Novel laparo-endoscopic hybrid technique of management of a rare case of duodeno-duodenal intussusception

Abstract

We herein report a rare case of duodeno-duodenal intussusception (IS) presenting with obstruction caused by tubulovillous adenoma in an adult with malrotation that was managed by a novel laparoendoscopic hybrid technique. This was done by passing transjejunal nasogastric tube (NG) through one of the ports and manoeuvring it towards the IS. Two hundred and fifty millilitre of saline was flushed by aseptosyringe with pressure connected to the NG. This hydrostatic reduction technique resulted in distension of the jejunal and duodenal loop achieving reduction of IS. Intraoperative endoscopy was performed to exactly localise the mass lesion. The duodenum was kocherised and was delivered through a 4-cm transverse incision. Anterior duodenotomy was performed; the mass was excised; and duodenotomy was closed transversely. An extensive literature search did not show any case report of duodenoduodenal IS being managed by this technique. The combination of novel retrograde decompression and intraoperative endoscopy helped us to manage this rare case by this novel technique.

Figure 1

(a) Features of intussusception of the duodenum – ‘target sign’ with concentric ring appearance and of a mass in the duodenum as the lead point (blue arrow) (b) Well-defined, reniform lesion showing multiple layers and concentric ring-like appearance with heterogeneous enhancement giving a ‘pseudo kidney’ appearance (blue arrow) (c and d) Malrotation of intestines with duodenojejunal flexure on the right side (blue arrow)

Figure 2

(a) Port placements, (b) Duodeno-duodenal intussusception (IS) (white arrow) with duodenojejunal flexure on the right (blue arrow), (c) Nasogastric tube (NG) passed through 5 mm port through an enterotomy done 25 cm from IS. Purse string suture (black arrow) tightened around enterotomy. Bowel grasper (white arrow) to clamp the distal jejunum, (d) Saline flushed through NG (blue arrow duodenum, green arrow NG tube, white arrow jejunum), (e) Hydrostatic reduction of IS, (f) Intraoperative endoscopy (blue arrow: distal clamp by grasper), (g) Mass from the posterior wall of duodenum on endoscopy (red arrow), (h) Stay sutures on duodenum, (i) Duodenum delivered through incision, (j) Polypoidal mass from posterior wall of duodenum, (k) NG tube across the closure of duodenotomy, (l) Anterior duodenotomy closure in two layers

Figure 3

Schematic Representation of the hydrostatic reduction technique, (a-e) AS, NG tube. AS: Asepto syringe, NG tube: Nasogastric tube