Early diagnosis and surgical management in adult ... of...Jejunojejunal n/a Resection of intussusception + mass (1198 Giordano et al., 2017) Jejunal small ectopic pancreas developing

Journal of Case Reports and Images in Surgery, Vol. 6, 2020.

J Case Rep Images Surg 2020;6:100078Z12SK2020. www.ijcrisurgery.com

Karki et al. 1

CASE REPORT OPEN ACCESS

Early diagnosis and surgical management in adult intussusceptions caused by ectopic pancreas

Smriti Karki, Hina Aziz, Joseph Watfah

ABSTRACT

Adult intussusception comprises of only 5% of all intussusception cases with majority occurring in children and accounts for only 1–5% cases of bowel obstruction in adults. Ectopic pancreas is an infrequent anomaly defined as pancreatic tissue that lacks anatomical or vascular communication with the normal body of the pancreas. When reported it is mostly found in the stomach and small intestines but seldom in the colon. We present a case of a 31-year-old male who presented with symptoms of an acute abdomen which was diagnosed as an intussusception of an unknown etiology on a contrast-enhanced computed tomography (CT). The patient was resuscitated and immediately operated on and underwent a right hemicolectomy and eventually an end ileostomy formation. No cause for the intussusception was apparent intra-operatively but histological examination of the resected bowel specimen demonstrated ectopic pancreas. The patient had a very short recovery time without incident which may be attributed to his age and absence of co-morbidities. He was discharged a follow-up plan to discuss the reversal. The patient went on to have reversal of his stoma after six months of the initial surgery with a very good outcome.

Smriti Karki1, Hina Aziz2, Joseph Watfah3

Affiliations: 1Core Trainee Year 1, General Surgery, North-wick Park Hospital, Watford Rd, Harrow, London, HA1 3UJ, United Kingdom; 2Foundation Year 2, General Surgery, Northwick Park Hospital, Watford Rd, Harrow, London, HA1 3UJ, United Kingdom; 3Consultant General Surgeon, Emer-gency Surgery, Northwick Park Hospital, Watford Rd, Har-row, London, HA1 3UJ, United Kingdom.Corresponding Author: Dr. Smriti Karki, Northwick Park Hospital, Watford Rd, Harrow, London, HA1 3UJ, United Kingdom; Email: [email protected]

Received: 03 May 2020Accepted: 24 July 2020Published: 21 August 2020

Keywords: Adult intussusception, Ectopic pancreas, Hemicolectomy, Heterotopic pancreas, Ileo-colic intussus-ception

How to cite this article

Karki S, Aziz H, Watfah J. Early diagnosis and surgical management in adult intussusceptions caused by ectopic pancreas. J Case Rep Images Surg 2020;6:100078Z12SK2020.

Article ID: 100078Z12SK2020

*********

doi: 10.5348/100078Z12SK2020CR

INTRODUCTION

Intussusception is defined as the invagination of a segment of bowel within an immediately adjacent segment and almost invariably occurs from proximal to distal. It is most frequent in children with incidence peaking at 5–10 months of age, becoming less common above two years and is predominantly rare in adults. Adult intussusception represents just 5% of all cases of intussusception and accounts for only 1–5% of cases of adult bowel obstruction [1–3]. Colo-colic type intussusception has been found to be more common in adults [4]. Unlike children, in whom around 90% of cases are idiopathic, adult intussusception is usually secondary to an underlying pathology, such as polyps, Meckel’s diverticulum, strictures, benign neoplasms, or carcinomas [3]. The presentation is mostly insidious in adults, with nonspecific symptoms but can lead to intestinal obstruction and ischemia of the advancing bowel. The primary management in children with uncomplicated intussusception consists of nonoperative reduction with air or barium enema. Adults, however, will typically require surgical intervention to identify the underlying pathology.

