- Email: [email protected]
An unusual abdominal mass in an elderly patient
CASE REPORT
AN UNUSUAL ABDOMINAL MASS IN AN ELDERLY PATIENT Adult intussusception is rare and is often not included in the differential diagnosis. Patients who have previously undergone some form of gastric bypass procedure are more susceptible. We report a case of retrograde intussusception following a Roux-en-Y gastric bypass in an elderly patient, who presented with an abdominal mass. Her initial provisional diagnosis was bowel obstruction. As the number of bariatric gastric bypass procedures continues to rise, we are likely to see more of this kind of post-operative complication. Hence, it is crucial for surgeons to consider intussusception as a cause of abdominal pain, obstruction or mass in patients who have undergone some form of gastric bypass procedure.
O. J. C. Greene1 E. Leung1 P. Maclean2 L. Buist1 1
Professorial Surgical Unit, Department of Radiology, Western Inrmary, Glasgow G11 6NT 2
Correspondence to: Edward Leung, 33 Fotheringay Road, 2/2, Pollockshields, Glasgow, G41 4NL Email: [email protected]
KEYWORDS: retrograde intussusception, Roux-en-Y, gastric bypass, complication Surgeon, 1 April 2008 121-123 INTRODUCTION A typical differential diagnosis in an elderly patient with a palpable abdominal mass would include intraabdominal malignancies and benign conditions, such as diverticular disease, incarcerated hernia or aortic aneurysm. However, when presenting together with small bowel obstruction, the diagnosis could be narrowed down to colonic neoplasms, diverticular disease or an incarcerated hernia. Intussusception, on the other hand, is an uncommon condition in the adult population and often not included in the initial differential diagnosis. Intussusception occurs when a portion of the bowel invaginates into the lumen of an adjacent piece of bowel, and almost always proceeds in an antegrade fashion from proximal to distal. It accounts for 1% of all small bowel obstructions in adults. About 93% of adult intussusceptions were associated with a pathological lesion. Forty-eight per cent of the enteric lesions and 43% of colonic lesions were found to be malignant. Most of the benign enteric intussusceptions were found to be due to post-operative adhesions, as the lead point in these cases is thought to be either the suture line of a previous enterotomy or an adhesion.1 Various surgical procedures, such as Rouxen-Y gastrectomy, Roux-en-Y gastric bypass, oesophagogastrectomy, jejunoileal bypass and pancreaticojejunostomy have also been reported to be associated with this type of post-operative complication. Although gastric bypass surgery is now becoming more popular in managing morbid obesity, long-term complications like intussusception in patients who previously had surgery for other conditions should not be ignored.2-9 © 2008 Surgeon 6; 2: 121-123
This case describes an elderly patient with a history of gastric bypass surgery who presented as an emergency with a palpable abdominal mass and bowel obstruction. Our high index of suspicions and prompt intervention prevented her from any detrimental effects of a potential extensive small bowel resection. THE CASE An 81-year-old woman presented to A&E in November 2005 with a two day history of severe abdominal pain, loose bowel motions and large volumes of bilious vomiting. Her past medical history consisted of hypothyroidism, a previous Roux-en-Y gastric reconstruction procedure in the early 1970s for suspected peptic ulceration, and a subsequent incisional hernia mesh repair in 2000. On examination she appeared cachetic but was undistressed. Her observations were stable and she was afebrile and normotensive. Her abdomen was soft, slightly distended and mildly tender throughout, but without overt signs of peritoneal irritation. There was also a large, but soft and reducible recurrent incisional hernia at the previous laparotomy site. In addition, there were multiple, small, firm and lumpy areas around the margins of the hernia. The other obvious finding was a palpable firm mass in the left hypochondrium. Bowel sounds were increased and rectal examination showed no masses but only a small amount of FOB negative faeces. All her blood tests, including full blood counts, urea and electrolytes, liver function test and amylase on admission were within normal limits. An erect chest and supine abdominal radiographs demonstrated no sign of pneumoperitoneum but a small the royal colleges of surgeons of edinburgh and ireland |
121
Figure 1. Scout CT lm showing dilated loops of bowel in the left iliac fossa
Figure 2. The contrast CT showed a large ‘target mass’ comprising the intussuscepted small bowel loop distal to the duodenojejunal (DJ) exure and a proximal distended stomach
