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Journal of the Korean Society of Coloproctology 2008;24:134-136 DOI: 10.3393/jksc.2008.24.2.134
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Spontaneous Jejunal Intussusception after a Colectomy: A Rare Cause of Postoperative Intestinal Obstruction - A Case Report Research Institute and Hospital, National Cancer Center, Goyang, Korea
Seok-Byung Lim, M.D., Hee Jin Chang, M.D., Jun Yong Jeong, M.D., Hyo Seong Choi, M.D., Seung-Yong Jeong, M.D.
Intussusception is a rare cause of intestinal obstruction in adults and is most often due to a primary abnormality of the bowel, which serves as the leading point. Idiopathic intussusception in adults is distinctly uncommon, comprising 10% of diagnosed intussusceptions. We report a case of a spontaneous jejunal intussusception in a 48-year-old man that developed shortly after an open colectomy. The 48-year-old man, with no history of a laparotomy, underwent a left hemicolectomy and a left hemihepatectomy for descending colon cancer with liver metastasis. For 14 postoperative days, the patient complained of ileus, and conservative management with a long intestinal tube failed. When the patient underwent a laparotomy, intussusception of the mid jejunum was observed. The intussusception was resected, and no underlying bowel abnormality was identified. This report highlights the importance of considering this rare etiology in patients with ileus who have recently undergone a laparotomy.
pathological condition, while 10% have no discernable 2
cause. The present report describes a case of intussusception where no underlying cause was identified.
CASE REPORT A 48-year-old man, with no history of a laparotomy, presented with intermittent epigastric pain and constipation of 2 months duration. A colonovideoscope indicated a descending colon mass suggestive of a malignancy, while abdominopelvic computed tomography (CT) scanning indicated two hepatic metastases at S4 and S8 (3.0 cm and 1.5 cm respectively). The pathology diagnosis from a colonoscopic biopsy of the colonic mass was a moderately differentiated adenocarcinoma. An uncompli-
J Korean Soc Coloproctol 2008;24:134-136
cated left hemicolectomy and extended left hemihepatec-
Key Words: Intussusception, Idiopathic, Bowel obstruction
tomy were performed through an abdominal incision. Examination of the bowel did not reveal any extrinsic
abnormalities. For 8 postoperative days the patient complained no flatus and abdominal distension. An
INTRODUCTION
abdominal X-ray series showed a bowel gas pattern Adult intussusception represents 5% of all intussuscep-
suggestive of ileus. Conservative management with a long
tion cases, and intussusception accounts for only 1∼5%
intestinal tube was undertaken for 6 days. Owing to a lack
of all causes of intestinal obstruction in adults. Almost
of clinical radiological resolution, the patient underwent
90% of adult intussusception cases are secondary to a
a laparotomy. Abdominal sonography or computed tomo-
1
graphy were not performed. In the operating room, intussusception of the mid jejunum was observed (Fig. 1).
Received August 8, 2007, Accepted March 13, 2008 Correspondence to: Seung-Yong Jeong, Research Institute and Hospital, National Cancer Center, 809, Madu-dong, Ilsan-gu, Goyang 411-764, Korea Tel: +82-31-920-2480, Fax: +82-31-920-2002 E-mail:
[email protected]
No other intra-abdominal organs, including the previously anastomosed colon, showed abnormalities. The intussusception was resected and found to be 15 cm in length. Grossly, there was no organic lesion, except adhesion. At
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Lim SB, et al. Spontaneous Jejunal Intussusception after a Colectomy: A Rare Cause of Postoperative Intestinal Obstruction 135
10% of cases, is more likely to occur in the small intestine, as was observed in present case, it can occur in the colon.2,4 Since the obstructive symptoms are dominant in most cases, the initial imaging usually involves plain abdominal films, which generally show findings consistent with ileus and may provide information regarding the site of obstruction.5 Few reports are available regarding the management of idiopathic adult intussusception. Although a report on 37 cases of adult small bowel intussusception found conservative management successful in 84% of cases,6 many clinicians recommend surgical intervention Fig. 1. Intraoperative-appearance of the jejunal intussusception segment (left). Pathology examination revealed adhesions (right upper) with subserosal fibrosis and reactive mesothelial hyperplasia (arrow, right lower). Tumor was not identified in the intestine.
due to considerations of the underlying etiology and the risk of bowel ischemia. Unenhanced CT may characterize the degree of vascular compromise and predict the need and urgency for surgery.7 In addition to the timing of surgical intervention, the extent of resection and whether or not the intussusception should be reduced remain
the subserosa, there was fibrosis with reactive mesothelial
matters of controversy. Due to the risk of perforation and
hyperplasia and suture granuloma (Fig. 1). Ten resected
spillage of bowel contents and tumor into the peritoneal
mesenteric lymph nodes showed reactive hyperplasia.
cavity, many surgeons advocate en-bloc resection of the
There was no surgical morbidity and the patient was
lesion without reduction.1,2 However, a selective approach
discharged 10 days later.
of reduction before resection has been proposed in other reports.5,8 Treatment of adult intussusception depends
DISCUSSION
largely upon its cause, location and the viability of the bowel.9 If a tumor is present, the tissue is ischemic or
In adults, intussusception is distinctly uncommon,
the intussusception is localized to the colon, resection is
representing approximately only 1% of all causes of
the recommended.1,2,5,8,9 Since small intestinal lesions are
1
intestinal obstruction.