CASE REPORT PEER REVIEWED | OPEN ACCESS


Karki et al. 2J Case Rep Images Surg 2020;6:100078Z12SK2020. www.ijcrisurgery.com

Ectopic pancreas is defined as pancreatic tissue that lacks anatomical or vascular communication with the normal body of the pancreas [5]. It is an infrequent congenital anomaly with an incidence of 0.55–13.7% on autopsy series [6, 7]. It has been reported to be most commonly located in the stomach (25–38% of cases), the duodenum (17–36% of cases), and the jejunum (15–22% of cases) although seldom described in other locations, such as Meckel’s diverticulum, colon, gallbladder, umbilicus, fallopian tube, mediastinum, spleen, liver and, as in our case, the ileum [8–10].

A literature review of 528 cases identified the prevalence of ileal heterotopic pancreas to be just 0.2% [11]. Ectopic pancreas (EP) usually presents in the form of small yellow nodules varying in size from 1 to 5 mm, thus can be misdiagnosed as a lipoma as reported on the primary CT scan in our patient’s case. In descending order of occurrence, the involved histologic layers are the submucosa, muscularis propria, and serosa [12]. They are classified according to the Heinrich classification system. Clinically significant lesions tend to be larger than 1.5 cm and involve or are adjacent to the mucosa [13].

Ectopic pancreas in the small intestine is typically benign and therefore most cases are asymptomatic, being discovered incidentally during endoscopy or surgery for another presentation or at autopsy. When symptomatic, patients can present with bleeding, pancreatitis and rarely symptoms associated with malignant transformation or, as in our case, bowel obstruction due to intussusception [8, 14–17]. In some cases it has led to death, as reported in literature [18].

We describe a rare case of an adult presenting with intussusception secondary to EP.

CASE REPORT

A 31-year-old male with no significant past medical history or previous abdominal operations presented with a 1-day history of severe lower abdominal pain, multiple episodes of vomiting, and loose stools. On examination, he had generalized abdominal tenderness with peritonism and absent of bowel sounds. Blood tests on admission displayed a raised white cell count (WCC) of 16 × 109/L, C-reactive protein (CRP) of <0.6 mg/L, and lactate of 6. A contrast-enhanced CT abdomen and pelvis was performed on a suspicion of acute abdomen caused by bowel ischemia. However, it revealed ileo-colic intussusception (Figures 1 and 2). A 26 mm fat density opacity representing a possible lipoma as a lead point.

The patient was resuscitated with intravenous fluids, antibiotics, and analgesia, and was taken to theatre for an emergency laparotomy within 3 hours of presentation. Intra-operatively, 50 cm of terminal ileum was found intussuscepted into 10 cm of ascending colon (Figure 3). Manual reduction was attempted without success. So, a right hemicolectomy was performed. Initially a defunctioning double barrel stoma formation was planned

but not performed at this time due to significant edema of the bowel. After discussion, consensus was for a re-look laparotomy once the patient had stabilized with a view for stoma formation as the ideal approach. Approximately 24 cm of ileum and 17 cm of colon including cecum, ascending and proximal transverse colon were resected and a temporary primary anastomosis was formed. The abdomen was closed by a vacuum-assisted closure dressing. No visible or palpable mass was identified intra-operatively but histological examination of specimen concluded a focal ectopic pancreas. However, grading of the ectopic pancreatic tissue had not been done histologically because of the patchy nature of the tissue.

The patient was initially treated in the surgical intensive recovery unit post-operatively then stepped down to the ward. He required rectus sheath infusion and morphine patient controlled analgesia. The patient was treated with intravenous antibiotics and parenteral nutrition.

Figure 1: Target sign in intravenous contrast-enhanced CT coronal view.

Figure 2: Target sign in intravenous contrast-enhanced CT cross-sectional view.



