Hemorrhage from a jejunal polypoid hemangioma: single incisional laparoscopic approach.
ABSTRACT Bleeding lesions in the small bowel are a much more significant challenge in terms of detection and treatment than those of the stomach or the large bowel, and require extensive gastrointestinal evaluation before a diagnosis can be made. The authors report the case of an 81-year-old female patient who underwent small bowel segmental resection by single incisional laparoscopic approach for distal jejunalhemangioma, which caused severe anemia. An abdominal computed tomography scan demonstrated a highly enhancing polypoid tumor in the distal ileum. During the single incisional laparoscopic exploration using a 2 cm sized skin incision, jejuno-jejunal intussusceptions and a jejunal tumor were noted. Single incisional laparoscopy was performed to assist the jejunal segmental resection. Pathologic reports confirmed the lesion to be a jejunalhemangioma. The authors report an unusual case of jejunalhemangioma caused by intussusception and gastrointestinal hemorrhage, which was treated by single incisional laparoscopic surgery.
- SourceAvailable from: Blair Lewis[Show abstract] [Hide abstract]
ABSTRACT: It is believed that cancers of the small intestine represent <2% of all malignant tumors of the gastrointestinal tract, although the accuracy of this estimate is unknown, because the current methodologies for examining the small bowel have proved inadequate. Capsule endoscopy allows a more detailed inspection of the small intestine and may improve the ability to diagnose small bowel tumors. The objective of this study was to evaluate the effectiveness of capsule endoscopy in diagnosing small bowel tumors and to help establish the true incidence of tumors in obscure gastrointestinal bleeding. A retrospective analysis of the charts of 562 patients who underwent capsule endoscopy from August 2001 to November 2003 for a variety of indications was performed. The indication for the procedure was bleeding (alone or in addition to another indication, such as abnormal imaging) in 443 patients. A diagnosis was made by capsule endoscopy in 277 patients (49.3%). Of 562 patients who were included in the study, 50 patients (8.9%) were diagnosed with small bowel tumors. The types of tumor diagnosed by capsule endoscopy included 8 adenocarcinomas (1.4%), 10 carcinoids (1.8%), 4 gastrointestinal stromal tumors (0.7%), 5 lymphomas (0.9%), 3 inflammatory polyps, 1 lymphangioma, 1 lymphangioectasia,1 hemangioma, 1 hamartoma, and 1 tubular adenoma. Of the tumors diagnosed, 48% were malignant. It was observed that 9 of 67 patients (13%) younger than age 50 years who underwent capsule endoscopy for obscure bleeding had small bowel tumors. The pathology results were not available for 10 patients. Capsule endoscopy diagnosed small bowel tumors in 8.9% of patients who underwent the procedure for a variety of reasons, establishing it as an effective diagnostic modality. This incidence of small bowel tumors suggests an important role for capsule endoscopy in the algorithm for the diagnostic work-up of patients with suspected small bowel lesions. Capsule endoscopy may lead to earlier detection and treatment of small bowel tumors and an improved prognosis for patients with these neoplasms.Cancer 07/2006; 107(1):22-7. · 5.20 Impact Factor
- Surgical Endoscopy 05/2009; 23(7):1419-27. · 3.43 Impact Factor
- [Show abstract] [Hide abstract]
ABSTRACT: We describe a 14-year-old boy with a solitary cavernous hemangioma in the proximal small intestine that caused recalcitrant iron deficiency anemia beginning at 3 years of age. After a number of attempts to ascertain the cause of the anemia were unsuccessful, the vascular tumor was ultimately diagnosed in the jejunum, approximately 80 cm distal to the ligament of Treitz. We discuss the differential diagnoses of vasoformative intestinal lesions and review the literature on enteric cavernous hemangiomas in childhood.Archives of pathology & laboratory medicine 10/1993; 117(9):939-41. · 2.78 Impact Factor
J Korean Surg Soc 2011;80:362-366
Copyright © 2011, the Korean Surgical Society
Journal of the Korean Surgical Society
pISSN 2233-7903ㆍeISSN 2093-0488
Received December 19, 2009, Accepted March 2, 2010
Correspondence to: Won Kyung Kang
Department of Surgery, Seoul St. Mary’s Hospital, The Catholic University of Korea, 505 Banpo-dong, Seocho-gu, Seoul, Korea
Tel: ＋82-2-2258-6104, Fax: ＋82-2-595-2992, E-mail: firstname.lastname@example.org
cc Journal of the Korean Surgical Society is an Open Access Journal. All articles are distributed under the terms of the Creative Commons
Attribution Non-Commercial License (http://creativecommons.org/licenses/by-nc/3.0/) which permits unrestricted non-commercial use,
distribution, and reproduction in any medium, provided the original work is properly cited.
