The management of colo-colic intussusception on left colon tumor in an adult: Case presentation and review of the literature.

A 50-year-old Moroccan male, with no notable personal or family pathological history, employed as a security guard, presented to the emergency department with an acute intestinal obstruction characterized by cessation of material and gas associated with fecal vomiting that had been evolving for 3 days. The patient described significant, localized pain in the upper left abdomen and left flank, marked by a deep, intense sensation that fluctuated with waves of pressure and discomfort. More detailed questioning revealed the presence of traces of blood in his stool 2 weeks ago and an estimated weight loss of 4 kg over the previous month. Physical examination revealed abdominal distension on inspection and tenderness on palpation of the left flank. Significant abdominal tympanism was noted on percussion. Rectal examination showed an empty rectal ampulla without palpable masses or blood. Overall, the patient was stable, with a heart rate of 84 beats per minute, blood pressure of 135/65 mmHg, temperature of 36.5 °C, and oxygen saturation of 100 %. Blood tests conducted in the emergency department were unremarkable. An abdomino-pelvic CT scan with contrast injection was performed and revealed significant colonic distension measuring 91 mm in diameter, with tissue thickening of the left colon measuring 28 × 25 mm. The CT scan also showed invagination of the colon and mesocolon, resembling a target sign, as well as small adjacent mesocolic nodes and moderate peritoneal effusion. ( Fig. 1 ). Fig. 1 Axial image of abdomino-pelvic CT scan with contrast injection showing colonic distension upstream of colonic thickening associated with colo-colic intussusception. A: Intussusception area. B: Colonic distension upstream the Intussusception. Fig. 1 Axial image of abdomino-pelvic CT scan with contrast injection showing colonic distension upstream of colonic thickening associated with colo-colic intussusception. A: Intussusception area. B: Colonic distension upstream the Intussusception. Due to the unpredictable progression of intussusception and the heightened risk of potential complications at any stage, a prompt decision to proceed with surgical intervention is imperative. A median laparotomy was performed. Exploration revealed distension of the cecum, ascending colon and transverse colon, with the presence of a tumoral mass in the left colon responsible for left colo-colic intussusception. There were no hepatic lesions or nodules of carcinosis. The patient underwent a left colectomy with lymph node dissection, limited to the affected section of the colon, and a Volkman Bouilly left iliac colostomy was created.(( Fig. 2 ). Fig. 2 Intra-operative view of colon-colic intussusception. Fig. 2 Intra-operative view of colon-colic intussusception. The postoperative course was uneventful, the patient was able to stand, resuming bowel movements and eating on the first postoperative day, and being discharged from hospital four days after the operation. As part of the staging evaluation, a chest CT scan was performed, which showed no secondary lesions. The pathological examination revealed a well-differentiated adenocarcinoma infiltrating the colonic wall up to the muscularis, measuring 11 cm in length, with clear resection margins and no lymph node involvement (0 N+/13 N). The tumor was classified as pT2N0M0. After a multidisciplinary discussion, it was decided to monitor the patient without adjuvant treatment, and regular follow-up was set up including a clinical examination and thoracic-abdominal-pelvic CT scans with tumor marker assessments every three months. Two months post-surgery, a colonoscopy confirmed the absence of recurrence or additional polyps, and then the colostomy was successfully closed with simple postoperative outcomes. After two years observation, the patient is in good health and shows no signs of recurrence.

AH designed the paper. KA and HS collected the data, KA, MB and HS wrote the first draft of the manuscript. RM, FS and AH critically reviewed the manuscript. All authors approved the final version of the manuscript.

Written informed consent was obtained from the patient for publication of this case report and accompanying images. A copy of the written consent is available for review by the Editor-in-Chief of this journal on request.

Ethical approval is exempt/waived at our institution.

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Kada Ali.

Early and accurate diagnosis of adult intussusception is essential to prevent severe complications, particularly given its frequent malignancy association. CT imaging enables timely intervention optimizing clinical outcomes and reducing risks. This case underscores the importance of vigilant diagnostic and therapeutic approaches.