Tabl

e 1:

A s

umm

ary

of a

ll re

port

ed c

ases

of a

dult

intu

ssus

cept

ion

caus

ed b

y ec

topi

c pa

ncre

as in

lite

ratu

re

Tit

leA

uth

orS

ymp

tom

sD

ura

tion

Imag

ing

Op

erat

ion

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ista

nce

fr

om I

C v

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Sit

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PS

ize

of

HP

Hei

nri

ch

clas

sifi

-ca

tion

Typ

e of

in

tuss

usc

e-p

tion

Pre

viou

s ab

dom

inal

su

rger

y

Tre

atm

ent

Post

-op

Ref

eren

ce

The

role

of

lapa

rosc

opy

in th

e m

anag

emen

t of a

di

agno

stic

dile

mm

a:

Jeju

nal e

ctop

ic

panc

reas

dev

elop

ing

into

jeju

noje

juna

l in

tuss

usce

ptio

n

Gio

rdan

o et

al.

Nau

sea,

in

term

itte

nt

abdo

min

al p

ain

2 da

ysC

T sc

an s

how

s a

spec

ific

thic

keni

ng o

f jej

unum

wit

h pa

rtia

l co

ntra

stog

raph

ic e

nhan

cem

ent

near

the

left

col

on, w

ith

a m

odes

t di

lata

tion

of t

he lu

men

of s

mal

l bo

wel

ups

trea

m o

f the

inju

ry

Dia

gnos

tic

lapa

rosc

opy

Jeju

num

--m

ass

of 4

cm in

di

amet

er w

as

disc

over

ed o

n th

e in

test

inal

se

rosa

l su

rfac

e of

the

anti

mes

ente

ric

side

Type

2Je

juno

jeju

nal

n/a

Res

ecti

on o

f in

tuss

usce

ptio

n +

m

ass

(119

8 G

iord

ano

et a

l.,

2017

)

Jeju

nal s

mal

l ect

opic

pa

ncre

as d

evel

opin

g in

to je

juno

jeju

nal

intu

ssus

cept

ion:

A r

are

caus

e of

ileu

s

Shoj

i H

iras

aki

Inte

rmit

tent

ab

dom

inal

pai

nSe

vera

l m

onth

sPl

ain

abdo

min

al r

adio

grap

hy

show

ed s

ome

inte

stin

al g

as

and

fluid

leve

ls. A

bdom

inal

CT

scan

dem

onst

rate

d a

targ

et s

ign

sugg

esti

ng b

owel

intu

ssus

cept

ion

and

dila

ted

smal

l bow

el. S

ubse

quen

t je

juno

grap

hy u

sing

a n

aso-

jeju

nal

tube

sho

wed

an

oval

-sha

ped

mas

s 15

mm

in d

iam

eter

wit

h a

smoo

th

surf

ace

in th

e je

junu

m, w

hich

su

gges

ted

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bmuc

osal

tum

or

(SM

T), a

nd e

dem

atou

s m

ucos

a ar

ound

the

mas

s

Lapa

roto

my

Jeju

num

3Je

juno

jeju

nal

noTh

e re

sect

ion

of

jeju

num

wit

h 2

cm

mar

gins

and

an

end-

to-e

nd a

nast

omos

is

was

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form

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he

rese

cted

ova

l sha

ped

tum

or, 1

4 ×

11

mm

in

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as c

over

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h no

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osa

and

no u

lcer

or

ero

sion

was

see

n on

the

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igur

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(120

0 H

iras

aki e

t al

., 20

09)

Adu

lt in

tuss

usce

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n an

d ga

stro

inte

stin

al

blee

ding

due

to a

n is

olat

ed h

eter

otop

ic

panc

reas

Wu

et a

l.In

term

itte

nt

abdo

min

al p

ain,

na

usea

, vom

itin

g

1 m

onth

Plai

n ab

dom

inal

film

sho

wed

a

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ted

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l bow

el a

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ssoc

iate

d ai

r flu

id le

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ve o

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truc

tion

. Com

pute

d to

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raph

y sc

ans

of th

e ab

dom

en

reve

aled

an

ileal

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ssus

cept

ion.

A

nod

ule

wit

h an

abu

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t fat

ty

com

pone

nt w

as n

oted

in th

e co

mpu

ted

tom

ogra

phy

scan

(Fig

ure

1), w

hich

incl

uded

sev

eral

str

ips

of h

igh

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ity

insi

de, a

nd w

as

iden

tifie

d at

the

prox

imal

end

of t

he

intu

ssus

cept

ion

Lapa

roto

my

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eum

n/a

6 ×

1.

