Approach to Management of Intussusception in Adults: A New Paradigm in the Computed Tomography Era

Abstract

Intussusception has been considered an operative indication in adults as a result of the risk of ischemia and the possibility of a malignant lead point. Computed tomographic (CT) scans can reveal unsuspected intussusception. All CT reports from July 1999 to December 2005 were scanned electronically for letter strings to include the keyword intussusception. Identified CT scans were analyzed to characterize the intussusception and associated findings. Clinical, laboratory, pathological, and follow-up variables were gleaned from medical records. Findings were analyzed by treatment and findings at operation. Review of 380,999 CT reports yielded 170 (0.04%) adult patients (mean age, 41 years) with intussusceptions described as enteroenteric in 149 (87.6%), ileocecal in eight (4.7%), colocolonic in 10 (5.9%), and gastroenteric in three (1.8%). Radiological features included mean length of 4.4 cm (range, 0.8-20.5 cm) and diameter of 3.2 cm (range, 1.6-11.5 cm). Twenty-nine (17.1%) had a lead point, and 12 (7.1%) had bowel obstruction. Clinically, 88 (48.2%) patients reported abdominal pain, 52 (30.6%) had nausea and/or vomiting, and 74 (43.5%) had objective findings on abdominal examination. Thirty of 170 (17.6%) patients underwent operation, but only 15 (8.8%) patients had pathologic findings that correlated with CT findings. Seven had enteroenteric intussusceptions from benign neoplasms (two), adhesions (one), local inflammation (one), previous anastomosis (one), Crohn's disease (one), and idiopathic (one). Three had ileocolic disease, including cecal cancer (one), metastatic melanoma (one) and idiopathic (one; whereas five patients had colocolonic intussusception from colon cancer (three), tubulovillous adenoma (one), and local inflammation (one). Of the 15 without intussusception at exploration, five had pathology related to trauma, four had nonincarcerated internal hernia after Roux-en-Y gastric bypass, four had negative explorations, one had adhesions, and one had appendicitis that did not correlate with CT findings. No patient in the observation group required subsequent operative exploration for intussusception at mean 14.1 months (range, 0.25-67.5 months) follow up. All operative patients demonstrated gastrointestinal symptoms versus 55.3 per cent of the observation group ( P < 0.006). Analysis of CT features demonstrated differences among patients observed without operation, those without intussusception at exploration, and confirmed intussusception with regard to mean intussusception length 3.8 versus 3.8 versus 9.6 cm, diameter 3.0 versus 3.2 versus 4.8 cm, lead point 12.1 per cent versus 30 per cent versus 53.3 per cent, and proximal obstruction 3.8 per cent versus 0 per cent versus 46.7 per cent, respectively. Intussusceptions in adults discovered by CT scanning do not always mandate exploration. Most cases can be treated expectantly despite the presence of gastrointestinal symptoms. Close follow up is recommended with imaging and/or endoscopic surveillance. Length and diameter of the intussusception, presence of a lead point, or bowel obstruction on CT are predictive of findings that warrant exploration.

Intestinal Intussusception: Etiology, Diagnosis, and Treatment

“…30 As such, retrospective studies have demonstrated successful nonoperative management in as many as 82% of radiographic intussusceptions, even in the setting of gastrointestinal symptoms. 31,32 This has created some degree of controversy regarding optimal management of these patients.…”

“…In the large majority of entero-enteric intussusceptions without lead point mass and short affected segments-defined as less than 3.5 to 3.8 cm in several series-expectant management can be employed with serial clinical and imaging evaluations where necessary to ensure resolution. [31][32][33] When indicated, surgery may be performed laparoscopically or open, depending on the skill and experience of the surgeon. Regardless of the approach, the intussusception must be successfully identified and then carefully reduced (in children) or resected (adults).…”

Hypersecretory Villous Adenoma as the Primary Cause of Intestinal Intussusception and Mckittrick-Wheelock Syndrome

“…Among the surgical options, transanal resection (transanal endoscopic microsurgery) using a posterior presacral approach (anterior tumours) or mucosectomy, and abdominal surgery for large tumours, are preferred. This type of benign tumour has the potential to become malignant; the only treament option that has been proven to be effective is surgery involving complete excision of the lesion, which results in normalization of electrolyte levels and prevents progression to a malignant tumour (17,18).…”

Adult intussusception: 14 case reports and their outcomes

“…Many reviews support invagination as an indication for surgery in adults due to the risk of intestinal ischemia and possible malignancy of the lead point of invagination. However, we consider it important to take associated symptoms into account and on the basis of these conduct more accurate diagnostic studies to rule out a tumor origin if not done previously; moreover, the diameter and length of the invagination, together with the presence or absence of an associated lesion, and the type of invagination are predictors of spontaneous resolution (13,14).…”