While the exact mechanism
usually benign, reduction is initially recommended to
underlying intussusception development is unknown, any
avoid resecting a long intestinal segment, unless there are
lesion in the bowel wall or irritant within the lumen that
signs of bowel ischemia or a suspected malignancy.9 In
alters normal peristaltic activity is believed capable of
the present case, reduction was impossible due to the long
2,3
initiating an invagination.
In adults, an organic lesion
is found within an intussusception in over 90% of cases, with
few
idiopathic
intussusceptions
having
intussusception length (15 cm), so a small bowel segment including the intussusception was resected.
been
In this case, small bowel intussusception occurred
reported.1,2 In general, the majority of lead points in small
immediately postoperatively. Of the different diagnoses
intestine consist of benign lesions such as benign
for a postoperative patient with ileus, the etiology of
neoplasms, inflammatory lesions, Meckel’s diverticuli,
adhesion is the most common. However, as the present
appendix, adhesions, and intestinal tubes. Malignant
case illustrates, rare conditions such as intussusception
lesions (either primary or metastatic) account for up to
must be considered.
2
30% of cases of intussusception in the small intestine.
The mechanisms underlying idiopathic intussusception development are also not well understood. Although idiopathic adult intussusception, which accounts for about
136 대한대장항문학회지: 제 24 권 제 2 호, 2008
REFERENCES 1. Azar T, Berger DL. Adult intussusception. Ann Surg 1997;226:134-8. 2. Begos DG, Sandor A, Modlin IM. The diagnosis and management of adult intussusception. Am J Surg 1997; 173:88-94. 3. Takeuchi K, Tsuzuki Y, Ando T, Sekihara M, Hara T, Kori T, et al. The diagnosis and treatment of adult intussusception. J Clin Gastroenterol 2003;36:18-21. 4. Haas EM, Etter EL, Ellis S, Taylor TV. Adult intussusception. Am J Surg 2003;186:75-6. 5. Eisen LK, Cunningham JD, Aufses AH Jr. Intussusception in adults: institutional review. J Am Coll Surg 1999; 188:390-5. 6. Lvoff N, Breiman RS, Coakley FV, Lu Y, Warren RS. Distinguishing features of self-limiting adult small-bowel intussusception identified at CT. Radiology 2003;227: 68-72. 7. Fujimoto T, Fukuda T, Uetani M, Matsuoka Y, Nagaoki K, Asoh N, et al. Unenhanced CT findings of vascular compromise in association with intussusceptions in adults. AJR Am J Roentgenol 2001;176:1167-71. 8. Martin-Lorenzo JG, Torralba-Martinez A, Liron-Ruiz R, Flores-Pastor B, Miguel-Perello J, Aguilar-Jimenez J, et al. Intestinal invagination in adults: preoperative diagnosis and management. Int J Colorectal Dis 2004;19: 68-72. 9. Napora TE, Henry KE, Lovett TJ, Beeson MS. Transient
adult jejunal intussusception. J Emerg Med 2003;24:395400.
국문 초록 대장수술 후 장폐쇄의 드문 원인인 공장의 특발성 장중첩증 1예 국립암센터 대장암센터 임석병ㆍ장희진ㆍ정준용ㆍ최효성ㆍ정승용
성인에서의 장중첩증은 장폐쇄를 일으키는 흔치 않은 질환이며, 대부분 장관의 일차적인 이상이 선두점 (leading point)으로 작용한다. 선두점이 없는 성인의 특 발성 장중첩증은 성인 장중첩증의 10%의 빈도로 매우 드물다. 저자들은 개복대장절제술 직후에 공장에서 발 생한 특발성 장중첩증 1예를 보고한다. 증례는 과거 수술력이 없는 48세 남자 환자로 간전이가 동반된 하 행결장암으로 좌반결장절제술과 좌측 간엽절제술을 시행하였다. 수술 후 14일 동안 환자는 장마비가 지속 되었고 장관 내 튜브를 이용한 보존적 치료를 시행하 였으나 실패하였다. 환자는 개복술을 시행 받았고, 공 장부위의 장중첩증을 발견하여 중첩된 장을 절제하였 다. 수술소견과 병리소견상 특별한 이상소견은 관찰되 지 않았다. 중심단어: 성인 장중첩증, 특발성, 장폐쇄