Hemorrhage from a jejunal polypoid hemangioma:
single incisional laparoscopic approach
Bong Hyeon Kye, Soo Hong Kim, Jae Im Lee, Jun Gi Kim, Seong Taek Oh, Won Kyung Kang,
Chan Kwon Jung1
Departments of Surgery and 1Pathology, The Catholic University of Korea School of Medicine, Seoul, Korea
Bleeding lesions in the small bowel are a much more significant challenge in terms of detection and treatment than those of
the stomach or the large bowel, and require extensive gastrointestinal evaluation before a diagnosis can be made. The au-
thors report the case of an 81-year-old female patient who underwent small bowel segmental resection by single incisional
laparoscopic approach for distal jejunalhemangioma, which caused severe anemia. An abdominal computed tomography
scan demonstrated a highly enhancing polypoid tumor in the distal ileum. During the single incisional laparoscopic explora-
tion using a 2 cm sized skin incision, jejuno-jejunal intussusceptions and a jejunal tumor were noted. Single incisional laparo-
scopy was performed to assist the jejunal segmental resection. Pathologic reports confirmed the lesion to be a
jejunalhemangioma. The authors report an unusual case of jejunalhemangioma caused by intussusception and gastro-
intestinal hemorrhage, which was treated by single incisional laparoscopic surgery.
Key Words: Jejunal hemangioma, Single incision, Gastrointestinal hemorrhage
Acute gastrointestinal (GI) bleeding is a common emer-
gency condition and an important cause of mortality.
Furthermore, the GI bleeding source is not found in ap-
proximately 3-5% of patients by esophagogastroduodeno-
scopy (EGD) and colonoscopy. In these cases, most lesions
responsible are found in the small bowel . However,
gastrointestinal bleeding originating in the small bowel is
often difficult to diagnose and treat.
Hemangiomas originating from the small bowelare un-
common benign tumors, and may cause massive or occult
GI bleeding. Although manytools can be used to diagnose
tumors in the small intestine, hemangiomas with a small
intestine origin are difficult to differentiate from other
more common entities .
Recently, single incisional laparoscopic surgery has
been utilized to treat various benign conditions in the ab-
domen . Here, we report a case of jejunal polypoid he-
mangioma, causing recurrent GI bleeding and subsequent
life-threatening anemia, which was treated using a single
incisional laparoscopic approach.
SILS small bowel resection
Fig. 1. Contrast enhanced CT scan
shows ahighly enhancing poly-
poid tumor in the distal ileum. This
lesion is considered to be the
probable bleeding focus.
Fig. 2. This picture shows the 2-cm sized vertical transumbilical
incision made to access the abdominal cavity.
An 81-year-old female patient complaining of intermitt
ent melena for 3 months, and of nausea and dizziness,
which were aggravated just days before presentation, was
found to have severe anemia. At presentation on emer-
gency room, her initial hemoglobin and hematocrit levels
were 4.7 g/dL and 15.8%, respectively. However, because
her vital signs and performance status were stable, we
went ahead the diagnostic evaluations with blood trans-
fusions instead of the emergency operation. She had a
medication history of hypertension and diabetes mellitus,
but had not taken aspirin. EGD revealed only a 0.5 cm ul-
ceration in stomach with no evidence of bleeding. Colono-
scopic findings were unremarkable except for a 0.3 cm pol-
yp in sigmoid colon, which also had no evidence of
bleeding. An emergency abdominal CT scan was per-
formed, and demonstrated a highly enhancing polypoid
tumor in the distal ileum (Fig. 1). Diagnostic consid-
erations included; adenocarcinoma or lymphoma, a pol-
yp, a carcinoid tumor, or a vascular lesion. However, a GI
contrast study failed to demonstrate any bleeding focus or
We decided to perform explorative laparotomy for
diagnosis and treatment purposes. Surgery was performed
using a single incisional laparoscopic approach with a
surgical glove and a wound protector. The patient was
placed in the supine position under general anesthesia with
an endotracheal tube, and a 2-cm vertical transumbilical
incision was made (Fig. 2) and the abdominal cavity
accessed. A small Allexis Wound Retractor (Applied
Medical, Rancho Santa Margarita, CA, USA) was placed,
and a size 6 surgical glove was installed over the external
ring. The thumb and middle finger of the glove were
partially cut and 10-mm trocar for a videoscope and 5 mm
trocar for a working device was placed and tied. When the
intra-abdominal cavity was explored, an intussusceptum
was found at the distal jejunal level (Fig. 3); no other
abnormality was observed. The small bowel, including the
intussusceptum, was taken out of the abdominal cavity, and
segmental resection of the small bowel and end-to-end
Bong Hyeon Kye, et al.
Fig. 5. Photomicrographs of the microscopic features of the jejunal mass. (A) The polypoid hemangioma consists of a proliferation of dilated
vessels and small capillaries, and infiltrated proper muscle and subserosa (H&E stain, x12). (B) The hemangioma consists of large
blood-filled spaces or sinuses lined by single endothelial layers (H&E stain, x100).
Fig. 4. The gross features of the jejunal mass. (A) Picture shows the 2-cm sized, pale brown, polypoid mass in the resected specimen. (B)
Picture shows that the lesion has infiltrated the subserosa.
