Ileoileal intussusception caused by the metastasis of cutaneous malignant melanoma to the small bowel 6 years after its excision presenting with small bowel obstruction.

Sir,

I have read the paper on adult intussusception by Udo et al. with interest, for what I would like to thank the authors.1 I would like to share an extremely rare and interesting case from our practice.

A 73-year-old male patient was admitted to Vladimir City Clinical Hospital of Emergency Medicine with 4-day history of colicky abdominal pain, bloating, nausea and vomiting, and absence of stools. His medical history was significant for melanoma of upper back which was excised 6 years before admission. During the follow-up, during these 6 years, he had no signs and symptoms of local recurrence or distant metastases. On admission, he was hemodynamically stable; abdominal pain and tenderness in lower abdominal quadrants and succussion splash on auscultation were revealed. Laboratory findings revealed hemoconcentration and hypokalemia. Erect abdominal X-ray revealed small bowel air-fluid levels. The patient underwent surgery after fluid and electrolyte replacement therapy. On laparotomy, multiple intestinal metastases were found. One of the metastases had an inverted shape (70 cm proximal to ileo-cecal junction) and led to isoperistaltic ileoileal intussusception [Figure 1]. Desinvagination with ileotransversal anastomosis was performed. The postoperative course was uneventful. The patient was discharged on 7th postoperative day. On the follow-up after 2 months, the patient did not have any recurrence of intussusception and/or bowel obstruction; however, metastatic disease was progressing.

Figure 1

(a) Ileoileal intussusception intraoperatively. (b) Intestinal melanoma metastasis with an inverted shape 70 cm proximal to the ileocecal junction

Intussusception is rare in adults accounting for 3%–5% of all cases.1 Seventy-one percent of all causes of adult enteric intussusceptions are benign neoplasms, 27% of which are owing to lipomas.2 Malignant tumors are only detected in 20% of enteric intussusception cases, of which 50% are primary and 50% are metastatic.23 Malignant melanoma ranks fifth among metastatic intestinal tumors (7%) and is considered to be the extraintestinal malignancy with the greatest predilection to metastasize to the bowel.2 The time from index surgery, that is, the excision of cutaneous malignant melanoma, to the presentation of symptomatic enteric metastases has been reported to vary from 2 months to 15 years.4 Clinical presentation is varicolored depending on the site and complications of intussusception. Abdominal ultrasonography is considered to be a useful tool which can reveal the intussuscept as a “target” or “pseudo-kidney” sign.234 Abdominal computed tomography and capsule endoscopy have also been shown to be beneficial test in revealing intestinal melanoma. Such as in our case, in emergency cases where acute intussusception presents with intestinal obstruction with hydroionic imbalance, the diagnosis is established intraoperatively. The treatment of complicated intestinal metastatic melanoma is palliative and appears to be small bowel resection with anastomosis to relieve obstruction and control blood loss.5 Adjuvant palliative chemotherapy can be administered postoperatively; however, evidence of its effectiveness is currently lacking.4

To conclude, surgeons, emergency physicians, gastroenterologists should be aware of this rare clinical entity. Patients after excision of the primary melanoma should be followed for possible emerging gastrointestinal symptoms. In patients with small bowel obstruction and a history of cutaneous malignant melanoma intussusception of enteric metastasis should be considered.

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