Approach to cases with multiple invagination

Abstract

Dear Editor, Invagination is a frequent cause of intestinal obstruction in children. Invagination, which is observed on a single site in most cases, has been reported to be present on multiple sites in adults in various case reports [1], [2]. Here, we discuss the importance of abdomen exploration by reporting multiple invagination phenomena in two child patients. A 6-month-old boy was admitted to our hospital with complaints of bilious vomiting and bloody feces. A physical examination revealed a palpable abdominal mass. Invagination was detected in the lower right quadrant through an ultrasonography. In the exploration, the two invaginated sites, which are ileocolic and colocolic (between the descending colon and the sigmoid), were discovered. Both invaginated sites were reduced manually. No recurrence was observed in the follow-ups during the postoperative 15 months. A 22-month-old girl was admitted to our hospital reporting bilious vomiting, abdominal distention, and inability to defecate for 24 hours. There was no trace of blood in the stool. A physical examination revealed right upper quadrant tenderness with no rebound tenderness and guarding. We found ileoileal invagination at the right lower quadrant of the abdomen in an ultrasonography. A laparatomy was then performed at our hospital. Exploration revealed nine invaginated ileoileal areas in total (Fig. 1). These areas were reduced manually. No recurrence was observed in the follow-ups during the postoperative 18 months. View of the multiple invaginated ileoileal areas in Case 2. The detection of invagination at more than one site simultaneously is a rare event and only a few cases have been documented in adults [1], [2]. Multiple sequential invagination has only been documented in newborns once [3]. In some literature, in the cases that are accompanied by more than one invagination, additional pathologies such as Peutz–Jeghers syndrome, adenomatous polyp, metastatic melanoma, metastatic lung cancer, malign pleural mesothelioma, and lymphoma are generally shown as leading points [1], [2], [4]. In our first patient, no anatomical leading point was encountered. In the second patient no triggering pathology for invagination was detected apart from multiple reactive lymphadenopathy secondary to bronchitis. Because multiple invagination is a rare phenomenon, sonographic study is generally terminated after an invaginated segment is detected at a single site. Similarly, in laparatomy, the procedure can be finalized after a single invaginated segment is reduced. Nevertheless, the intestinal tract should be explored, keeping in mind the fact that there may be other invaginated segments. We manually reduced two sites on which invagination was detected in our first patient. As for the second patient, if we had ended the procedure having manually reduced the first ileoileal invagination, we would have overlooked the other invaginated sites and complaints would have resumed in both patients in the postoperative period. Relapse percentage in the pediatric population has been reported to be 8–15% [5]. Our cases led us to consider the fact that a fraction of relapse invaginations in the postoperative period may actually be multiple invagination cases. As a result, we strongly recommend the exploration of the intestinal tract, keeping in mind that there may also be multiple invaginations in the pediatric population.