Adult intussusception: A 15‐year retrospective review

Objective: Adult intussusception is an uncommon disease and is usually associated with malignancy. In many cases, diagnosis is made only in the theatre as a result of its non‐specific presentation and low index of suspicion. By reporting the present study, we would like to share our experience in managing this condition. Methodology: Patients with the diagnosis of intussusception admitted to Queen Elizabeth Hospital within the period 1996–2010 were included. Demographic data, presenting symptoms, and operative and pathological findings were collected and analysed. Results: There were 37 adult intussusceptions in the study period; 18 of them were female and 19 of them were male. The mean age of the patients was 67 years. More than 40% of the patients had subacute onset of the symptoms. Abdominal pain was the most common presenting symptom, present in 83.5% of the patients. Preoperative diagnosis was made in 62.2% of the cases and all of these received either preoperative computed tomography and/or ultrasonography. There were nine enteric and 28 colonic intussusceptions. A pathological lead‐point could be identified in 83.8%, and their size ranged from 2 cm to 8 cm. The malignant lead‐point was larger than the benign one lead‐point (4.74 vs 3.3, P = 0.021). Malignancy was found in 33.3% of the enteric lesions and 60.7% of the colonic lesions. respectively. Age older than 70 years was found to be an associated risk factor for malignancy (P = 0.022). Conclusion: Intussusception should be considered as one of the differential diagnoses, especially in elderly patients complaining of subacute abdominal pain. Computed tomography scan should be the imaging of choice. Oncological resection should be carried out without attempt of reduction if the patient is older than 70 years, having colonic intussusception and containing a large lead‐point.     

Adult intussusception.

OBJECTIVE: The objectives were to review adult intussusception, its diagnosis, and its treatment. SUMMARY BACKGROUND DATA: Adult intussusception represents 1% of all bowel obstructions, 5% of all intussusceptions, and 0.003%-0.02% of all hospital admissions. Intussusception is a different entity in adults than it is in children. METHODS: The records of all patients 18 years and older with the postoperative diagnosis of intussusception at the Massachusetts General Hospital during the years 1964 through 1993 were reviewed retrospectively. The 58 patients were divided into those with benign enteric, malignant enteric, benign colonic, and malignant colonic lesions associated with their intussusception. The diagnosis and treatment of each were reviewed. RESULTS: In 30 years at the Massachusetts General Hospital, there are 58 cases of surgically proven adult intussusception. The patients' mean age was 54.4 years. Most patients presented with symptoms consistent with bowel obstruction. There were 44 enteric and 14 colonic intussusceptions. Ninety-three percent of the intussusceptions were associated with a pathologic lesion. Forty-eight percent of the enteric lesions were malignant and 52% were benign. Forty-three percent of the colonic lesions were malignant and 57% were benign. CONCLUSIONS: Intussusception occurs rarely in adults. It presents with a variety of acute, intermittent, and chronic symptoms, thus making its preoperative diagnosis difficult. Computed tomography scanning proved to be the most useful diagnostic radiologic method. The diagnosis and treatment of adult intussusception are surgical. Surgical resection of the intussusception without reduction is the preferred treatment in adults, as almost half of both colonic and enteric intussusceptions are associated with malignancy.     

Giant lipoma causing a colo-colonic intussusception

Intussusception is much more common in children than in adults. Unlike in children, intussusception in adults is associated with an identifiable etiology in 90 per cent of cases. Lipomas are the second most common benign tumors of the colon. Small lipomas are usually asymptomatic and are found incidentally during colonoscopy. Giant lipomas are uncommon causes for colonic intussusception. This usually presents as abdominal pain and vomiting and less commonly as diarrhea. Computed tomography is an excellent method to diagnose giant colonic lipomas, by showing a well demarcated, round, low-attenuated lesion in the lumen of the colon. The definitive treatment for symptomatic lipomas is surgical resection. Both laparoscopic and open resections have been described. Endoscopic resection of colonic lipomas is associated with a high complication rate. In this report, we present a patient with a giant colonic lipoma causing colocolonic intussusception.     

