的作用、手术治疗及并发症的防治。方法 对经手术治疗的84例小儿坏死性肠套叠进行回顾性分析。结果 本组原发性肠套叠73例,继发性肠套叠11例。套叠类型回-结肠型68例,小肠型12例,结-结肠型4例。全组均行套叠复位加坏死肠段切除一期吻合术。术前误诊5例,死亡3例。结论 ①局部解剖因素是小儿肠套叠发生的主要原因;②B超检查有助于肠套叠的诊断;③对于复发性肠套叠不宜反复多次地进行低压空气灌肠复位;④手术原则是对于高度怀疑肠管坏死的不能姑息,应积极切除,但同时亦应尽可能多地保留有活力的肠管及回盲瓣。     

Laparoscopic treatment of ileocecal intussusception caused by primary ileal lymphoma

Intussusception seldom occurs naturally in adults, but is frequently found due to an underlying disease. We present the case of a 46-year-old man with the chief complaint of repeated abdominal cramping pain, especially in the right lower quadrant, and diarrhea of 1 year's duration. Abdominal sonography and computed tomography showed ileocecal intussusception, and colonoscopy found one protruding tumor at the cecum. Biopsy of the tumor revealed malignant lymphoma cells. Due to persistent symptoms, fear of intestine obstruction caused by further intussusception, and the possibility of mesenteric vascular compression, the patient underwent laparoscopic right hemicolectomy before systemic chemotherapy. The symptoms were relieved successfully after surgery. We emphasize that the majority of adults with intussusception may have an underlying malignancy. The most important rule in treatment is avoidance of tumor emboli spread during manipulation. Therefore, a trial of reduction of the intussuscepted intestine should be prohibited.     

Sigmoid colon cancer with mediastinal lymph node metastases

Mediastinal lymph node metastasis from colorectal cancer is rarely seen. We herein report on a 74-year-old man who was hospitalized with multiple brain metastases and mediastinal lymph node metastasis from an adenocarcinoma of the sigmoid colon. A preoperative brain magnetic resonance image showed multiple brain tumors, and a chest computed tomography (CT) scan indicated a mediastinal tumor. CT-guided aspiration biopsy cytology of the mediastinal tumor showed metastatic adenocarcinoma from a digestive tract tumor. Barium enema and sigmoid colonoscopy showed that the cancer was located in the sigmoid colon. Laparoscopic assisted sigmoidectomy with lymph node dissection was performed. Pathological findings of the specimen showed a moderately differentiated adenocarcinoma that invaded to the subserosa, but no evidence of lymph node metastasis was found. The patient was discharged 3 weeks after the operation and died 3 months later.     

Cecal volvulus

The cecum is the second most common site of colonic volvulus after the sigmoid. The mechanism is torsion or hyperflexion of the enlarged, poorly-fixed, and hypermobile cecum. It presents clinically as an acute bowel obstruction with strangulation. Diagnosis can be made by plain abdominal X-ray in more than half the cases on the basis of cecal distention (with a classical "teardrop" or "comma" appearance), proximal small bowel distention with air-fluid levels, and a gasless distal colon. Barium enema shows lack of filling of the cecum, often with a "beaked" termination of the column of contrast. CT images are pathognomonic when they reveal a cecal "vortex". After surgical reduction of the torsion, ileo-cecal resection is usually the best therapeutic alternative. Cecopexy may be aDDrouriate in older and debilitated Datients if there is no concomitant cecal necrosis.     

Pediatric total colonoscopy

One hundred fifty-one total colonoscopies were performed in 105 children ranging from 1 month to 15 years of age. The cecum was reached successfully in 136 examinations without complications, generally within 30 minutes. Our major indications for total colonoscopy were abnormal findings in a contrast enema, undiagnosed rectal bleeding, and possible organic lesion causing intussusception. All procedures were performed using sedation only. The pediatric gastroscope was employed for total colonoscopy on infants less than 6 years of age; the cecum was reached successfully in 98 of 106 procedures with this instrument. Our total colonoscopy series contributed to the diagnosis of various disorders in 86 children and of normality in the 19 remaining children. The results suggest that, if performed with proper precautions and techniques, total colonoscopy is a safe and useful procedure with which to examine the entire colon of infants and children.     

Continent catheterizable urinary diversion using the ileocecal segment with stapled intussusception of the ileocecal valve

A continent ileocecal reservoir was created as an alternative to ileal loop urinary diversion in 7 patients. In 3 patients the bladder neck was closed, the in situ bladder was augmented and a continent stoma was formed by intussusception of the ileocecal valve. In the remaining 4 patients an isolated cecal reservoir with a continent stoma replaced the bladder. Creation of a stoma that was continent and easy to catheterize was achieved by intussusception of the ileocecal valve with stabilization of the intussuscepted nipple using a Marlex collar. In most cases the cecal segment was hyperactive but this was controlled with anticholinergic medication. All 7 patients have a satisfactory capacity and a continent stoma without significant catheterization difficulties.