interval laparoscopic ileocecectomy in a child with cecal diverticulitis

Journal of Pediatric Surgery Case Reports 17 (2017) 20e24 Contents lists available at ScienceDirect Journal of Pediatric Surgery Case Reports journal homepage: www.jpscasereports.com Interval laparoscopic ileocecectomy in a child with cecal diverticulitis John D Horton a, George E Black IV a, Mauricio A Escobar Jr b, * a b Madigan Army Medical Center, Fort Lewis, WA, USA Pediatric Surgery, Mary Bridge Children's Hospital and Health Center, MultiCare Health System, Tacoma, WA, USA a r t i c l e i n f o a b s t r a c t Article history: Received November 2016 Received in revised form 22 November 2016 Accepted 24 November 2016 Available online 25 November 2016 Cecal diverticulitis is a rare condition in children that can present diagnostic and surgical challenges Cecal diverticulitis has a similar presentation to appendicitis, but the surgical management is much different We present a case of cecal diverticulitis in a 13-year-old Hispanic male who was initially treated nonoperatively, but ultimately underwent laparoscopic assisted ileocecectomy as definitive treatment This is the only case report to describe a delayed surgical approach to this rare medical condition We feel this approach has particular merit with respect to cecal diverticulitis as the possibility of diagnostic uncertainty is high Cecal diverticulitis is a rare disease process, particularly in children Patients predictably present with right lower quadrant abdominal pain in a manner similar to appendicitis Imaging may reveal a phlegmon, perforation, bowel wall thickening, or nonspecific inflammatory changes These imaging findings may not always indicate a clear diagnosis, especially if the appendix cannot be well visualized Urgent operation may be ill advisable in this situation as the surgeon may encounter a hostile operative field with dense inflammatory changes resulting in an increased risk of ileostomy creation We present a case of cecal diverticulitis managed safely with a delayed surgical approach We feel a delayed surgical approach may provide an alternative option for patients with an uncertain diagnosis or surgeons who wish to avoid a potentially hazardous dissection A delayed approach may also help to facilitate a minimally invasive approach © 2016 The Authors Published by Elsevier Inc This is an open access article under the CC BY-NC-ND license (http://creativecommons.org/licenses/by-nc-nd/4.0/) Case report A 13-year-old Hispanic male with no significant past medical or surgical history presented to Mary Bridge Children's Hospital with two days of abdominal pain His pain was described as right lower quadrant (RLQ), cramp like in quality, and waxed and waned in intensity He denied any coexisting symptoms such as nausea, vomiting, diarrhea, constipation, fevers or chills He was evaluated in the emergency room and was found to have moderate tenderness with voluntary guarding in the RLQ His exam was otherwise normal with normal vital signs He had a leukocytosis of 13 with an elevated absolute neutrophil count as well as an elevated erythrocyte sedimentation rate (ESR) and c-reactive protein (CRP) on laboratory evaluation His labs, including chemistry and liver function tests, were otherwise normal * Corresponding author Mary Bridge Children’s Hospital and Health Center, Department of Surgery, PO Box 5299, MS: 311-3W-SUR, Tacoma, WA 98415, USA E-mail address: Mauricio.Escobar@multicare.org (M.A Escobar) He underwent ultrasound of his RLQ to attempt to confirm the working diagnosis of acute appendicitis However, the appendix was unable to be visualized on ultrasound He then underwent computed tomography scanning of his abdomen and pelvis with intravenous contrast (Fig 1a and b) This showed inflammation around his mid ascending colon with adjacent mesenteric lymphadenopathy, some trace free fluid in the retrocolic space, and what appeared to be a few small diverticula in the region of inflammation His appendix was identified and found to be dilated up to 10 mm However, it contained air throughout and exhibited no surrounding inflammatory changes At this point, the pediatric surgical team was not convinced the patient had appendicitis The differential diagnosis included inflammatory bowel disease, colonic mass with perforation, Meckel's diverticulitis, and cecal diverticulitis He was admitted to the hospital and treated with IV ciprofloxacin, metronidazole, and bowel rest His symptoms improved with this treatment, and he was discharged two days later with a 10-day course of oral ciprofloxacin