Predictive Factors of Malignancy in Adults with Intussusception

Introduction Adult intussusception is an unusual entity, and its etiology differs from that in pediatric patients. The aim of this study was to evaluate our experience of 60 adult patients with intussusception and determine if there are any preoperative factors predictive of malignancy. Methods The records of 60 adult patients (> 18 years of age) with a diagnosis of intussusception surgically treated at Singapore General Hospital and Changi General Hospital between 1990 and 2004 were retrospectively reviewed. The intussusceptions were classified as enteric or colonic. Preoperative predictive factors of malignancy were analyzed using univariate and multivariate analyses, and P < 0.05 was considered statistically significant. Results There were 60 patients with a median age of 57.5 years (range 21–85 years). Altogether, 34 (56.7%) patients were male, and there were 31 enteric and 29 colonic intussusceptions. A lead point was identified in 54 patients (90%). A total of 22 (36.7%) patients presented with intestinal obstruction, and the correct preoperative diagnosis of intussusception was made in 31 patients (51.7%). Computed tomography was the most useful diagnostic modality, correctly identifying an intussusception in 24 of 30 patients. A malignant pathology was present in 8 of 31 (26%) enteric versus 20 of 29 (69%) colonic intussusceptions. Age (P = 0.009), the presence of anemia (P < 0.001), and the site of the intussusception (P = 0.001) showed significant differences between the benign and malignant groups by univariate analyses. On multivariate analysis, intussusception in the colon (P = 0.004) and the presence of anemia (P = 0.001) were independent predictive factors of malignancy. Conclusions Adult intussusception is most commonly secondary to a pathologic lead point. The site of intussusception in the colon and the presence of anemia are independent preoperative predictors of malignancy. All colonic intussusceptions should be resected en bloc without reduction, whereas a more selective approach can be applied for enteric intussusceptions.     

Intussusception in adults: a retrospective study

Objective Intestinal intussusception in adult patients is rare. In contrast with paediatric patients, it is usually secondary to a definable lesion, often malignant. The purpose of this study was to determine the causes and the management of intussusception in adult patients. Method A retrospective review was performed looking at patients over 18 years with intestinal intussusception who were admitted to a tertiary university hospital from 1997 to 2007. Result There were 16 patients (out of whom 10 were female subjects) of mean age 49 years (range 19–76). All presented with abdominal pain and in seven (46.6%) patients, this was acute. The diagnosis of intussusception was correctly made preoperatively in eight (50%) patients. Six (37.5%) patients had the lead point for the intussusception at the ileocaecal valve, five (31.25%) in the small bowel and five (31.25%) had a colonic lead point. An anatomical cause was found in 14 (87.5%). In two (12.5%), the intussusception occurred in the postoperative period without any definable lesion. Half the patients had a malignant neoplasm. All patients underwent surgery. In 14 (87.5%) patients, this was by resection and in two (12.5%), a reduction with no resection was carried out. Conclusion The features of intussusception may be nonspecific and the diagnosis is often made only during laparotomy. An identifiable organic lesion is present in most cases. En bloc resection is recommended for ileocaecal and colocolic intussusception.     

Adult colonic intussusception

Objective: To study the clinical characteristics, investigations, management and pathology in adult colonic intussusception. Methods: A retrospective study of seven adult patients who were operated on for the diagnosis of colonic intussusception in our department from January 1999 to September 2003 was carried out. The case records of the seven patients were retrieved. Their clinical presentations, investigations, operative records and pathology were studied. Results: The mean age of the patients was 67.4 years. There were four men and three women. Five of the patients presented with chronic non‐specific symptoms and the other two patients presented with acute symptoms. Transabdominal ultrasonography (USG) and computed tomography (CT) scan were used for investigation. In the majority of the patients (87.5%), radiological features of intussusception were shown by USG or CT scan. All seven patients underwent laparotomy exploration with bowel resection. Six patients (85.7%) had lead points with definable pathology. Within the lead points, five patients had primary malignant lesions. Conclusion: With more liberal use of imaging techniques, more adult intussusception can be diagnosed before explorative surgery. Ultrasound would be an ideal tool for initial evaluation. In view of the high chance of associated malignancy, adult colonic intussusception should be resected without prior reduction at the time of surgery.     

