Laparoscopic partial cecum resection in appendiceal intussusception/Apendiks intususepsiyonunda laparoskopik parsiyel cekum rezeksiyonu.
Appendiceal intussusception (Al), which is one of the rare types of intussusception, is seen in 0.01% of the patients who undergo appendectomy (1). Anatomical changes such as partially mobile meso-appendix or large
proximal appendicular umen may be the cause of Al. Appendiceal intussusception-related symptoms include lower abdominal pain, irregular defecation, nausea, vomiting, or rectal hemorrhage. Making a preoperative diagnosis of Al is quite difficult, and usually a computed tomography (CT) of the abdomen and colonoscopy are required (2). The aim of this study was to report a case of Al, secondary to endometriosis, on whom laparoscopic partial cecum resection was performed, preserving the ileocecal valve.
A 35-year-old female patient presented to the general surgery outpatient clinic with lower abdominal pain, nausea, and vomiting persisting for the past one week. The patient did not have any defecation problems, did not describe weight loss, altered defecation habit, or urinary tract complaints but had a history of left oophorectomy performed due to endometriosis 6 years ago.
On physical examination, the patient was hemodynamically stable. There was no abdominal distention. Tenderness was found in the right lower quadrant, and a palpable mass could be detected on deep palpation. No defense or rebound was determined. Rectal examination was normal. Intestinal sounds were active. Routine blood tests demonstrated C-reactive protein (CRP) of 16mg/L, white blood cell count of 8490/[mm.sup.3], hemoglobin of 9.5 g/dL, hematocrit of 31%, and platelet count of 340.000/[mm.sup.3].
A polypoid mass lesion measuring 3 x 2.5 cm, protruding toward the cecum lumen in the right lower quadrant, was detected on abdominal CT (Figure 1). On colonoscopic examination, a mass lesion, which had exudative and necrotic fields, appearing as the appendix, protruding into the cecum was detected at the appendix root site (Figure 2). Pathology of the colonoscopic biopsy revealed that the findings could be related to gangrenous appendicitis and also an inflammatory condition involving the ileocecal region.
Laparoscopic surgery was planned with a preliminary diagnosis of Al.The patient was informed that different interventions could be applied if needed during the operation. Verbal and written informed consent were obtained from the patient. First, diagnostic laparoscopy was performed. On exploration, the appendix was found to be completely inverted into the cecum (Figure 3). After having decided that the inverted appendix could not be reduced, laparoscopic partial cecum resection was performed, preserving the ileocecal valve (Figure 4).
The patient was followed in the hospital for 3 days without any complications. No complications developed during the postoperative 30 days. Foci of endometriosis externa infiltrating the muscular layer were detected on histopathological examination.
Laparoscopic surgery was planned with the pre-diagnosis of Al. The patient was informed that different interventions could be applied if needed during the operation. Verbal and written informed consent was obtained from the patient. First, diagnostic laparoscopy was performed. On exploration, the appendix was found to be completely inverted into the cecum (Figure 3). After having decided that the inverted appendix could not be reduced, laparoscopic partial cecum resection was performed, preserving the ileocecal valve (Figure 4).
The patient was follewed in the hospital for 3 days without any complications. No complications developed during the postoperative 30 days. Foci of endometriosis externa infiltrating the muscular layer were detected on the histopathological examination.
Al is a rare condition. It was first reported by McKidd in 1858 (3). Collins have reported the incidence of Al as 0.01% as a result of the study conducted with 71.000 patients suffering appendicitis over the course of 40 years (4). Chaar et al. have reported in his study investigating 191 Al cases that 76% of the cases were adult and 24% were children (2).
Anatomical changes such as partially mobile meso-appendix or large proximal appendicular lumen may be the cause of Al. While inflammation is the most common cause of Al in children, endometriosis is the most common cause in adults (2,5,6). Other common causes include mucocele, adenoma, carcinoid, and adenocarcinoma (7-14). Papilloma, hamartoma, juvenile polyp, Crohn's disease, and melanosis coli are rare causes of Al (15-18).
