Kongkrit Chaiyasate, Surgical Resident; Melhem Solh, Surgical Resident; Sumet Silapasvang, Surgical Attending; Vijay Mittal, Program Director, Department of Surgery, Providence Hospital and Medical Centers, Southfield, MI
Kongkrit Chaiyasate, MD
Surgical Resident Melhem Solh, MD
Surgical Resident Sumet Silapasvang, MD Surgical Attending Vijay Mittal, MD
Department of Surgery
Providence Hospital and Medical Centers
Intussusception is a rare complication following gastric surgery and is estimated to occur in 0.1% of patients. The authors describe a case of retrograde intussusception after Roux-en-Y gastrojejunostomy that was initially diagnosed as pancreatitis because the classic symptoms of intussusception were absent. Computed tomography scanning of the abdomen and pelvis showed a dilated duodenum and proximal jejunum, raising suspicion of intussusception. Surgical treatment included manual reduction with resection of the gangrenous bowel segment. It has been suggested that retrograde intussusception may be an extreme form of the Roux stasis syndrome.
Intussusception is a rare complication in patients who have undergone previous gastric surgery. It was first reported in 1917, 30 years after the first gastrojejunostomy. An estimated 0.1% of patients who have had Billroth II reconstruction or Roux-en-Y reconstruction will de­velop adult intussusception.1 Je­junogastric intussusceptions after Billroth II are typically categorized according to four anatomic variants: afferent (type 1), efferent (type 2), combined (type 3), and side-to-side jejunojejunal anastomosis (type 4). This classification system is difficult to apply to the anatomy of a Rouxen-Y. We present a case of retrograde intussusception that occurred years after distal gastrectomy with antecolic Roux-en-Y gastrojejunostomy.
A 49-year-old man presented to the emergency department with a 36-hour history of acute periumbilical pain accompanied by nausea and vomiting. The pain was relieved by upright fetal positioning. His surgical history was significant for gastric resection 5 years earlier, which was performed because of peptic ulcer perforation. An edematous pancreas was the only significant finding on ultrasonography. Amylase and lipase levels were elevated to 1,972 IU/L and 6,510 IU/L, respectively. A preliminary diagnosis of acute pancreatitis was made, and the patient was admitted to the hospital. Physical examination of the abdomen revealed marked distention and tenderness on palpation, but no abdominal mass. A nasogastric tube was placed, which drained 750 cc of coffee-ground blood. The patient was febrile and had leukocytosis, with a white blood cell count of 27.8 x 103/µL. A subsequent computed tomography (CT) scan of the abdomen and pelvis demonstrated gastric dilatation with distinct proximal small bowel air fluid levels (Figure 1).
After intensive fluid and electrolyte resuscitation, the patient underwent ex­ploratory laparotomy, which showed his previous surgery was a subtotal gastrectomy and antecolic Rouxen-Y jejunogastrostomy. He had developed a retrograde jejunojejunal intussusception involving the distal end of the Roux limb, which led to complete obstruction of the jejunum below the jejunojejunostomy site (Figure 2). The duodenal loop was distended to a diameter of 10 cm, causing its contents to reflux into the gastric lumen. The intussusception was reduced manually, a 25-cm segment of gangrenous intussuscepted bowel was resected, and a successful primary anastomosis was performed. Thorough gross inspection of the resected specimen showed no evidence of an intraluminal, intramural, or extraluminal lesion, which could have acted as a nidus for the intussusception and subsequent ischemia. The patient tolerated the surgery well and improved exponentially. His serum amylase and lipase levels returned to normal, and he was discharged to home in excellent condition on postoperative day 8.