大肠脂肪瘤15例报告

目的 探讨大肠脂肪瘤的外科治疗方法。方法 回顾性分析我院40年间手术治疗的15例大肠脂肪瘤患者的临床资料。结果 其临床表现为不同程度的腹痛、大便次数增多和黏液血便。术前均经钡剂灌肠或纤维结肠镜检查。术前诊断为结肠良性肿瘤1例，大肠恶性肿瘤14例。15例均经手术治疗。病理报告为大肠脂肪瘤。结论 大肠脂肪瘤易误诊为大肠恶性肿瘤，临床上当病人全身情况良好，且并发慢性肠套叠可考虑到有大肠脂肪瘤的可能。     

Intussusception in adults: a 21-year experience in the university-affiliated emergency center and indication for nonoperative reduction

BACKGROUND: While intussusception is relatively common in children, it is rare in adults. METHODS: We retrospectively reviewed the records of all patients older than 18 years with the diagnosis of intussusception between 1981 and 2001. RESULTS: Eleven patients with surgically or endoscopically proven intussusception were encountered at the University-affiliated emergency center. The patients ranged in age from 19 to 88 years with a mean age of 45 years. Males predominated by a ratio of 7:4. Most patients (82%) presented with symptoms of bowel obstruction. The mean duration of symptoms was 4.5 days with a range of 4 h to 25 days. Correct pre-treatment diagnosis was made in 82% of the patients using abdominal ultrasonography and computed tomography (CT). The causes of intussusception were organic lesions in 64% of the patients, postoperative in 18% and idiopathic in 18%, respectively. 73% of patients had emergency operations, and an attempt at nonoperative reduction was performed and completed successfully in 3 patients with ileo-colic or colonic type of intussusception. There have been no cases of morbidity or mortality in our series and no recurrence has occurred up to the present time. CONCLUSIONS: Abdominal ultrasonography and CT were effective tools for the diagnosis of intussusception. Patients with ileo-colic and colonic intussusception without malignant lesions could be good candidates for nonoperative reduction prior to definitive surgery.     

巨大结肠脂肪瘤并发肠套叠误诊为结肠癌五例分析

目的 总结巨大结肠脂肪瘤的外科诊断和治疗经验,提高对本病的认识,减少误诊.方法 回顾性分析5例被误诊为结肠癌的巨大结肠脂肪瘤合并肠套叠患者的临床资料,探讨造成误诊的原因.结果 结肠脂肪瘤是一种少见的结肠良性肿瘤,肿瘤体积增大后可出现腹痛、血便、腹部包块,甚至肠套叠、肠梗阻等症状,临床医师缺乏对其认识常将其误诊为结肠癌.钡灌肠及结肠镜检查足诊断结肠脂肪瘤的重要手段,但容易受操作者主观印象的误导;增强CT扫描能客观地反映肿瘤密度和解剖特点.外科治疗首选手术切除病变肠段.结论 巨大结肠脂肪瘤误诊率高,尤其并发肠套叠后易被诊断为结肠癌.     

Seminal vesicle‐rectal fistula: A review of an unusual complication following low anterior resection for rectal cancer

Low anterior resection is the most common operation in the USA for low rectal cancers. Seminal vesicle‐rectal (SV‐R) fistula is an extremely uncommon complication of this operation. The objective of the present literature review was to investigate risk factors that lead to the development of SV‐R fistula, clinical presentation, investigation and management options. There were nine articles of relevance which reported a total of 12 cases of SV‐R fistula. All other iatrogenic or cryptogenic fistula were excluded. Twelve cases were identified in the literature, and we describe one further case. Pneumaturia and fever were presenting symptoms in 10 of 13 cases; 69.2 per cent (n = 9) of cases presented within 2 weeks of the procedure. Computed tomography was the investigation of choice in nine of 13 cases. A variety of surgical and conservative management plans were utilized. Conservative management was successful in 46.1 per cent (n = 6) of cases. The present study provides the first concise review of SV‐R fistula following low anterior resection and adds a further case. It is also the first article of its kind to recommend a treatment algorithm that consists of a trial of conservative management.     

