Case Report
Copyright ©The Author(s) 2024. Published by Baishideng Publishing Group Inc. All rights reserved.
World J Gastrointest Surg. Mar 27, 2024; 16(3): 955-965
Published online Mar 27, 2024. doi: 10.4240/wjgs.v16.i3.955
Abdominal cocoon syndrome-a rare culprit behind small bowel ischemia and obstruction: Three case reports
Witcha Vipudhamorn, Tawan Juthasilaparut, Pawit Sutharat, Suwan Sanmee, Ekkarin Supatrakul
Witcha Vipudhamorn, Pawit Sutharat, Suwan Sanmee, Ekkarin Supatrakul, Department of Colorectal Surgery, Chiang Mai University, Chiang Mai 50200, Thailand
Tawan Juthasilaparut, Department of Surgery, Lampang Hospital, Lampang 52000, Thailand
Co-first authors: Witcha Vipudhamorn and Tawan Juthasilaparut.
Author contributions: Vipudhamorn W and Juthasilaparut T contributed to manuscript writing and editing, and data collection; Sutharat P, Sanmee S and Supatrakul E contributed to conceptualization and supervision; all authors have read and approved the final manuscript. Notably, Vipudhamorn W and Juthasilaparut T, as doctors directly involved in the care of the patients featured in this case report, not only spearheaded the drafting of the manuscript but also contributed their clinical insights and expertise. While Vipudhamorn W and Juthasilaparut T took the lead in composing the manuscript, Sutharat P, Sanmee S, and Supatrakul E diligently reviewed articles for discussion and contributed significantly to the revision process. Furthermore, all authors played integral roles in the critical review of the results, collectively ensuring the accuracy and validity of the final manuscript, which has been unanimously approved by the entire team. Vipudhamorn W and Juthasilaparut T are designated as co-first authors for several compelling reasons. Firstly, their involvement extended beyond writing; their direct patient care and clinical insights profoundly influenced the depth and context of this study. Secondly, both Vipudhamorn W and Juthasilaparut T made substantive and equal contributions throughout the research process, reflecting the essence of teamwork and dedication. In essence, designating Vipudhamorn W and Juthasilaparut T as co-first authors aptly reflects the collaborative spirit, equal contributions, and clinical expertise they brought to this manuscript. Their direct involvement with the patients, combined with their writing efforts, significantly enriched the depth and authenticity of this study, thereby enhancing its value to the medical community.
Informed consent statement: Informed written consent was obtained from the patient for publication of this report and any accompanying images.
Conflict-of-interest statement: The authors declare that they have no conflict of interest.
CARE Checklist (2016) statement: The authors have read the CARE Checklist (2016), and the manuscript was prepared and revised according to the CARE Checklist (2016).
Open-Access: This article is an open-access article that was selected by an in-house editor and fully peer-reviewed by external reviewers. It is distributed in accordance with the Creative Commons Attribution NonCommercial (CC BY-NC 4.0) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited and the use is non-commercial. See: https://creativecommons.org/Licenses/by-nc/4.0/
Corresponding author: Witcha Vipudhamorn, FRCS (Gen Surg), Surgeon, Department of Colorectal Surgery, Chiang Mai University, No. 110 Intavaroros, Sripoom, Maung, Chiang Mai 50200, Thailand. witcha.vip@cmu.ac.th
Received: November 26, 2023
Peer-review started: November 26, 2023
First decision: December 15, 2023
Revised: December 16, 2023
Accepted: February 6, 2024
Article in press: February 6, 2024
Published online: March 27, 2024
Processing time: 116 Days and 22.5 Hours
Abstract
BACKGROUND

Abdominal cocoon syndrome (ACS) represents a category within sclerosing encapsulating peritonitis, characterized by the encapsulation of internal organs with a fibrous, cocoon-like membrane of unknown origin, resulting in bowel obstruction and ischemia. Diagnosing this condition before surgery poses a challenge, often requiring confirmation during laparotomy. In this context, we depict three instances of ACS: One linked to intestinal obstruction, the second exclusively manifesting as intestinal ischemia without any obstruction, and the final case involving a discrepancy between the radiologist and the surgeon.

CASE SUMMARY

Three male patients, aged 53, 58, and 61 originating from Northern Thailand, arrived at our medical facility complaining of abdominal pain without any prior surgeries. Their vital signs remained stable during the assessment. The diagnosis of abdominal cocoon was confirmed through abdominal computed tomography (CT) before surgery. In the first case, the CT scan revealed capsules around the small bowel loops, showing no enhancement, along with mesenteric congestion affecting both small and large bowel loops, without a clear obstruction. The second case showed intestinal obstruction due to an encapsulated capsule on the CT scan. In the final case, a patient presented with recurring abdominal pain. Initially, the radiologist suspected enteritis as the cause after the CT scan. However, a detailed review led the surgeon to suspect encapsulating peritoneal sclerosis (ACS) and subsequently perform surgery. The surgical procedure involved complete removal of the encapsulating structure, resection of a portion of the small bowel, and end-to-end anastomosis. No complications occurred during surgery, and the patients had a smooth recovery after surgery, eventually discharged in good health. The histopathological examination of the fibrous membrane (cocoon) across all cases consistently revealed the presence of fibro-collagenous tissue, without any indications of malignancy.

CONCLUSION

Individuals diagnosed with abdominal cocoons commonly manifest vague symptoms of abdominal discomfort. An elevated degree of clinical suspicion, combined with the application of appropriate radiological evaluations, markedly improves the probability of identifying the abdominal cocoon before surgical intervention. In cases of complete bowel obstruction or ischemia, the established norm is the comprehensive removal of the peritoneal sac as part of standard care. Resection with intestinal anastomosis is advised solely when ischemia and gangrene have been confirmed.

Keywords: Sclerosing encapsulation peritonitis; Abdominal cocoon; Peritoneal Fibrosis; Peritoneal encapsulation syndrome; Intestinal obstruction; Surgery; Case report

Core Tip: Diagnosing Abdominal cocoon syndrome (ACS) poses challenges, often necessitating laparotomy for confirmation. This study presents three distinct ACS cases: one featuring bowel obstruction, another with isolated ischemia, and the last highlighting disparities between radiological findings and surgical assessments. Preoperative computed tomography scans played a crucial role in diagnosis, revealing diverse manifestations such as capsules encasing the bowels, mesenteric congestion, or ambiguous obstructions. Surgical excision of encapsulating structures led to successful recovery. Additionally, one case involved a traumatic event, requiring exploratory laparotomy a year later, where no fibrosis was found around the previously removed intestine. Early clinical suspicion, coupled with precise radiological examination, aids in identifying ACS before surgery. Complete removal of the sac during obstruction/ischemia is the established approach, recommending resection solely for confirmed ischemic complications.