Postoperative intussusception is a rare complication of gastric surgery. The reported incidence is approximately 0.1%.2 In 2004, Goverman and colleagues reported two cases of retrograde intussusception out of more than 600 Roux-en-Y gastric bypass procedures in their experience, which confirms the rarity of this disease.3Symptoms of mechanical obstruction can be delayed from 2 weeks to as long as 20 years in adults with postoperative intussusception. Patients may present with an acute surgical emergency or chronic postprandial pain. The literature reports pain, a palpable abdominal mass, and rectal bleeding as a classical triad of symptoms indicating intussusception, al­though this triad is rarely seen. The constellation of symptoms is easily confused with those caused by postoperative ileus and abdominal adhesions, and it is difficult to find distinctions because there are no pathognomonic symptoms to rely on. As evidenced by our patient, intussusception can have a similar presentation to pancreatitis occurring secondary to afferent loop syndrome.
A preoperative diagnosis of intussusception can be made radiologically through the use of an upper gastrointestinal study, ultrasonography, and CT scanning. Endoscopy may be performed if there is a high index of suspicion. Ultimately, intussusception must be confirmed by laparotomy. A retrospective review of our patient’s CT scan suggests that the original evaluation did not appreciate the target-like concentric circles that strongly suggest an intussusception. Radiologic demonstration of a dilated proximal segment of small bowel in a patient with a history of gastrectomy should lead the surgeon to consider postoperative intussusception in the differential diagnosis.4
The pathogenesis of intussusception in a patient with a history of gastric surgery with either Billroth II or Roux-en-Y jejunostomy remains debatable. In the case of Billroth II anastomosis, the most commonly accepted theory postulates that antegrade or retrograde peristalsis in the afferent or efferent limbs may lead to intussusception. Other possible etiological factors include intestinal luminal prosthesis, suture or staple approximations, postoperative adhesions, and electrolyte imbalances.4-6 In the case presented, no intraluminal, intramural, or extraluminal cause could be deduced as having led to the retrograde jejunojejunal intussusception. We strongly agree with other investigators that the retrograde intussusception in Roux-en-Y anastomosis could be secondary to Roux stasis syndrome.3,4,7 The etiology of this syndrome results from disruption of myoelectrical activity confounded by the presence of an ectopic pacemaker distal to the jejunojejunostomy site. The resulting atony and dilatation of the Roux limb, together with antiperistaltic contraction at its distal end, could explain this unusual complication following gastrectomy and Rouxen-Y gastrojejunostomy. Hocking and colleagues reported the utility of intraluminal manometry in a patient noted to have recurrent intussusception after Roux-en-Y gastric by­pass.8 They obtained direct evidence of abnormal intestinal motility in that patient, which pointed toward abnormal motility as the etiology of the pathologic process.
The development of an uncut Roux operation that allows for the propagation of normal pacesetter potentials may prevent this type of intussusception; however, this technique may not prevent other forms of jejunogastric intussusception. This is because the uncut Roux operation is somewhat similar to Billroth II reconstruction, with additional jejunal occlusion at the afferent limb and creation of the jejunojejunostomy between the afferent and efferent limbs. Long-term observation is required before the benefits of an uncut Roux operation can be assessed.
One of the most important decisions in performing a Roux-en-Y reconstruction is whether to bring the Roux limb behind (retro) or in front of (ante) the transverse colon. In performing the gastrectomy for benign disease, there is no clear evidence that this makes any difference. For malignant disease, it has generally been held that the retrocolic position may be predisposed to obstruction owing to the enlargement of lymph nodes or serosal implants in the transverse mesocolon. Whether or not this predisposition exists, positioning the jejunal limb in front of the colon requires a somewhat longer mesentery. As long as the anastomosis will not be under tension, the antecolic position will permit emptying as effectively as that through a retrocolic anastomosis.
In an acute presentation of intussusception, surgery is the treatment of choice. Early diagnosis is critical be­cause mortality rates increase abruptly if surgery is delayed. The reported mortality rate ranges from 10% for treatment within the first 48 hours to 50% with a 96-hour delay.9 After the diagnosis is made, surgical findings guide the operative procedures performed. In cases of intussusception after Roux-en-Y gastric bypass, surgeons familiar with bariatric procedures should be consulted for both the operative and perioperative management of such patients.3
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