Acute intestinal intussusceptions in adults: analysis of 20 cases

AIM OF THE STUDY: To report our experience in the management of acute intestinal intussusceptions in adults. PATIENTS AND METHODS: Retrospective study of data of patients older than 15 years who were operated on for acute intestinal intussusceptions from January 1997 to December 2001. RESULTS: Twelve of the patients were males and eight females with an average age of 41 years (range: 16-71). The clinical and radiological findings were suggestive of bowel obstruction (N = 14), peritonitis (N = 5) and appendicular abscess (N = 1). Correct preoperative diagnosis of acute intestinal intussusceptions was established in 6 cases. Type of intussusception was jejunojejunal (N = 1), ileo-ileal (N = 8), ileocolic (N = 1), ileocecocolic (N = 7) and colocolic (N = 3). Necrosis was found in the intussusceptum in 10 cases and a tumor on the lead point in 14 cases (5 benign lesions and 9 malignant ones). For intussusception involving the colon, all patients underwent en bloc resection with immediate anastomosis, while intussusception located on the small bowel were treated by surgical reduction (N = 1), en bloc resection (N = 8) with immediate (N = 7) or delayed (N = 1) anastomosis. The mortality rate was 15%. CONCLUSION: In our experience, intussusceptions in adults is not an uncommon clinical entity but correct diagnosis is often established peroperatively. En bloc resection is recommended because of the frequency of neoplasms and bowel ischemia.     

Open-magnet MR defaecography compared with evacuation proctography in the diagnosis and management of patients with rectal intussusception

Objective The aim of this study was to determine whether open‐magnet magnetic resonance (MR) defaecography could provide more useful clinical information than evacuation proctography (EP) alone in the evaluation of a cohort of patients with full‐thickness rectal intussusception and could assist in decisions concerning management. Methods Ten patients (4 male; median age 43, range 30–65) with symptomatic circumferential rectal intussusception diagnosed on EP, underwent open‐magnet MR defaecography. Pathologies visible with each technique were recorded and 12 parameters of anorectal configuration and morphology measured and compared. Results There was discordance in the diagnosis of rectal intussusception in three cases. In another two patients, MR defaecography demonstrated mucosal descent only. Measurements of anorectal configuration and morphology were similar between techniques; only rectal size and lateral dimensions of the rectocoele were significantly different, being smaller on MR defaecography than EP. Two patients were shown on MR defaecography to have significant bladder descent and two female patients had significant vaginal descent. Conclusion EP remains the first line investigation for the diagnosis of rectal intussusception, but may not distinguish mucosal from full‐thickness descent. MR defaecography further complements EP by giving information on movements of the whole pelvic floor, 30% of the patients studied having associated abnormal anterior and/or middle pelvic organ descent. If surgery is planned for patients with rectal intussusception, MR defaecography provides useful information regarding the presence and degree of anterior pelvic compartment descent that may need to be addressed if a good functional outcome is to be achieved.     

Laparoscopy-assisted resection of ileoileal intussusception caused by intestinal lipoma

Intussusception is the second most common abdominal emergency in children. In contrast, it is rare in adults. Adult intussusception represents only 1%-3% of patients with bowel obstruction. Although 95% of intussusception in children is idiopathic, merely 7% of adult intussusception is considered idiopathic. Owing to vague symptoms and signs, the preoperative diagnosis of adult intussusception is difficult. Once adult intussusception is diagnosed, surgical intervention is indicated because about half of both colonic and small intestinal intussusceptions are caused by malignant lesions. In this paper, we describe a case of ileoileal intussusception caused by an intestinal lipoma that was diagnosed preoperatively by computed tomography scans and was treated successfully by laparoscopy-assisted surgery. The patient was discharged uneventfully 4 days after the operation. We recommend laparoscopy-assisted surgery as a feasible therapeutic option for adult intussusception.     