and metronidazole One month after his initial hospitalization, he underwent a colonoscopy to further evaluate the colon for the possibility of a mass, http://dx.doi.org/10.1016/j.epsc.2016.11.012 2213-5766/© 2016 The Authors Published by Elsevier Inc This is an open access article under the CC BY-NC-ND license (http://creativecommons.org/licenses/by-nc-nd/4.0/) J.D Horton et al / Journal of Pediatric Surgery Case Reports 17 (2017) 20e24 21 Fig Colonoscopy depicting diverticulosis of the cecum Fig a Cecal diverticulitis noted on axial CT images at presentation b Cecal diverticulitis noted on coronal CT images at presentation inflammatory bowel disease, or presence of diverticula The colonoscopy was normal except for diverticulosis of the cecum (Fig 2) Repeat cross sectional imaging at that time showed a persistent mass in the prior area of inflammation (Fig 3) Due to concern for this mass being a neoplastic process and the presence of diverticula in the cecum, he and his parents were counseled for a laparoscopicassisted ileocecectomy The surgical team felt the procedure would be diagnostic in terms of the mass and possibly therapeutic in terms of the cecal diverticula The family agreed and he underwent laparoscopic assisted ileocecectomy with primary anastomosis without complication (Fig 4) His cecum was opened following resection in the operating room and multiple diverticula of the cecum were identified (Fig 5) There was a palpable mass in the mesentery adjacent to the resected cecum Pathology showed a 1.7 cm focus of dense granulomatous, mixed inflammation, and fecal material, representing the site of a ruptured diverticulum There was no evidence of neoplasia He was advanced to a regular diet quickly post operatively and was discharged home on post-operative day number one The patient was last seen in clinic ten months after surgery At that time, he was doing well and without any complaints been numerous case reports and case series describing cecal diverticulitis in the adult literature [2] Current understanding of cecal diverticulitis is based on this relatively large body of literature The diverticulum may be a true diverticulum containing all layers of the colonic wall, or a false diverticulum consisting of mucosa and submucosa only This distinction may be important with respect to the surgical management of this disease [3] However, there have been only a handful of recent (since 2005) case reports describing this clinical entity in pediatric patients (Table 1) Granted, the separation between proximal right sided colonic diverticulitis and cecal diverticulitis is an arbitrary anatomic distinction, but this discussion will focus on cecal diverticulitis in children Cecal diverticulitis and appendicitis can be difficult to distinguish based solely on clinical presentation Historically, right sided diverticulitis and cecal diverticulitis have been reported more commonly in patients from Asian heritage Two of the seven patients in modern pediatric case reports come from an Asian background Cecal diverticulitis can present as early as years of age [4] Discussion Colonic diverticular disease is a rare clinical entity in children first described by Ashurst in 1908 [1] Since that time, there have Fig Cecal diverticulitis noted on axial CT images at one month follow up Note the mass-like appearance to the cecum 22 J.D Horton et al / Journal of Pediatric Surgery Case Reports 17 (2017) 20e24 Fig Intraoperative photos of the cecum demonstrating diverticulosis There are no modern case reports of this disease in neonates and infants Appendicitis and cecal diverticulitis typically present with RLQ abdominal pain that progresses over a few days prior to patients seeking medical attention Patients with diverticula along the lateral colonic wall may present with the point of maximal tenderness more superior and lateral than typical appendicitis [5] Patients may also exhibit nausea, vomiting, and fever Laboratory assessment demonstrates a typical inflammatory or infectious process with an elevated white blood cell count, elevated neutrophils, and elevated CRP Standard imaging of children with RLQ abdominal pain often begins with an ultrasound At this point in the patient's work-up, the clinician may first begin to entertain the diagnosis of cecal diverticulitis Ultrasound may identify a normal appendix, and a focal outpouching of the colon may be evident In these case reports, ultrasound was usually followed by abdominal CT scan CT scan may demonstrate inflammatory changes in the right lower quadrant without clearly identifying the