bowel obstruction with dilated loops of small bowel and stomach. The patient was treated with intravenous crystalloids and nasogastric decompression overnight. It was initially thought that the patient had a large obstructing colonic malignancy with possibly widespread peritoneal deposits. In order to determine whether a palliative operation was appropriate, an emergency CT scan with intravenous contrast was performed the following morning. Interestingly the CT scan showed a proximal duodenal and small bowel dilatation (Figure 1) due to a large proximal small bowel intussusception creating a 7cm mass on the left side of the abdomen. The mass was described as complex with concentric layers of fat, soft tissue and enhancing mucosa which in the axial plane conferred a ‘target mass’ appearance and in the coronal plane (Figure 2) could be described as a ‘pseudo kidney’. The small bowel affected appeared oedematous and thickened although the mucosa appeared viable, suggested by good contrast enhancement. In addition, there was a small volume of free fluid in the upper abdomen and pelvis and a small collection of fluid adjacent to the gastro-oesophageal junction above the oesophageal hiatus and adjacent to the fundus of the stomach. It showed no evidence of colonic malignancy or peritoneal deposits but confirmed the presence of a large incisional hernia containing both small and large bowel. Based on the clinical and radiological findings, an exploratory laparotomy was performed and a small bowel intussusception was identified just distal to her retrocolic Roux-en-Y jejunojejunostomy. The intussusception appeared to be in a retrograde fashion. Although the bowel involved was oedematous, the intussusception was easily reduced. The Roux-en-Y loops were examined and no obvious palpable intraluminal lesions or lead point other than the anastomosis could be identified. The bowel loops appeared viable and therefore no resection was required. It was also decided that the risk of resection and reconstruction of her Roux-en-Y would probably outweigh its benefit. The previously noted areas of palpable lumpiness on her abdomen were
found to be her non-absorbable suture materials along the margins of her previous hernia mesh repair. The patient developed basal atelectasis on her first post-operative day, but had no other complications. Her bowel activity returned fully on her fourth post-operative day and she was discharged from hospital seven days after her operation. The patient remained symptom free four months after her operation.
122 |
DISCUSSION This case has demonstrated another unusual cause of abdominal mass in an elderly patient. Adult intussusception accounts for only approximately 5% of all cases of intussusception, with the vast majority occurring in paediatric cases.1 Although adult intussusception is rare, it has been demonstrated that various types of small bowel bypass may predispose adults to intussusception. Hence, it requires a high index of suspicion to make a prompt diagnosis. Furthermore, mortality from intussusception is around 10% but can be as high as 50% if treatment if delayed.10 There are three recognised types of intussusception; antegrade, retrograde and combined. The retrograde intussusception following a Roux-en-Y procedure was found to be uncommon as the incidence rate has been reported to be 1 in 600 in one retrospective study.10 However, it was found to be the the most common type following some forms of gastric bypass surgery and accounts for about 80% of all cases.11 Retrograde intussusception was first described by John Hunter in 1789 and defined as ‘an invagination of the intussusceptum in an antiperistaltic or proximal direction as opposed to the usual peristaltic or distal direction’.12 There are a number of hypotheses concerning intussusception in patients after gastric bypass surgery; a) the suture line acts as a lead point, b) hyperperistalsis of the excluded segment telescopes the bowel, and c) accumulation of intraluminal fluid in the excluded segment forces the invagination. However, there are still
the royal colleges of surgeons of edinburgh and ireland
© 2008 Surgeon 6; 2: 121-123
no data available to support any of the above theories.4,7,8 The case presented here shows a typical clinical manifestation for the acute onset type of intussusception. However, it has been reported that chronic onset can occur.11-13 In the chronic onset type, patients can present with recurrent episodes of vague abdominal pain precipitated by eating. This can, therefore, be confused with the diagnosis of mesenteric angina. A number of different radiological modalities have been described to aid the diagnosis of intussusception. These include plain film, angiography, radioactive isotope studies, barium studies, abdominal ultrasound and CT scan.14-17 Although barium studies are both diagnostic and therapeutic in children with presumed intussusception, CT scan with contrast has been shown to be the most reliable method to diagnose intussusception in adults.1,18 CT often reveals a target pattern with an intraluminal soft tissue mass (Figure 2), which can be seen with bowel intussusceptions. Since over 60% of adult cases are associated with gastrointestinal malignancy, it has been advocated that all patients with enteric lesions should undergo resection without reduction. However, for patients who previously had gastric surgery and the lead point is thought to be either the suture line or adhesion, resection is not always necessary.1 Defective motor function and myoelectric activity have been shown in the Roux limb in patients with Roux-en-Y anastomosis.19-20 It has therefore been suggested that performing two long side-to-side anastomoses instead of end-to-side or end-to-end, or plicating both anastomoses several centimetres along the antimesenteric borders would minimise the risk of recurrence.9,19 CONCLUSION Intussusception rarely occurs in adults. It can present with a variety of symptoms ranging from acute to chronic in nature. Contrast CT scan is the most useful pre-operative diagnostic technique but the ultimate treatment of adult intussusception is surgical. As the number of bariatric gastric bypass procedures continues to rise, a high index of suspicion of intussusception must be employed when dealing with patients who have previously undergone some form of gastric bypass procedure.
