Primary and secondary abdominal cocoon- diagnostic and management challenges: retrospective study

Abstract

Background: Abdominal cocoon is a rare cause of intestinal obstruction characterized by fibro collagenous membrane encapsulating the abdominal contents to varying degrees. The most commonly identified etiology remains to be ‘idiopathic’ and hence it is also known as idiopathic sclerosing encapsulating peritonitis.. Few case reports of abdominal cocoon secondary to gastrointestinal malignancy and tuberculosis have also been reported. The objective of the study was to study the spectrum of clinical presentation, identify the various aetio pathogenesis described and their impact on outcome of surgically managed patients with abdominal cocoon.

Methods: The clinical data of twelve different cases of abdominal cocoon presented to a general surgery unit from January 2012 to December 2017 with minimum of 1 year follow up were analyzed.

Results: In our series we had 12 patients with cocoon who underwent surgical intervention out of which 8 were primary and 4 were secondary to TB. In primary type one out of eight patients had acute presentation, but in secondary three out of four had acute presentation. In primary 6 out of 7 patient’s pre-operative CT showed cocoon, but in secondary only 1 out of 3 showed cocoon. In patients with primary cocoon 3 out of 8 patients had bowel resection and only one had post-operative morbidity. In patients with secondary cocoon three patients had bowel resection, stoma creation and reoperations with stormy post operative period. All 4 had post-operative morbidity, however all of them received ATT and definitive surgery was performed 1-2 years later with minimal resection and serial images also showed resolution of cocoon formation with ATT. Primary group up to 5 years follow up, there was no recurrence of symptoms. Both groups did not have any mortality.

Conclusions: Abdominal cocoon is a rare disorder and the cause may be primary or secondary. In our series tuberculosis is the aetiology for secondary cocoon. Primary cocoon is easier to diagnose, manage and associated with less post operative complications compare to secondary cocoon. Damage control first surgery, nutritional build up and treatment with anti tubercular drugs are needed for management of cocoon secondary to TB for a better outcome in acute presentations. Definitive surgery can be performed once the nutritional status improves with less morbidity.