Intestinal intussusception is characterized by the telescoping of a proximal segment of the intestine into an adjacent segment, resulting in luminal obstruction and compromised blood flow. [ 15 ]. It was first described in 1674 by Barbette of Amsterdam and, in 1789, John Hunter wrote a detailed report on the condition, then called “intussusception” [ 1 ]. The first successful operation on a child was performed by Jonathan Hutchinson in 1871 [ 16 ]. The incidence is significantly higher in children than in adults, representing only 1 to 5 % of obstructions in adults [ 15 ]. It takes a variety of forms, depending on the intestinal parts involved [ 17 ]: ✓ Ileocolic location: 60–70 % of cases, the most common form in children. ✓ Enteric location: 20 to 30 % of cases ✓ Colo-colonic location: 5 to 10 % of cases Ileocolic location: 60–70 % of cases, the most common form in children. Enteric location: 20 to 30 % of cases Colo-colonic location: 5 to 10 % of cases The clinical presentation of intestinal intussusception in adults can be variable and less specific than in children, making diagnosis more complex. Symptoms arise due to the continuous peristaltic contractions of the invaginated segment [ 18 ]. Symptoms of colo-colic intussusception may include abdominal pain (present in 71–90 % of cases), rectal bleeding, changes in bowel habits and abdominal distension. In some cases, it may reduce spontaneously, leading to a temporary resolution of symptoms, which may further delay diagnosis [ 18 , 19 ]. The classic clinical triad, including abdominal pain, a palpable abdominal mass, and bloody stools, can guide diagnosis but is relatively rare. Warning signs such as fever and deterioration of general condition may indicate a complication requiring immediate intervention [ 20 ]. In children, 90 % of intussusceptions are idiopathic, whereas in adults the figure is only 8–10 %. An organic lesion is found in 90 % of adult cases. Malignant tumors are the most common, as in our case, where the starting point was identified as a tumor in the left colon. However, other benign pathologies may be responsible: polyps, adenomas, lipomas, endometriosis and post-operative adhesions [ 20 , 21 ]. ( Table 1 ). Table 1 : Lesions associated with intussuception. Table 1 Benign Malignant Primary Metastatic ✓ Crohns disease ✓ Celiac disease ✓ Lipoma ✓ Leiomyoma ✓ Neurofibromatosis ✓ Fibro-epithelial polyps ✓ Human immunodeficiency virus ✓ Post-operative adhesions ✓ Endometriosis ✓ Meckel's diverticulum ✓ Adenocarcinoma ✓ Gastrointestinal stromal tumor ✓ Caarcinoids ✓ Leiomyosarcomas ✓ Lymphoma ✓ Melanoma ✓ Lung ✓ Renal cell cancer ✓ Breast : Lesions associated with intussuception. Crohns disease Celiac disease Lipoma Leiomyoma Neurofibromatosis Fibro-epithelial polyps Human immunodeficiency virus Post-operative adhesions Endometriosis Meckel's diverticulum Adenocarcinoma Gastrointestinal stromal tumor Caarcinoids Leiomyosarcomas Lymphoma Melanoma Lung Renal cell cancer Breast Intestinal intussusception can lead to ischemia, intestinal perforation, and septicemia [ 15 ]. Recent data on the complications of adult intussusception indicate that ischemia and perforation are the most frequently encountered outcomes due to restricted blood flow caused by the intussuscepted bowel segment [ 22 ]. Ischemia is reported in about 40–50 % of cases, particularly when diagnosis and treatment are delayed [ 22 ]. Perforation, while less frequent, remains a critical risk due to the possibility of resulting septicemia, which occurs in approximately 10–15 % of cases when perforation has led to bacterial translocation and infection. These complications are closely linked to underlying malignancies in adults with intussusception, emphasizing the need for timely surgical intervention to prevent adverse outcomes [ 23 , 24 ]. Early diagnosis is essential to minimize the incidence of severe complications, and to improve patient prognosis. Imaging plays a pivotal role in achieving prompt diagnosis, with abdominal CT scans remaining the gold standard due to their high diagnostic accuracy, estimated between 58 % and 100 % and a specificity from 57 to 71 % in recent studies. It is commonly used to identify the intussusception, its location and describe the associated starting point or underlying pathologies [ 19 ]. Abdominal ultrasound also remains a useful tool, but less sensitive than CT in adults. This is due to the presence of massive air in cases of distension or morbid obesity [ 23 , 26 ]. It can also be used to assess the extent of intestinal involvement and facilitate surgical planning. In our case, the CT scan detected the left colo-colic intussusception and the extension of the tumor mass, enabling us to anticipate and plan the surgical procedure. As for the best treatment, the literature remains controversial due to the different etiologies in children and adults. According to the literature, the association of a mass on imaging as a presumed starting point for intestinal obstruction is associated in the majority of cases with a malignant neoplasm and should be treated surgically [ 27 ]. However, controversy persists, as the evolution of modern radiological examinations has made it possible to distinguish intussusceptions with or without an underlying cause, thus avoiding unnecessary surgical interventions [ 19 , 25 ]. Despite this, the literature seems to agree that an intussusception involving the colon should be treated surgically without prior manipulation or reduction, particularly in patients over 60 years of age, due to the higher risk of perforation and dissemination of tumor cells in the abdominal cavity and through the bloodstream, as well as the increased risk of anastomotic complications [ 28 ]. Nevertheless, when the intussusception is considered to be caused by benign lesions and there are no obvious signs of inflammation or intestinal ischemia, the surgeon may first reduce the intussusception by treating it in a distal-to-proximal direction, followed by localized resection [ 29 ]. Surgical resection can be performed laparoscopically or via an open approach, depending on the surgeon's experience, and must adhere to strict oncological principles in the case of malignant tumor intussusception [ 30 ]. In our case, our patient was diagnosed with colo-colic invagination of a left colon tumor, and we performed an emergency laparotomy with resection of the affected colonic segment, adhering to oncological principles with satisfactory histopathological results.