Dysplasia in the ileoanal pouch

Formation of an ileo‐anal pouch is an accepted technique following colectomy in the surgical management of ulcerative colitis (UC) and familial adenomatous polyposis (FAP). The configuration of pouches and anastomotic techniques has varied over the last two decades. The increased use of stapling devices in formation of the pouch‐anal anastomosis avoids the need for endoanal mucosal stripping and may contribute to improved functional results, but leaves a ‘columnar cuff’ of residual rectal mucosa in situ. Concerns regarding the long‐term safety of the ileo‐anal pouch have been raised by reports of the occurrence of dysplasia in the pouch mucosa and 15 cases of adenocarcinoma. In UC, persistence of underlying disease in the residual rectal mucosa, anal transition zone and columnar cuff provides the site for development of dysplasia and malignancy. Pouchitis is unlikely to be a major cause of dysplasia or malignancy, as long‐term follow‐up of patients with Koch pouches has demonstrated. In FAP, any persistent rectal mucosa and mucosa of the small intestine is at risk of adenomatous dysplasia due to the genetic alterations causing the disease. Long‐term surveillance should focus on all FAP pouch patients, and in UC patients should be directed towards the diagnosis of residual rectal mucosa in the area distal to the pouch anastomosis. Specialist histopathological opinion is essential in the diagnosis of dysplasia in the ileo‐anal pouch.     

Community teaching hospital surgical experience with adult intussusception: Study of nine cases and literature review

IntroductionAlthough more commonly thought of as a surgical problem affecting children, surgeons evaluating the adult acute abdomen should remain vigilante in diagnosing intussusception. In this case series, we reviewed 6 years of medical records at a community teaching hospital in order to analyze the etiology, presentation, and management of nine cases of adult intussusception.Presentation of casesMost of the patients in our series shared symptoms of nausea, vomiting, and abdominal pain. Computed tomography scan was crucial in distinguishing adult intussusception from other causes of acute abdomen. Eight patients underwent operative exploration, five of whom underwent bowel resection. One patient’s symptoms resolved with no surgical intervention. All nine patients had excellent outcomes.DiscussionAlthough detailed history and physical examination are essential in all cases of acute abdomen, CT scan findings of “target” signs are pathognomonic of intussusception. Laparoscopy should be strongly considered in select cases. Current literature suggests that reduction may be performed before resection if the lesion meets certain stringent parameters. The primary concern with regards to reduction before resection is potential embolization of malignant cells. Colonic intussusception is almost always treated with resection without reduction, while small intestinal intussusception could be treated by reduction before resection, if the small bowel lead points are less likely to be malignant.ConclusionIntussusception is a rare but serious etiology of the acute abdomen in adults. Each case should be evaluated independently according to the specific type of lead-point lesion. Excellent outcomes may be anticipated with prompt diagnosis and surgical treatment.     

Adenocarcinoma of the rectum with associated colorectal adenomatous polyps in tuberous sclerosis: a case report

The authors present the case of a 17-year-old girl with tuberous sclerosis (TS) who presented with symptoms of intussusception. Although endoscopically diagnosed with multiple colonic polyps, presumed to be hamartomas, and an invasive rectal adenocarcinoma, postoperative pathology findings confirmed the rectal cancer and showed multiple colonic adenomas. Multiple colonic adenomatous polyps in a young girl with tuberous sclerosis is extremely rare. Furthermore, we believe that this is the first report of an invasive adenocarcinoma of the large intestine occurring in a patient with TS.     

