|Ahead of print publication
Laparoscopic reduction of intussusception in a 13-year-old girl with multiple intestinal polyps: A case report
Usman M Bello1, Lawal B Abdullahi1, Soladoye A Abdulmajeed2
1 Department of Surgery, Aminu Kano Teaching Hospital Kano, Bayero University Kano, Kano, Nigeria
2 Department of Surgery, Federal Medical Center, Katsina, Nigeria
|Date of Submission||07-Sep-2022|
|Date of Decision||24-Sep-2022|
|Date of Acceptance||27-Sep-2022|
|Date of Web Publication||10-Apr-2023|
Usman M Bello,
Department of Surgery, Bayero University Kano, P. M. B 3011, Kano
Source of Support: None, Conflict of Interest: None
Intussusception has been one of the common causes of intestinal obstruction in infancy and early childhood period with a challenge in diagnosis in older children. It is the telescoping of a segment of bowel into another, commonly a proximal segment into a distal one. Intussusception in infancy and early childhood is usually primary or idiopathic as there is no associated pathological lead point involved. However, in older children and adult, there is most often time an identifiable lead point that predisposes to the intussusception.
Keywords: Intussusception, laparoscopic reduction, lead point
|How to cite this URL:|
Bello UM, Abdullahi LB, Abdulmajeed SA. Laparoscopic reduction of intussusception in a 13-year-old girl with multiple intestinal polyps: A case report. Niger J Basic Clin Sci [Epub ahead of print] [cited 2023 Jun 10]. Available from: https://www.njbcs.net/preprintarticle.asp?id=373997
| Introduction|| |
Intussusception refers to the telescoping of bowel segment mostly proximal into an adjacent distal bowel resulting in intestinal obstruction.
It is a condition that often causes mechanical bowel obstruction in children with over 56 per 100,000 cases reported. The etiology is idiopathic in the majority of cases but may be attributed to hypertrophy of Peyer's patches in response to an acute viral infection.
Secondary intussusception with an identifiable pathological lead point is found in 2.2–15% of children and their presence occurs more in older children.
The anatomic location can involve any segment of the bowel but most often affect the ileocolic segment. It typically affects children in the age range of 3–24 months and the incidence reduces after the age of 2 years.
The diagnosis of intussusception can be quiet challenging as the presentation is often time nonspecific. Only about 25% of patients show simultaneous manifestation of the classic symptoms of abdominal pain, vomiting, and passage of red currant jelly stool.
Ultrasound is considered the imaging modality of choice as it can diagnose intussusception with a sensitivity and specificity of 97.9% and 97.8%, respectively.
The goal standard treatment for intussusception currently involves nonoperative reduction which encompasses contrast enema and hydrostatic reduction. When nonoperative reduction fails or is contraindicated, operative reduction becomes necessary. This has been by open surgery, though reduction by laparoscopy has been successful in uncomplicated cases. Laparoscopic management of intussusception was never reported in Nigeria; this informs the need for us to report this case.
| Case|| |
We present the case of a 13-year-old girl who was seen at our surgical outpatient department with complaint of anal protrusion of 8 years duration. The protrusion occurs mostly after defecation with associated hematochezia and passage of mucoid bloody stool which in recent time became so frequent to have warranted blood transfusion on five different occasions. Two months prior, she developed recurrent severe colicky abdominal pain, which was postprandial and located in the periumbilical region severe enough to prevent her from her daily activities with associated multiple episodes of bilious vomiting, though there was no abdominal distension.
The parents have tried many over-the-counter medications and local herbs with no resolution of her symptoms necessitating her presentation at our surgical outpatient department.
She has two relatives with Hirschsprung's disease, one of whom is her first-degree relative and the other her second-degree relative.
Her physical examination revealed some facial puffiness. She was not pale, afebrile, anicteric, and no pedal edema.
The abdominal examination was unremarkable, however digital rectal examination revealed pedunculated anorectal polyps which became prominent with valsalva, firm their upper limit could not be reached [Figure 1].
Abdominal ultrasonography showed features of intussusception.
The parents and the patient were counseled for laparoscopic reduction of the intussusception, which she had. Intaoperative finding of ileocolic intussusception was made [Figure 2]. The intussusception had reduced laparoscopically successfully [Figure 3]. The ports wound were closed with vicryl suture [Figure 4].
She did well postoperatively with resolution of the abdominal pain and being prepared for a colonoscopic evaluation of the anal masses.
| Discussion|| |
Intussusception in most cases is idiopathic in children with only about 5% of cases attributed to a pathological lead point which could be a Meckel's diverticulum, a benign polyp, or a lymphoma. The presence of these is more likely in older children.
Other clinically important lead points identified are lymphomas, hemangiomas, hamartomas, and lipomas. In cases where there are pathological lead points, it is reported to vary from 0.33% to 20%.
In the study by Zhao Linglin et al., intussusception associated with pathological lead points is caused by Meckels diverticulum and intestinal duplication cysts in 81% of cases in children less than 2 years of age, while Meckel's diverticulum and Peutz–Jegher's syndrome accounted for 72% of cases in children 2 years and above. Our patient also presented with multiple rectal and large bowel polyps.
Patients with intussusception present classically with colicky abdominal pain, emesis, passage of red currant jelly stool, and a palpable abdominal mass seen in about 20% of cases. The hematochezia and passage of mucoid stool in our patient were earlier attributed to the anal protrusion until she developed colicky abdominal pain and vomiting, together with ultrasound features of intussusception.
The gold standard treatment of uncomplicated intussusception remains enema reduction with air, barium, or saline as popularized by Ravitch and McCune in 1848 with about 79–90% success rate. Some 20% of patients however will require operative intervention due to unsuccessful reduction or presence of complications at presentation. This traditionally has been in the form of manual reduction at laparotomy. The introduction of laparoscopic approach in the late-1990s with a reported success rate of less than 50% made its role controversial in the treatment of intussusception.
However, several advantages were attributed to the laparoscopic treatment including less pain, short hospital stay, better cosmetic result, and less risk of postoperative adhesive intestinal obstruction. Factors earlier considered as limitations to successful laparoscopic treatment such as pathological lead point and bowel necrosis are now being reviewed with the advent of new instruments and improvement in the surgeon's skills.
| Conclusion|| |
Intussusception though rare in older children can represent a diagnostic challenge and always associated with a pathological lead point. Though reduction with fluid enema remains the gold standard in management, there has been a paradigm shift toward laparoscopic reduction in recent time with the advancement in technology and increased surgical skills.
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Conflicts of interest
There are no conflicts of interest.
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[Figure 1], [Figure 2], [Figure 3], [Figure 4]