appendix, cecal diverticula, or other etiology to explain the clinical presentation Aside from acute appendicitis and cecal diverticulitis, the differential diagnosis based on presentation and imaging could include perforated appendicitis, infectious colitis/ileitis, inflammatory bowel disease, typhlitis, cecal perforation, foreign body reaction, Meckel's diverticulitis, and neoplasia Overall, the diagnosis of cecal diverticulitis was made based on imaging alone in only out of cases Despite modern imaging techniques, differentiating the more common appendicitis from cecal diverticulitis can be a challenging endeavor Management of cecal diverticulitis can proceed via operative or nonoperative strategies According to the adult literature, only 4e16% of cases are diagnosed preoperatively [2] Intuitively, appendicitis is typically the preoperative diagnosis for many patients who are ultimately found to have cecal diverticulitis The surgical approach to cecal diverticulitis may begin with a Fig Specimen opened revealing diverticulosis laparoscopic approach, but all but one of the recent case reports in children required a laparotomy to complete the procedure Once an operative approach is selected, surgeons must decide whether to perform a diverticulectomy or ileocecectomy The adult literature reports good results for diverticulectomy with follow-up as long as 25 years [3] If diverticulectomy is performed, surgeons should also consider performing an appendectomy in order to minimize future diagnostic dilemma [6] However, there have been no recent reports of diverticulectomy for cecal diverticulitis in children Presumably, diverticulectomy would only be feasible for true diverticula, and most of the reported pediatric cases were found to have false diverticula In our case the diverticula were small enough that diverticulectomy was not feasible While not specifically mentioned in the pathology report, we surmise that these were most likely false diverticula Surgical outcomes in children with cecal diverticulitis have been good There have been no reported complications with a hospital stay of 5e7 days Surgeons may also choose to pursue nonoperative management This treatment consists of hospital admission, broad spectrum antibiotics, serial abdominal exams, and close observation This approach was employed initially in three of the seven cases reported in the pediatric literature One patient failed this approach and was taken to the operating room where an open ileocecectomy was performed [7] Another patient underwent successful nonoperative management and was asymptomatic at 15 month follow up [5] The nonoperative strategy was also initially successful for our patient However, we decided to proceed with laparoscopic ileocecectomy due to concerns for neoplasia and recurrent diverticulitis Nonoperative approach to right sided colonic diverticulitis in adults is usually successful with a reported recurrence rate of approximately 20% [2] Due to its similar presentation as appendicitis, cecal diverticulitis has historically been diagnosed at the time of surgery However, modern imaging has increased the probability of diagnosing cecal diverticulitis prior to surgical exploration A recent report described successful nonoperative management of cecal diverticulitis in nine out of twelve patients In addition, two of the three patients who underwent surgery only had an appendectomy performed, thus essentially managing the cecal diverticulitis nonoperatively Follow-up is not clearly delineated in the study, but none of the patients were readmitted for recurrence [8] Based on the adult literature, the current trend is to manage right sided colonic diverticulitis and cecal diverticulitis nonoperatively Given the limited data in the pediatric population, strong recommendations for the management of cecal diverticulitis are not possible However, extrapolation of the adult literature seems to suggest that the nonoperative strategy is a reasonable approach in selected patients Specific patient characteristics which should factor in the decision include patient comorbidities, surgical history, future access to pediatric surgical care, diagnostic uncertainty, and judgment regarding family compliance to medical recommendations Given our experience with this case and the success of nonoperative management in the adult literature, we feel a trial of initial nonoperative management is warranted in patients with cecal diverticulitis who not present with evidence of free intraperitoneal perforation or hemodynamic instability (Fig 6) This approach allows for more