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n/a

Segm

enta

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ecti

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of th

e ile

um w

ith

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tom

y w

as c

ompl

eted

. A

n en

tero

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nfir

med

the

pres

ence

of a

pe

dunc

ulat

ed n

odul

e (6

0 m

m b

y 18

mm

) w

ith

fatt

y ti

ssue

in

side

Unr

emar

kabl

e(1

207

Wu

et a

l., 2

013)

Het

erot

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pan

crea

s:

A r

are

caus

e of

ileo

-ile

al in

tuss

usce

ptio

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Mon

ier

et a

l.E

piso

des

of

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aena

+

cons

tipa

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1 ye

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tero

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evea

led

a la

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circ

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ial l

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prox

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8.0

× 1

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g th

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rmin

al il

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, whi

ch

acte

d as

a le

adin

g po

int t

o an

ileo

-ile

al in

tuss

usce

ptio

n (F

igur

e 1A

–C

).

Ther

e w

ere

also

oth

er s

mal

l mul

tipl

e sa

telli

te le

sion

s

n/a

Ileu

mSu

bmuc

osal

n/

aIl

eoile

aln/

aR

esec

tion

of t

he

segm

ent c

onta

inin

g th

e su

bmuc

osal

le

sion

was

car

ried

ou

t wit

h si

de-t

o-si

de

anas

tom

osis

.

n/a

(120

8 M

onie

r,

2014

)

Adu

lt I

ntus

susc

epti

on

caus

ed b

y he

tero

topi

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ncre

as

Kok

et a

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ause

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inte

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tent

ab

dom

inal

pai

n

10 d

ays

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iogr

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of t

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hest

and

ab

dom

en a

nd a

bdom

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raso

und

stud

y sh

owed

no

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rmal

itie

s.

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pute

d to

mog

raph

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T) o

f th

e ab

dom

en w

as a

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ged

as

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bstr

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on w

as

high

ly s

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cted

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linic

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d sy

mpt

oms.

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-con

tras

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veal

ed w

all a

nd

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osa

fold

thic

keni

ng, l

umen

di

lata

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in a

seg

men

t of s

mal

l in

test

inal

loop

s ab

out t

he je

juna

l le

vel o

ver

the

left

sid

e of

the

low

er

abdo

men

, and

sof

t tis

sue

mas

s in

the

bow

el lu

men

(Fig

ure

1). A

ta

rget

shap

ed le

sion

con

sist

ing

of

mul

tipl

e co

ncen

tric

rin

gs w

as fo

und

on th

e le

ft s

ide

on c

ontr

aste

nhan

ced

CT

(Fig

ure

2)

Lapa

roto

my

30 c

m fr

om

ligam

ent t

reit

zJe

junu

mSe

rosa

l sur

face

of

anti

mes

ente

ric

side

(3.6

×

2.2

×

1.6

cm

Aci

nar

glan

ds,

duct

ules

, is

lets

Jeju

noje

juna

lno

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t seg

men

t of

intu

ssus

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ions

was

re

duce

d m

anua

lly, a

ye

llow

ish

lipom

atou

s m

ass

(3.6

× 2

.2 ×

1.6

cm

) was

dis

cove

red

on th

e se

rosa

l sur

face

of

the

anti

mes

ente

ric

side

(Fig

ure

3).

