early diagnosis and surgical management in adult ... of...jejunojejunal n/a resection of...
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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
Journal of Case Reports and Images in Surgery, Vol. 6, 2020.
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.
Journal of Case Reports and Images in Surgery, Vol. 6, 2020.
Karki et al. 3J Case Rep Images Surg 2020;6:100078Z12SK2020. www.ijcrisurgery.com
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
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
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
a su
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
per
form
ed. T
he
rese
cted
ova
l sha
ped
tum
or, 1
4 ×
11
mm
in
siz
e, w
as c
over
ed
wit
h no
rmal
jeju
nal
muc
osa
and
no u
lcer
or
ero
sion
was
see
n on
the
muc
osal
su
rfac
e (F
igur
e 2)
(120
0 H
iras
aki e
t al
., 20
09)
Adu
lt in
tuss
usce
ptio
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
dila
ted
smal
l bow
el a
nd a
ssoc
iate
d ai
r flu
id le
vels
indi
cati
ve o
f a
smal
l-bo
wel
obs
truc
tion
. Com
pute
d to
mog
raph
y sc
ans
of th
e ab
dom
en
reve
aled
an
ileal
intu
ssus
cept
ion.
A
nod
ule
wit
h an
abu
ndan
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
dens
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
60 c
mIl
eum
n/a
6 ×
1.
8 cm
n/a
Ileo
ileal
n/a
Segm
enta
l res
ecti
on
of th
e ile
um w
ith
ileoi
leos
tom
y w
as c
ompl
eted
. A
n en
tero
tom
y co
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
opic
pan
crea
s:
A r
are
caus
e of
ileo
-ile
al in
tuss
usce
ptio
n
Mon
ier
et a
l.E
piso
des
of
mal
aena
+
cons
tipa
tion
1 ye
arC
T en
tero
grap
hy r
evea
led
a la
rge
circ
umfe
rent
ial l
esio
n m
easu
ring
ap
prox
imat
ely
8.0
× 1
.8 c
m
invo
lvin
g th
e te
rmin
al il
eum
, 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
c pa
ncre
as
Kok
et a
l.N
ause
a,
inte
rmit
tent
ab
dom
inal
pai
n
10 d
ays
Rad
iogr
aphs
of t
he c
hest
and
ab
dom
en a
nd a
bdom
inal
ult
raso
und
stud
y sh
owed
no
abno
rmal
itie
s.
Com
pute
d to
mog
raph
y (C
T) o
f th
e ab
dom
en w
as a
rran
ged
as
inte
rmit
tent
bow
el o
bstr
ucti
on w
as
high
ly s
uspe
cted
due
to h
er c
linic
al
sign
s an
d sy
mpt
oms.
Non
-con
tras
t en
hanc
ed C
T re
veal
ed w
all a
nd
muc
osa
fold
thic
keni
ng, l
umen
di
lata
tion
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
Shor
t seg
men
t of
intu
ssus
cept
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)
Journal of Case Reports and Images in Surgery, Vol. 6, 2020.
Karki et al. 4J Case Rep Images Surg 2020;6:100078Z12SK2020. www.ijcrisurgery.com
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
)
Journal of Case Reports and Images in Surgery, Vol. 6, 2020.
Karki et al. 5J Case Rep Images Surg 2020;6:100078Z12SK2020. www.ijcrisurgery.com
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
Journal of Case Reports and Images in Surgery, Vol. 6, 2020.
Karki et al. 6J Case Rep Images Surg 2020;6:100078Z12SK2020. www.ijcrisurgery.com
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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Figure 3: Intra-operative picture of ileum invaginating into the cecum.
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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.
Journal of Case Reports and Images in Surgery, Vol. 6, 2020.
Karki et al. 8J Case Rep Images Surg 2020;6:100078Z12SK2020. www.ijcrisurgery.com
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