Copyright © 8 May 2007
REFERENCES 1. Azar T, Berger D Adult intussusception. Ann Surg 1997; 226: 135-38 2. Loizou MC, Koundourakis SS, Kollias VD et al. Jejunojejunal intussusception after Roux-en-Y gastrojejunostomy: a rare cause of postoperative bowel obstruction in an adult. Eur J Surg 1994; 160: 451-52 3. Denath F, Kweka E. Retrograde intussusception of the bypassed duodenojejunal segment after Rouxen-Y gastrectomy: computed tomography ndings. Can Assoc Radiol J 1991; 42: 135-38 4. Duane T, Wohlgemuth S, Rufn K. Intussusception after Roux-en-Y gastric bypass. Am Surg 2000; 66(1): 82-4 5. Majeski J, Fried D. Retrograde intussusception after roux-en-Y gastric bypass surgery. Imag Surg 2004; 199(6): 988-89
© 2008 Surgeon 6; 2: 121-123
6. Ozdogan M, Hamaloglu E, Ozdemir A, Ozenc A. Antegrade jejunojejunal intussusception after Rouxen-Y oesophagojejunostomy as an unusual cause of postoperative intestinal obstruction: report of a case. Surg Today 2001; 31: 355-57 7. Nelson R, Williams L, Bombeck T. A unique late mechanical complication of jejunoileal bypass. Dis Col Rect 1985; 28: 738-40 8. Miller D. Intussusception of the by-passes segment after jejunoileal by-pass for obesity. Am J Gastroenterol 1979; 72: 434-40 9. Whipple OC, Stringer EF, Senkowski CK, Hartley M. Retrograde intussusception of the efferent limb after a pancreaticojejunostomy. Am Surg 2003; 69(4): 353-55 10. Goverman J, Greenwald M, Gellman L, Gadaleta D. Antiperistaltic (retrograde) intussusception after Roux-en-Y gastric bypass. Am Surg 2004; 70(1): 67-70 11. Waits J, Beart R. Jejunogastric intussusception. Arch Surg 1980; 115: 1449-52 12. Mason L., Williams R, Marshburn E. Retrograde jejunogastric intussusception following gastrectomy. Arch Surg 1960; 81: 485-91 13. Caudell W, Lee CJ. Acute and chronic jejunogastric intussusception. N Eng J Med 1955; 21: 359-63 14. Lande A, Schechter L, Bole P. Angiographic diagnosis of small intestinal intussusception. Radiology 1977; 122: 691-93 15. Duszynski D, Anthone R. Jejunal intussusception demonstrated by tc99m pertechnetate and abdominal scanning. Am J Roentgenol 1970; 109: 729-32 16. Montali G, Croce F, De Pra L, Solbiati L. Intussusception of the bowel: a new sonographic pattern. Br J Radiol 1983; 56: 621-23 17. Bar-Ziv J, Solomon A, Computed tomography in adult intussusception. Gastrointest Radiol 1991; 16: 264-66 18. Gayer G, Apter S, Hofmann C et al. Intussusception in adults: CT diagnosis. Clin Radiol 1998; 53: 53-7 19. 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 20. Mathias J, Fernandez A, Sninsky CA et al. Nausea, vomiting, and abdominal pain after Roux-en-Y anastomosis: motility of the jejunal limb. Gastroenterology 1985; 88: 101-7
the royal colleges of surgeons of edinburgh and ireland |
123
AN UNUSUAL ABDOMINAL MASS IN AN ELDERLY PATIENT Adult intussusception is rare and is often not included in the differential diagnosis. Patients who have previously undergone some form of gastric bypass procedure are more susceptible. We report a case of retrograde intussusception following a Roux-en-Y gastric bypass in an elderly patient, who presented with an abdominal mass. Her initial provisional diagnosis was bowel obstruction. As the number of bariatric gastric bypass procedures continues to rise, we are likely to see more of this kind of post-operative complication. Hence, it is crucial for surgeons to consider intussusception as a cause of abdominal pain, obstruction or mass in patients who have undergone some form of gastric bypass procedure.