Segm

enta

l res

ecti

on

of th

e je

junu

m

incl

udin

g th

e m

ass

and

end-

to-e

nd

anas

tom

osis

was

pe

rfor

med

Unr

emar

kabl

e(1

216

Kok

, 20

07)



Tabl

e 1:

(Con

tinu

ed)

Tit

leA

uth

orS

ymp

tom

sD

ura

tion

Imag

ing

Op

erat

ion

D

ista

nce

fr

om I

C v

alve

Sit

e of

H

P

Lay

er o

f H

PS

ize

of

HP

Hei

nri

ch

clas

sifi

-ca

tion

Typ

e of

in

tuss

usc

e-p

tion

Pre

viou

s ab

dom

inal

su

rger

y

Tre

atm

ent

Post

-op

Ref

eren

ce

Adu

lt I

ntus

susc

epti

on

caus

ed b

y in

vert

ed

Mec

kel’s

div

erti

culu

m

cont

aini

ng m

esen

teri

c he

tero

topi

c pa

ncre

as

and

smoo

th m

uscl

e bu

ndle

s

Lee

et a

l.In

term

itte

nt

abdo

min

al p

ain

+

haem

atoc

hezi

a +

m

alae

na

2 m

onth

sA

n en

dosc

opic

stu

dy w

as u

nabl

e to

lo

cate

the

site

of t

he b

leed

ing.

An

abdo

min

al a

nd p

elvi

c co

mpu

ted

tom

ogra

phy

(CT)

sca

n sh

owed

a

pedu

ncul

ated

intr

alum

inal

mas

s w

ith

cent

ral h

eter

ogen

eous

fat

atte

nuat

ion

Min

i-la

paro

tom

yIl

eum

A n

odul

ar le

sion

w

ithi

n th

e ad

ipos

e ti

ssue

san

dwic

hed

betw

een

the

cont

inuo

us

linin

g of

the

prop

er m

uscl

e la

yers

(Fig

ure

2B).

Mic

rosc

opic

ex

amin

atio

n re

veal

ed th

at th

e bu

lbou

s ti

p le

sion

w

as c

over

ed b

y th

e fu

ll th

ickn

ess

of th

e in

test

inal

w

all a

nd h

ad d

eep

ulce

rati

ons

(Fig

ure

2C).

The

muc

osa

of

the

tip

cont

aine

d no

ndys

plas

tic

epit

helia

l gla

nds.

Fo

cal h

eter

otop

ic

antr

al-t

ype

gast

ric

tiss

ue w

as a

lso

pres

ent (

Figu

res

2C a

nd 3

A).

In

tere

stin

gly,

ec

topi

c pa

ncre

atic

ti

ssue

and

sm

ooth

m

uscl

e bu

ndle

s w

ere

loca

ted

wit

hin

the

entr

appe

d m

esen

teri

c fa

t

5.1

×

3.0

× 2

.8

cm

Type

1Il

eoile

alA

ppen

dect

omy

10 y

ears

ago

Seg

men

tal r

esec

tion

n/

a(1

217

Lee,

20

17)

Intu

ssus

cept

ion

caus

ed b

y a

hete

roto

pic

panc

reas

. C

ase

repo

rt a

nd

liter

atur

e re

view

Cha

ndra

et

al.

Inte

rmit

tent

ab

dom

inal

pai

n,

borb

oryg

mi,

alte

rnat

ing

bow

el

habi

t

3 ye

ars

Ult

raso

und

exam

inat

ion

reve

aled

a

loop

of a

bnor

mal

bow

el in

the

pelv

is e

xten

ding

to th

e ri

ght i

liac

foss

a ov

er w

hich

it w

as n

oted

that

th

e pa

tien

t exp

erie

nced

mar

ked

tend

erne

ss fr

om th

e ul

tras

ound

pr

obe.

It c

onta

ined

con

cent

ric

ring

s of

hig

h an

d lo

w e

chog

enic

ity,

hi

ghly

sug

gest

ive

of a

sm

all b

owel

in

tuss

usce

ptio

n. N

o pr

oxim

al

dila

tati

on w

as n

oted

Lapa

roto

my

n/a

Jeju

num

n/a

60

× 4

0 ×

35

mm

Aci

nar

+

duct

sJe

juno

jeju

nal

n/a

n/a

(122

0 C

hand

ra,

2004

)

Het

erot

opic

pa

ncre

as a

s a

lead

ing

poin

t for

sm

all-

bow

elin

tuss

usce

ptio

n in

a p

regn

ant w

oman

.