Intestinal intussusception, first described in 1674 by Paul Barbette, is defined as the penetration or telescoping of an intestinal segment and its mesentery into another adjacent intestinal segment, leading to acute intestinal obstruction [ 1 , 2 ]. When diagnosis and intervention are delayed, complications such as bowel ischemia, necrosis, and perforation can occur, potentially resulting in peritonitis, sepsis, and increased morbidity and mortality [ 3 ]. This pathology is more frequent in children, and most often affects infants between 5 and 9 months of age [ 4 ]. In contrast, it is rare in adults, with an overall incidence of 2 to 3 cases per 1 million population each year, accounting for around 5 % of all cases of intussusception [ 5 , 6 ]. The presence of a lead point is common, and can be observed in 70–90 % of adult intussusceptions, unlike intussusception in children, which is idiopathic in 90 % of cases [ 7 ]. Most cases of intussusception in adults are diagnosed intraoperatively and are often caused by malignant tumor lesions in 30 % of cases [ 8 , 9 ]. Malignancies serve as a n initiating lesion that disrupts normal peristalsis, which can initiate the invagination process as the abnormal mass is “pulled” by the contracting bowel segment. This mechanism is especially relevant in adult intussusception cases, as 30 % to 50 % are attributed to malignant neoplasms, such as colonic adenocarcinoma, which can obstruct and distort bowel motility, prompting telescoping of the intestinal wall [ 10 ]. However, several other causes have been described, including benign lesions such as intestinal lipomas and polyps, postoperative adhesions, Meckel's diverticulum and inflammatory bowel diseases [ 8 , 11 ]. Despite advances in medical imaging, the diagnosis of intussusception in adults remains challenging; however, computed tomography (CT) is the examination of choice for diagnosis [ 12 ]. The diagnostic accuracy can reach 100 %, with specificity estimated at 71 % [ 13 ]. Early diagnosis and treatment are essential to reduce serious complications. The definitive management of intussusception in adults involves treating the underlying cause and surgical resection of the affected intestinal segment [ 14 ]. In line with the 2023 SCARE criteria [ 27 ], we present the case of a 50-year-old patient admitted for colo-colic intussusception affecting the descending colon, which required urgent carcinological resection.

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