Retrograde Jejuno-jejunal Intussusception after Roux-en-Y Gastric Bypass: A Potential à la Mode Complication

Abstract

Intussusception, a rare event in adults, is a form of bowel obstruction that is caused by telescoping of a segment of the bowel into the adjacent part. Small bowel intussusception, once believed to be an uncommon long-term complication of Roux-en-Y gastric bypass surgery (REYGB) is becoming more prevalent with the rapid increase in the rate of bariatric surgery over the past 20 years. This condition could be potentially devastating if not promptly recognized and its etiology still remains unclear. Herein, we report a rare case of retrograde jejuno-jejunal anastomotic intussusception 6 years after REYGB. 41-year-old woman who underwent open REYGB 6 years prior, presents with diffuse crampy abdominal pain, intermittent vomiting and obstipation of few days. Physical examination revealed abdominal tenderness. Laboratory tests disclosed microcytic anemia. Abdominal computed tomography scan showed dilatation of the biliopancreatic limb of the REYGB with small bowel intussusception through the jejunojejunostomy (Fig1, 2, 3). An exploratory laparoscopy was performed with full reduction of a retrograde intussusception where involved bowel loops appeared viable. Extensive lysis of adhesions was done and no bowel resection was deemed necessary. Bowel function returned 2 days after operation and patient was discharged home. Intussusception accounts for only 1-5% of all bowel obstructions in adults. The origin of intussusception after REYGB is different from other etiologies in that there is usually no lead point. It is believed to be related to motility disorders in the divided small bowel which could commonly lead to a retrograde (antiperistaltic) telescoping, as in our patient. Rarely the telescoping could be anterograde or isoperistaltic. This condition may cause obstruction and lead to bowel necrosis if not promptly recognized and treated. Clinical presentation is typically non specific. Computerized tomography scan represents the diagnostic test of choice, but surgery is sometimes the only way to establish the diagnosis. Management should include early involvement of a bariatric surgeon, and is usually limited to surgical reduction if the small bowel is still viable. However, resection of the affected segment is still controversial but often recommended, since it seems to result in fewer recurrences. Increased awareness of this entity and high index of suspicion are required to make the correct diagnosis and offer appropriate treatment in a timely fashion. (Figure Presented).