The dramatic presentation of colonic lipomata: report of two cases and review of the literature

Colonic lipoma with a dramatic presentation requiring urgent operation is a rare occurrence. We report two such cases in conjunction with a review of the literature on colonic lipomata. Clinicopathologic features of two patients who required urgent resection were studied. The preoperative diagnosis of colonic lipoma was suggested on imaging study in one case. A MEDLINE search was conducted with a special goal of revealing cases with a dramatic presentation. One patient presented with rectal bleeding and intussusception related to a partially infarcted 4.5-cm submucosal lipoma of the lower descending colon. The second patient presented with intestinal obstruction related to a near-totally infarcted 6-cm submucosal lipoma at the splenic flexure. In both cases a florid reactive vascular and fibro-/myofibroblastic proliferation and associated hyperplastic mucosal pattern were present at the base and edge of the lipoma. Among 275 previously reported cases of colonic lipoma 28 patients had a dramatic presentation with pain and/or rectal bleeding being the most significant prodromal symptom. In this subset the lipomas tended to be larger, frequently had associated marked necrosis/ulceration, and were less likely to be located in the ascending colon/cecum. Whereas colonic lipomas are relatively common occasional cases present dramatically with massive bleeding, intussusception, or even perforation for which emergency operation is required. Such lipomas usually reveal marked ischemic changes.     

Cancers of the sigmoid and upper rectum extending to the bladder or ureter, treated by monobloc resection. Apropos of 13 cases

The aim of this retrospective study is to assess the operative and functional risks and the results of "en bloc resection" performed for tumors of the sigmoid colon or of the rectum extending to the bladder. Thirteen patients required this resection, the sigmoid was involved in ten cases, the rectum in three. The urinary tract involvement was an operative finding in ten cases, while recurrent cystitis was observed in three cases. This extension reached the dome of the bladder in 11 cases, and the terminal portion of the ureter in 2 cases. All the patients underwent curative "en bloc resection" including colectomy and partial cystectomy or cysto-ureterectomy: operative mortality was 7.6%. Precise histological staging of lymph node and bladder involvement was only obtained in 11 cases; all were Astler Coller's stage B2. In 9 cases the malignant tissue involved the urinary tract; in 2 cases there were only inflammatory adhesions. In all cases the functional urinary results were good. The 5 year direct survival rate was 50%; following Kaplan Meier's actuarial method this rate was 68%. Bladder involvement by a colonic or rectal adenocarcinoma does not seem to have any "en bloc resection" is worthwhile for this kind of extensive prognostic valve.     

Postoperative intussusception in children

BACKGROUND: Postoperative intussusception is an uncommon and sometimes forgotten cause of postoperative intestinal obstruction in children. METHODS: Eleven consecutive cases of postoperative intussusception during a period of 16 years (1981-1997) were analysed retrospectively. RESULTS: Symptoms developed after a median period of 5 days after operation. With one exception, postoperative intussusception was not diagnosed before reoperation. In ten of the 11 cases the intussusception was successfully treated with intraoperative manual reduction. CONCLUSION: Postoperative intussusception is a rare but typical complication in the paediatric age group and should be kept in mind.     

Mucosectomy and stapled pouch‐anal anastomosis in familial adenomatous polyposis

Aim In familial adenomatous polyposis, a restorative proctocolectomy with an ileo‐anal pouch may be performed either with a mucosectomy and a hand‐sewn anastomosis or as a stapled anastomosis without a mucosectomy. The disadvantage of the former is suboptimal bowel function and the disadvantage of the latter is a high risk of recurrent adenomas in the rectal mucosal remnant. Method A procedure is presented that combines the advantages of mucosectomy and stapled ileo‐anal anastomosis. Results No severe complications were seen in 14 patients. After a median follow up of 29 (range 7–144) months, 13 (93%) patients were fully continent day and night with a median frequency of defecation of 5 (range 2–8)/24 h. No adenomas were found at the annual endoscopic follow up. Conclusion Mucosectomy with a stapled ileo‐anal pouch has few complications. Short‐term results show good function and a very low risk of recurrent adenoma development.