Gur

bula

k et

al.

31 w

eeks

gra

vid,

ab

dom

inal

pai

n,

bile

-sta

ined

vo

mit

4 da

ysC

ompu

ted

tom

ogra

phy

of

the

abdo

men

rev

eale

d ‘ta

rget

le

sion

s’ s

ugge

stiv

e of

sm

all b

owel

in

tuss

usce

ptio

n an

d fr

ee-f

luid

in th

e ab

dom

inal

cav

ity

Lapa

roto

my

+ c

-sec

tion

80 c

mIl

eum

n/a

n/a

Aci

ni +

du

cts

Ileo

ileal

n/a

The

ileal

seg

men

t in

volv

ed w

as r

esec

ted

and

an e

nd-t

o-en

d an

asto

mos

is w

as

perf

orm

ed

Unr

emar

kabl

e re

cove

ry fo

r pa

tien

t + b

aby

(122

2 G

urbu

lak,

20

07)

Ileo

ileal

in

tuss

usce

ptio

n du

e to

ile

al e

ctop

ic p

ancr

eas

wit

h ab

unda

nt fa

t ti

ssue

mim

icki

ng

lipom

a

Chu

ang

et a

l.In

term

itte

nt

abdo

min

al p

ain,

ep

isod

ic v

omit

ing

6 m

onth

The

plai

n ab

dom

inal

film

sh

owed

dila

ted

smal

l bow

el, a

nd

com

pute

d to

mog

raph

y (C

T) s

can

of th

e ab

dom

en a

nd p

elvi

s sh

owed

di

lata

tion

of t

he s

mal

l bow

el

and

inva

gina

tion

of t

he s

mal

l bo

wel

into

itse

lf, a

find

ing

whi

ch

sugg

este

d in

tuss

usce

ptio

n (F

igur

e 1)

. Mor

eove

r, a

nod

ule

wit

h an

ab

unda

nt fa

tty

com

pone

nt w

as

iden

tifie

d at

the

prox

imal

end

of t

he

intu

ssus

cept

ion

Lapa

roto

my

n/a

Ileu

mA

cini

+

duct

sIl

eoile

alSe

gmen

tal r

esec

tion

of

the

ileum

wit

h ile

oile

osto

my

was

co

mpl

eted

(122

3 C

huan

g,

2010

)



Tabl

e 1:

(Con

tinu

ed)

Tit

leA

uth

orS

ymp

tom

sD

ura

tion

Imag

ing

Op

erat

ion

D

ista

nce

fr

om I

C v

alve

Sit

e of

H

P

Lay

er o

f H

PS

ize

of

HP

Hei

nri

ch

clas

sifi

-ca

tion

Typ

e of

in

tuss

usc

e-p

tion

Pre

viou

s ab

dom

inal

su

rger

y

Tre

atm

ent

Post

-op

Ref

eren

ce

Ect

opic

pan

crea

s,

intu

ssus

cept

ion,

and

a

rupt

ured

mes

ente

ric

band

:A

n un

usua

l ass

ocia

tion

Gan

apat

hi

et a

l.A

bdom

inal

pa

in, v

omit

ing,

di

arrh

oea

acut

ePl

ain

abdo

min

al r

adio

grap

hy

show

ed o

nepr

omin

ent l

oop

of s

mal

l bow

el w

itho

ut c

lear

ev

iden

ceof

obs

truc

tion

. A C

T sc

an o

f his

abd

omen

8 h

ours

aft

er

adm

issi

on s

how

ed fe

atur

es o

f ile

o-ile

al in

tuss

usce

ptio

n (F

igur

e 1)

, wit

h di

late

d sm

all b

owel

loop

s pr

oxim

ally

, alo

ng w

ith

larg

e am

ount

of f

ree

fluid

. The

rew

as a

lso

a su

gges

tion

of a

larg

e so

ft ti

ssue

m

assw

ithi

n th

e pe

lvis

(Fig

ure

2) a

nd in

tim

atel

y re

late

d to

the

intu

ssus

cept

ion

Lapa

roto

my

30 c

mIl

eum

30

mm

Aci

ni +

du

cts

Ileo

ileal

noTh

e ba

nd w

as

ligat

ed a

nd 2

0 cm

of

intu

ssus

cept

ed s

mal

l bo

wel

was

res

ecte

d.

