Management of Intussusception in Adults

Diagnostic Approach

• The World Journal of Emergency Surgery recommends CT scan as the imaging modality of choice to confirm diagnosis and identify potential complications in hemodynamically stable patients 1, 2
• Evaluation for signs of peritonitis, strangulation, or bowel ischemia is necessary, which necessitate immediate surgical intervention 2
• Assessing hemodynamic stability is crucial to determine the urgency of intervention 2

Treatment Algorithm

Initial Management

• Fluid resuscitation is necessary to restore intravascular volume and promote physiological stability 1
• Antimicrobial therapy should be initiated once intussusception is diagnosed or suspected 1
• Surgical consultation should be obtained in all cases, even when considering non-operative management 2

Surgical Management

• Surgical exploration is recommended as the primary treatment due to the high risk of incarceration and strangulation 3, 4, 5
• Delaying intervention beyond 48 hours significantly increases mortality 3, 5
• The high rate of underlying pathology (86-93% of cases have a definable lesion) supports surgical exploration 3, 4, 5

Special Considerations for Post-Bariatric Surgery Intussusception

• The pathophysiology involves modified intestinal motility, staple lines, and anatomic peculiarities 3, 4
• Classification of post-bariatric surgery intussusception includes Type I (afferent loop), Type II (efferent loop), or Type III (combined) 3, 5
• Treatment options include resection of the invaginated segment, reconstruction of jejuno-jejunostomy, and anchoring techniques or conversion to other bariatric procedures in selected cases 4, 5, 6

Non-operative Management

• Non-operative management may be considered only in highly selected cases, including hemodynamically stable patients with no signs of peritonitis or bowel compromise and endoscopic expertise readily available 2
• Endoscopic reduction carries a high recurrence risk 3, 2
• Close monitoring for at least 24 hours after reduction is necessary 2

Pitfalls and Caveats

• Delay in surgical intervention beyond 48 hours significantly increases mortality 3, 5

Complications Following Intussusception Surgery

Early Postoperative Complications (Within 10 Days)

• Recurrence occurs in 0.1-0.3% of cases after surgical reduction, with the highest risk in the first 10 days postoperatively, according to the World Journal of Emergency Surgery 7
• Bowel perforation, peritonitis, and fistula formation occur in approximately 15% of cases after stapled transanal rectal resection (STARR) procedures for rectal intussusception, as reported by Clinical Gastroenterology and Hepatology 8, 9
• Gastrojejunostomy stenosis develops in 3-27% of post-bariatric surgery cases, potentially causing secondary obstruction, according to the World Journal of Emergency Surgery 7

Management of Postoperative Intussusception

• For post-bariatric surgery intussusception, reduction should begin from the ileocecal valve (distal to obstruction) where bowel is less dilated and safer to handle laparoscopically, as recommended by the World Journal of Emergency Surgery 7
• Indocyanine green (ICG) fluorescence angiography can guide resection margins when intestinal perfusion is questionable, according to the World Journal of Emergency Surgery 7
• All mesenteric defects must be closed with non-absorbable sutures after reduction to prevent recurrence, as suggested by the World Journal of Emergency Surgery 7

Morbidity Outcomes

• Severe constipation develops in 50% of patients after posterior rectopexy for rectal prolapse/intussusception, as reported by Clinical Gastroenterology and Hepatology 8, 9
• Fecal incontinence, chronic pain, infection, and depression occur in approximately 15% of STARR patients, occasionally requiring further surgery, according to Clinical Gastroenterology and Hepatology 8, 9
• Recurrence rates: 0-8% for transabdominal rectopexy, 5-21% for perineal procedures, as reported by Clinical Gastroenterology and Hepatology 8, 9
• Avoid bowel resection in patients with preexisting diarrhea or incontinence, as these symptoms worsen postoperatively, as recommended by Clinical Gastroenterology and Hepatology 8, 9

Diagnostic Imaging and Surgical Management of Adult Large Bowel Intussusception

Imaging Recommendations

• Contrast‑enhanced CT is the mandatory diagnostic modality for suspected adult large‑bowel intussusception; it demonstrates the intussusception, identifies the lead point, and detects complications such as ischemia or perforation with a sensitivity of approximately 80 % and a specificity approaching 100 %【10】.

Surgical Technique by Lesion Location and Patient Condition

• Right‑sided colonic intussusception should be managed with a right hemicolectomy and primary anastomosis when the patient is stable【10】.
• Left‑sided malignant colonic intussusception in a hemodynamically stable patient without perforation is best treated with segmental resection and primary anastomosis【10】.
• High‑risk patients or those presenting with perforation should undergo a staged operative approach, such as a Hartmann procedure, to mitigate postoperative morbidity【10】.

Management of Intussusception in Peutz‑Jeghers Syndrome

Indications for Elective Polyp Resection

• In patients with Peutz‑Jeghers syndrome, polyps larger than roughly 1.5–2 cm are a specific cause of jejunal intussusception; elective surgical removal of such polyps is recommended to prevent this complication. 11

Pathologic Evaluation of Adult Intussusception Lead Points

Required Diagnostic Determinations

• The pathologist must identify whether an intraluminal lesion serves as the lead point and classify it as benign or malignant. 12
• The report must state whether the resection achieved complete excision of the lesion. 13

Histologic Characterization (WHO Guidelines)

• When a malignant lead point is present, the lesion should be subtyped according to the WHO classification system. 12
• The grade of differentiation (well, moderate, poor, or undifferentiated) must be recorded. 12
• The maximal size of the invasive component and overall tumor extent should be measured and reported. 12
• Depth of submucosal (or deeper) invasion should be quantified using an optical micrometer. 12

Margin and Invasion Assessment

• The distance from the tumor to both deep (vertical) and lateral resection margins must be measured in millimetres. [13][12]
• Margin status must be designated as positive, negative, or close. 12
• Presence or absence of lymphovascular invasion should be documented. [13][12]
• Tumor budding, when observed, should be quantified in hotspot fields. 12
• Perineural invasion, if identified, must be noted. 12

Clinical Management Implications

• Adequate oncologic resection is confirmed when margins are negative and lymphovascular invasion is absent. 12
• Positive margins or high‑risk features (e.g., lymphovascular invasion, tumor budding, perineural invasion) indicate the need for additional surgical intervention. 12
• Recommendations for adjuvant therapy should be based on tumor grade, stage, and the presence of adverse prognostic factors. 12

Reporting Standards

• When malignancy is identified, the pathology report should follow the College of American Pathologists structured templates to ensure systematic documentation of all prognostic variables. 12