Official Journal of the American Society of Abdominal Surgeons, Inc.
This article originally appeared in the Winter 20011 / Spring 2012 issue of the Journal.
Retrograde Intussusception after Gastric Bypass: Case Report and Literature Review
Audencio Alanis, M.D.
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Intussusception is a rare event in the adult.1 A 32 year-old female with a significant past surgical history of a laparoscopic Roux-en-Y Gastric Bypass (LGBP) two years prior to onset of symptoms, presented to the emergency room with a three day history of mid-abdominal pain. The LGBP was performed antecolic, antegastric with a 100 cm roux limb. She was admitted to a hospital where no bariatric surgical care was provided and was given a diagnosis of acute pancreatitis. After five days of fluid resuscitation her physical examination did not improve, and became hemodinamicaly unstable. She was then transferred to the care of her initial bariatric surgeon. The patient had a prior history of intermittent abdominal with no other symptoms. However, prior to presenting to the emergency room, her pain was similar, but more intense compared to previous episodes. Nausea and vomiting were associated symptoms. Her vital signs showed a heart rate of 120 beats per minute. Her abdominal exam showed generalized peritonitis. Her white blood cell count was 25. The decision for an emergent laparotomy was made immediately after admission.
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On exploration, a retrograde intussusception was identified. The small bowel distal to the jejunojejunostomy intussuscepted into this anastomosis. After the intussusception was reduced, the intussusceptum consisted of necrotic jejunum without the presence of tumor or any other abnormalities. The panceatico-biliary limb along with the gastric remnant was severely dilated. The gastric remnant showed an area of necrosis on its anterior wall measuring 4cm by 5cm. The linear cutter device (Auto Suture, Connecticut), was utilized to disconnect the necrotic jejunum and jejunojejunostomy from the common channel, roux limb, and pancreatico-biliary limb en-block. The small bowel was reconstructed by creating a side-to-side anastomosis between the Roux limb and the common channel using the linear cutter staple device. Ten centimeters distal to this anastomosis, the biliopancreatic limb was anastomosed to the common channel in a similar fashion. The necrotic portion of the stomach was reseceted and closed in two layers. A gastrostomy tube was then placed. The patient did well in the post operative period. Her hemodynamic status improved, and eventually was started on a bariatric diet. She was discharged on post operative day 5.
The intussusception seems to most commonly involve the area of the jejunojejunostomy seen in previous reports and the present case.3 The function of peristaltic contractions in the small intestine is to transport chyme aborally at a rate of 1 to 2 cm per second. In the fed state, the pacesetter of these contractions are thought to be initiated in the duodenum. During the interdigestive period (fasting), the bowel is swept every 60 to 90 minutes, constrictions initiated by the migrating myoelectric complex (MMC) controlled by humoral and neural pathways. Motilin has been shown to affect intestinal motility possibly affecting the MMC. Extrinsic neural pathways are vagal and sympathetic. vagal effects are both cholinergic (stimulatory) and peptidergic. The sympathetic activity inhibits motor function. 4 Several causes have been proposed; however, dysmotility seems to be the most likely cause. Hocking reported abnormal motility after Roux-en-Y gastric bypass with no phase 2 activity.5 In addition, our patient suffered a mechanical small bowel obstruction at the jejunojejunostomy level causing nausea, vomiting which decompressed the Roux limb. It also produced a closed loop obstruction in the biliopancreatic limb causing gastric remnant necrosis. As in this case, a mildly elevated amylase is a nonspecific sign misleading the nonbariatric surgeon. Creation of a Roux-en-Y anastomosis seems to disrupt the normal peristaltic function of the small bowel. Several causes have been proposed: suture line as lead point, hyperperistalsis, accumulation of intraluminal fluid, and dysmotility. In addition, the gastric bypass jejunojejunostomy component is normaly created with the biliopancreatic limb placed in an antiperistaltic fashion.
Early diagnosis is imperative in a patient with suspected intussusception or other abdominal pathology. CT of the abdomen with contrast is the most reliable method of diagnosis. 3,6 Edwards described CT with contrast carries an accuracy of up to 80%.7
Treatment remains controversial. Surgical options include simple reduction, en-block resection with jejunojejunostoy reconstruction and/or plication. Simper presented a series of cases where different treatments were described. At least resection and/or plication is recommended. Most importantly, two of his patients were reduced and monitored with subsequent recurrence in both while 40% of patients with reduction and plication recurred.2
1. Coster D, Sundberg S, Kermode D, Beitzel D, Noun S, Severidt M. Small Bowel Obstruction Due to Antegrade and Retrograde Intussusception after Gastric Bypass: Three Case Reports in Two Patients, Literature Review, and Recommendations for Diagnosis and Treatment. Surg Obes Relat Dis. 2008; (4):69-72.
2. Simper S, Erzinger J, Mckinlay R, Smith S. Retrograde (Reverse) Jejunal Intussusception Might not Be Such a Rare Problem: A Single Group’s Experience of 23 Cases. Surg Obes Relat Dis 2008; (4):77-83.
3. Shaw D, Huddleston S, Beilman G. Anetrograde Intussusception following Laparoscopic Roux-en Y: A Case Report and Review of the Literature. Obesity Surg. 2009; (20):1191-1194.
4. Townsend CM. Sabiston Textbook of Surgery, Sixteenth Edition. Philadelphia: WB Saunders Company; 2001:879.
5. Hocking MP, McCoy DM, Vogel SB, et al. Antiperistaltic and isoperistaltic intussusception associated with abnormal motility after Roux-en-Y gastric bypass: A case report. Surgery 1991; (110):109-12.
6. Majeski J, Fried D. Retrograde intussusception after Roux-en-Y gastric bypass surgery. J Am Coll Surg 2004; 199(6):988-9.
7. Edwards MA, Grinbaum R, Ellsmere J, Jones DB, Schneider BE. Intussusception after Roux-en-Y gastric bypass for morbid obesity: a case report and literature review of rare complication. Surg Obes Relat Dis 2006; 2(4):483-9.
8. McAllister M, Donoway T, Lucktong T. Synchronous Intussusceptions Following Roux-en-Y Gastric Bypass: Case Report and Review of the Literature. Obesity Surg. 2009; (19):1719-1723.
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