Hea

lthy

inte

stin

e w

as a

nast

omos

ed

end-

to-e

nd

Une

vent

ful

(122

4 G

anap

athi

, 20

11)

Abb

revi

atio

ns:

CT:

Com

pute

d to

mog

raph

y; I

C: i

leoc

ecal

; HP:

het

erot

opic

pan

crea

s



On day 8, the patient returned to the theatre for re-look laparotomy, washout, closure of abdominal wall, and formation of end ileostomy. He recovered well in intensive treatment unit (ITU) post-operatively. He was extubated on day 9 and stepped down to the ward on day 11.

The patient’s symptoms slowly resolved and he recovered well. He was discharged on day 25 with follow-up arranged for review and discussion of stoma reversal. His stoma was reversed electively after six months with a very good outcome. He was discharged with a long-term follow-up plan.

DISCUSSION

Even if symptomatic, the pre-operative diagnosis of EP still remains challenging with imaging studies such as ultrasonography, CT, and endoscopy, not being specific as demonstrated in our case. Definitive diagnosis is reached with histopathology.

When EP has previously been located in the ileum causing intussusception, often a coexisting Meckel’s diverticulum has been noted, which is thought to exacerbate the ability of the EP to act as a lead point for intussusception [19, 20]. Isolated EP of the ileum causing intussusception without the presence of Meckel’s diverticulum, as reported here, is particularly rare. Cases

of ileal pancreatic heterotopia causing intussusception has been described in children up to the age of 12 [21]. We provide a summary of all reported cases of adult intussusception caused by ectopic pancreas in literature (Table 1).

Manual reduction in our case was unsuccessful. Previous reviews recommend that the treatment of adult intussusception is resection of the intussusception mass without prior attempts to reduce it. The vast majority of adults with intussusception have an underlying pathology as the cause [22–24].

CONCLUSION

The role of laparoscopy in the management of intussusception has been described as an attractive option, especially in the emergency setting in hemodynamically stable patients with non-conclusive imaging. Although this may go on to require laparotomy in most adults and in children whose manual reduction fails, with confirmation of the diagnostic suspect of intussusception. It may entail smaller subsequent laparotomy incisions, shorter bowel manipulation time along with general reduction in post-operative hospital stay, and possible reduction in analgesia requirements, surgical site infections, cardiac respiratory complications, and post-operative mortality. However, in this case laparoscopy was not an option. Most of the times an adult has an underlying pathology for intussusception that will require proper exploration and resection. In some cases endoscopic approach has also been described as a safe and effective approach especially when found in upper gastrointestinal tract especially in the stomach.

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*********

Author ContributionsSmriti Karki – Conception of the work, Design of the work, Acquisition of data, Analysis of data, Interpretation of data, Revising the work critically for important intellectual content, Final approval of the version to be published, Agree to be accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved

Hina Aziz – Acquisition of data, Analysis of data, Interpretation of data, Drafting the work, Final approval of the version to be published, Agree to be accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved

Joseph Watfah – Conception of the work, Design of the work, Revising the work critically for important intellectual content, Final approval of the version to be published, Agree to be accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved

Guarantor of SubmissionThe corresponding author is the guarantor of submission.

Source of SupportNone.

Consent StatementWritten informed consent was obtained from the patient for publication of this article.

Conflict of InterestAuthors declare no conflict of interest.

Data AvailabilityAll relevant data are within the paper and its Supporting Information files.

Copyright© 2020 Smriti Karki et al. This article is distributed under the terms of Creative Commons Attribution License which permits unrestricted use, distribution and reproduction in any medium provided the original author(s) and original publisher are properly credited. Please see the copyright policy on the journal website for more information.



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