Fig. 3. The small bowel lesion is
presented as the intussusceptions
of jejuno-jejunal type. The intus-
susceptum is about 2-3 cm dia-
SILS small bowel resection
anastomosis by hand sewing were performed extra-
corporeally. The anastomosed small bowel was then
placed in the abdominal cavity, and the wound was closed
after saline irrigation. The resected mass was soft, pale
brown, and 2 cm in size (Fig. 4), and was histologically
confirmed to be a jejunal polypoid hemangioma (Fig. 5).
The patient was discharged on postoperative day 7 with-
out any complication.
Hemangiomas of the GI tract are uncommon, and ac-
count for only 0.05% of all intestinal neoplasms and 7 to
10% of all benign tumors of the small bowel. Ninety per-
cent of hemangiomas are clinically evident, and present
with symptoms, such as, acute or chronic GI hemorrhage,
anemia, or obstruction, and rarely with platelet sequestra-
tion . Other potentially serious complications of he-
mangiomas of the GI tract, such as, intussusception, small
bowel obstruction, perforation, malabsorption, and bleed-
ing from other sites of involvement, may also occur .
Bleeding is one of the symptoms associated with a small
bowel neoplasm, and is usually occult and requires an ex-
tensive GI evaluation before a diagnosis is obtained.
However, the diagnosis and localization of small bowel tu-
mors remains a clinical challenge, because of the in-
accessibility of this region to conventional diagnostic
modalities. CT is frequently used as a front line tool for the
evaluation of abdominal symptoms, especially in critically
ill patients. CT scans show transluminal thickening of the
wall of involved bowel loops with non-homogenous and
persistent lesion contrast enhancement . Double con-
trast studies demonstrate a nodular defect, which may
change in configuration after compression or distension,
which suggests a soft, possibly vascular tumor. The de-
tection of this pathologic finding by double contrast study
depends on the size of lesion and on the presence of active
intestinal peristalsis [4,5].
Livengood and associates  described the feasibility of
the angiographic localization of hemangioma of the small
bowel. They performed angiography with methylene
blue, which allowed lesions to be identified from an extra-
luminal vantage point. This method avoids the guesswork
involved in transillumination and palpation for tumor lo-
calization during laparoscopy. In our case, we performed
EGD, colonoscopy, an abdominal CT scan, and a double
contrast study to indentify the bleeding focus, and with
the exception of abdominal CT, these modalities did not
indenty the problematic lesion.
We performed a single incisional laparoscopic explora-
tion to localize and treat the jejunal tumor. Laparoscopic
small bowel resection is an established technique and is
performed by exteriorizing the diseased bowel segment
and using traditional resection and anastomotic techni-
ques . Recently, multiple attempts have been made to re-
duce parietal trauma and visible scar formation even after
laparoscopic surgery, and patient satisfaction has become
a rapidly evolving issue, particularly in terms of single in-
cisional laparoscopic surgery [3,7,8]. This issue reflects the
importance of cosmesis and body image trauma asso-
ciated with surgical procedures, and many surgeons have
devised “scarless” surgical procedures using standard
laparoscopic instruments. In the described case, standard
laparoscopic instruments were used during the proce-
Bleeding that originates from the small bowel presents
challenges in terms of diagnosis, localization, and treat-
ment. However, single incisional laparoscopic exploration
may be helpful for localization and treatment purposes. In
addition to its superior cosmetic results, a single incisional
laparoscopic approach causes less morbidity by minimiz-
ing skin incisions. However, some bleeding lesions in the
small bowel may be manifestations of a malignant proc-
ess, and thus, it is essential that the surgeon has multiport
laparoscopic skills, because these are vital for safe and ef-
fective single incisional laparoscopic surgery.
CONFLICTS OF INTEREST
No potential conflict of interest relevant to this article
Bong Hyeon Kye, et al.
1. Okazaki H, Fujiwara Y, Sugimori S, Nagami Y, Kameda N,
Machida H, et al. Prevalence of mid-gastrointestinal bleed-
ing in patients with acute overt gastrointestinal bleeding:
multi-center experience with 1,044 consecutive patients. J
2. Cobrin GM, Pittman RH, Lewis BS. Increased diagnostic
yield of small bowel tumors with capsule endoscopy.
3. Romanelli JR, Earle DB. Single-port laparoscopic surgery:
an overview. Surg Endosc 2009;23:1419-27.
4. Boyle L, Lack EE. Solitary cavernous hemangioma of small
intestine. Case report and literature review. Arch Pathol
Lab Med 1993;117:939-41.
5. Corsi A, Ingegnoli A, Abelli P, De Chiara F, Mancini C,
Cavestro GM, et al. Imaging of a small bowel cavernous
hemangioma: report of a case with emphasis on the use of
computed tomography and enteroclysis. Acta Biomed
6. Livengood JC, Fenoglio ME. Gastrointestinal hemorrhage
from a small bowel polypoid hemangioma. JSLS 2002;6:
7. Remzi FH, Kirat HT, Kaouk JH, Geisler DP. Single-port
laparoscopy in colorectal surgery. Colorectal Dis 2008;10:
8. Bucher P, Pugin F, Morel P. Single port access laparoscopic
right hemicolectomy. Int J Colorectal Dis 2008;23:1013-6.