Endometriosis is a common disease, which affects approximately 15% of the menstruating women in the United States. In the review of Robert et al. including 29 studies, appendix endometriosis has been reported in 336 out of 87.343 patients (0.4%) undergoing appendectomy (19).
Four different clinical types of Al have been reported. The first type mimics the classical type of acute appendicitis. The second type shows typical intussusception signs, which include abdominal pain and sometimes vomiting, accompanied by diarrhea and melena.The third type has signs and symptoms such as melena, vomiting, and recurrent right lower quadrant pain that can persist for weeks or months. The forth type includes patients who are completely asymptomatic (20). The most common signs are abdominal pain (78%), vomiting (26%), and rectal hemorrhage (23%). A mass lesion is detected in the right lower quadrant in 13% of adult patients and 37% of pediatric patients (2).
Preoperative diagnosis of Al is difficult. It is made postoperatively in many cases (57%). Diagnosis is made with postoperative pathological examination in 11% of the cases. Consequently, correct preoperative diagnosis has been made in only 32% of the cases (2). Barium contrast studies and abdominal ultrasonography have a limited value in the diagnosis of this rare condition. Abdominal CT is the most common imaging method. Colonoscopy is a very useful method in the diagnosis of Al in cases with abdominal pain and suspicious imaging findings (21). Our patient was evaluated with abdominal CT and the diagnosis was made with colonoscopy.
Different approaches have been used in the treatment of Al. Despite reports of successful colonoscopic appendectomy using the endo-loop ligation system, this approach may be harmful in patients who have partial intussusception (22-24). Spontaneously reduced Al cases have also been reported in the literature (25).
A total of 191 cases have been analyzed in one of the largest series in the literature, and appendectomy has been reported as the most common intervention (42% in adults, 71% in children), leocecectomy (27%) and right hemicolectomy (21%) have been performed in the remaining patients. Treatment with colonoscopy has been reported in four adult patients (3%) (2). While appendectomy is sufficient in cases with only intussusception, right hemicolectomy is more appropriate for patients who are suspected to have neoplasia (26,27). In our case, laparoscopic partial cecum resection was perfomed, preserving the ileocecal valve, as appendix reduction was not possible.
Preoperative diagnosis of Al, which is a rare condition, is important. We consider that laparoscopic partial cecum resection through preservation of the ileocecal valve anatomy is an appropriate approach in patients who are not suspected to have malignancy and whose appendix cannot be reduced.
Informed Consent: Verbal informed consent was obtained from the patient.
Peer-review: Externally peer-reviewed.
Author Contributions: Concept - S.Z., C.B., D.B.; Design - S.Z., C.B.; Supervision - D.B.; Resource - S.Z., C.B., D.B.; Materials - S.Z., C.B., D.B.; Data Collection and/or Processing - S.Z., C.B., D.B.; Analysis and/or Interpretation - S.Z., C.B., D.B.; Literature Search - S.Z., C.B., D.B.; Writing Manuscript - S.Z., C.B., D.B.; Critical Reviews - D.B.
Conflict of Interest: The authors have no conflicts of interest to declare.
Financial Disclosure: The authors declared that this study has received no financial support.
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Serkan Zenger (1), Cagri Bilgic (1), Dursun Bugra (1,2)
(1) Clinic of General Surgery, VKV American Hospital, Istanbul, Turkey
(2) Department of General Surgery, Koc University School of Medicine, Istanbul, Turkey
Available Online Date: 28.18.2018
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|Title Annotation:||CASE REPORT/OLGU SUNUMU-OZET|
|Author:||Zenger, Serkan; Bilgic, Cagri; Bugra, Dursun|
|Publication:||Turkish Journal of Surgery|
|Article Type:||Case study|
|Date:||Mar 1, 2019|
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