time to gather diagnostic data as a definitive diagnosis may not be clear Colonoscopy 4e6 weeks after initial presentation can be a useful adjunct to assess for inflammatory bowel disease, presence of diverticula, or intraluminal mass For patients who ultimately go to surgery, initial nonoperative management may also provide a “cooling off” period This may facilitate a minimally invasive approach and alleviate the need to operate in an acutely inflamed or infected surgical field Ultimately, surgeons must use their best judgment and counsel J.D Horton et al / Journal of Pediatric Surgery Case Reports 17 (2017) 20e24 23 Table Case reports describing cecal diverticulitis in pediatric patients since 2005 Huntington [9] Rich [7] Cheng [4] Cheng [4] Sigaloff [10] Bogue [5] Present Case Age (Yr) Sex Ethnicity Treatment 10 15 13 13 13 Male Female Female Female Male Male Male Unknown Unknown Hispanic Caucasian Korean Asian Hispanic Open ileocecectomy Open ileocecectomy, failed nonoperative management Open ileocecectomy Open ileocecectomy Open ileocecectomy Successful non-operative management Interval laparoscopic ileocecectomy families carefully as objective data for cecal diverticulitis in children is lacking Conclusion The diagnosis of cecal diverticulitis may not be straight forward Surgical resection provides valuable diagnostic and therapeutic benefits When diagnosis is in doubt, an initial nonoperative approach allows the surgeon to gather additional data in order to formulate an operative plan After additional clinical data is gathered, the surgeon may be able to narrow the differential diagnosis In addition, the interval approach to this disease may enhance the probability of utilizing minimally invasive surgery techniques Fig Proposed algorithm for the management of right-sided or cecal diverticulitis in children 24 J.D Horton et al / Journal of Pediatric Surgery Case Reports 17 (2017) 20e24 Conflict of interest The authors confirm there are no conflicts of interest in the manuscript, including financial, consultant, institutional and other relationships that might lead to bias or a conflict of interest Acknowledgements The views expressed herein are those of the authors (JH, GEB) and not reflect the official policy or position the US Army Medical Department, the US Army Office of the Surgeon General, the Department of the Army, the Department of Defense, or the US Government References [1] Ashurst A Sigmoid diverticulitis (mesosigmoiditis) in a child Ann Surg 1908;47:300e5 [2] Telem DA, Buch KE, Nguyen SQ, Chin EH, Weber KJ, Divino CM Current recommendations on diagnosis and management of right-sided diverticulitis Gastroenterol Res Pract 2009;2009:359485 [3] Papaziogas B, Makris J, Koutelidakis I, Paraskevas G, Oikonomou B, Papadopoulos E, et al Surgical management of cecal diverticulitis: is diverticulectomy enough? Int J Colorectal Dis 2005;20(1):24e7 [4] Cheng E, Cohen L, Gasinu S, Sy C, Beneck D, Spigland N Cecal diverticulitis as a continuing diagnostic and management dilemma: a report of two cases in children Pediatr Surg Int 2012;28(1):99e102 [5] Bogue CO, Mann EH Imaging findings in right-sided diverticulitis in a child Pediatr Radiol 2008;38(10):1125e7 [6] Koshy RM, Abusabeib A, Al-Mudares S, Khairat M, Toro A, Di Carlo I Intraoperative diagnosis of solitary cecal diverticulum not requiring surgery: is appendectomy indicated? World J Emerg Surg 2016;11:1 [7] Rich BS, Cheng E, Cohen L, Sy C, Spigland N Another case of pediatric cecal diverticulitis Pediatr Surg Int 2012;28(12):1243 [8] Cristaudo A, Pillay P, Naidu S Caecal diverticulitis: presentation and management Ann Med Surg (Lond) 2015;4(1):72e5 [9] Huntington JT, Brigode W, Thakkar RK, Raval MV, Teich S A case of pediatric cecal diverticulitis mimicking acute appendicitis Int J Colorectal Dis 2016;31(1):147e8 [10] Sigaloff KC, van den Berg JG, Benninga MA Cecal diverticulitis in an adolescent J Pediatr Gastroenterol Nutr 2005;40(5):603e5  ... Standard imaging of children with RLQ abdominal pain often begins with an ultrasound At this point in the patient''s work-up, the clinician may first begin to entertain the diagnosis of cecal diverticulitis. .. management may also provide a “cooling off” period This may facilitate a minimally invasive approach and alleviate the need to operate in an acutely in? ??amed or infected surgical field Ultimately, surgeons... diagnostic and therapeutic benefits When diagnosis is in doubt, an initial nonoperative approach allows the surgeon to gather additional data in order to formulate an operative plan After additional clinical