O. J. C. Greene1 E. Leung1 P. Maclean2 L. Buist1 1
Professorial Surgical Unit, Department of Radiology, Western Inrmary, Glasgow G11 6NT 2
Correspondence to: Edward Leung, 33 Fotheringay Road, 2/2, Pollockshields, Glasgow, G41 4NL Email: [email protected]
KEYWORDS: retrograde intussusception, Roux-en-Y, gastric bypass, complication Surgeon, 1 April 2008 121-123 INTRODUCTION A typical differential diagnosis in an elderly patient with a palpable abdominal mass would include intraabdominal malignancies and benign conditions, such as diverticular disease, incarcerated hernia or aortic aneurysm. However, when presenting together with small bowel obstruction, the diagnosis could be narrowed down to colonic neoplasms, diverticular disease or an incarcerated hernia. Intussusception, on the other hand, is an uncommon condition in the adult population and often not included in the initial differential diagnosis. Intussusception occurs when a portion of the bowel invaginates into the lumen of an adjacent piece of bowel, and almost always proceeds in an antegrade fashion from proximal to distal. It accounts for 1% of all small bowel obstructions in adults. About 93% of adult intussusceptions were associated with a pathological lesion. Forty-eight per cent of the enteric lesions and 43% of colonic lesions were found to be malignant. Most of the benign enteric intussusceptions were found to be due to post-operative adhesions, as the lead point in these cases is thought to be either the suture line of a previous enterotomy or an adhesion.1 Various surgical procedures, such as Rouxen-Y gastrectomy, Roux-en-Y gastric bypass, oesophagogastrectomy, jejunoileal bypass and pancreaticojejunostomy have also been reported to be associated with this type of post-operative complication. Although gastric bypass surgery is now becoming more popular in managing morbid obesity, long-term complications like intussusception in patients who previously had surgery for other conditions should not be ignored.2-9 © 2008 Surgeon 6; 2: 121-123
This case describes an elderly patient with a history of gastric bypass surgery who presented as an emergency with a palpable abdominal mass and bowel obstruction. Our high index of suspicions and prompt intervention prevented her from any detrimental effects of a potential extensive small bowel resection. THE CASE An 81-year-old woman presented to A&E in November 2005 with a two day history of severe abdominal pain, loose bowel motions and large volumes of bilious vomiting. Her past medical history consisted of hypothyroidism, a previous Roux-en-Y gastric reconstruction procedure in the early 1970s for suspected peptic ulceration, and a subsequent incisional hernia mesh repair in 2000. On examination she appeared cachetic but was undistressed. Her observations were stable and she was afebrile and normotensive. Her abdomen was soft, slightly distended and mildly tender throughout, but without overt signs of peritoneal irritation. There was also a large, but soft and reducible recurrent incisional hernia at the previous laparotomy site. In addition, there were multiple, small, firm and lumpy areas around the margins of the hernia. The other obvious finding was a palpable firm mass in the left hypochondrium. Bowel sounds were increased and rectal examination showed no masses but only a small amount of FOB negative faeces. All her blood tests, including full blood counts, urea and electrolytes, liver function test and amylase on admission were within normal limits. An erect chest and supine abdominal radiographs demonstrated no sign of pneumoperitoneum but a small the royal colleges of surgeons of edinburgh and ireland |
121
Figure 1. Scout CT lm showing dilated loops of bowel in the left iliac fossa
Figure 2. The contrast CT showed a large ‘target mass’ comprising the intussuscepted small bowel loop distal to the duodenojejunal (DJ) exure and a proximal distended stomach
bowel obstruction with dilated loops of small bowel and stomach. The patient was treated with intravenous crystalloids and nasogastric decompression overnight. It was initially thought that the patient had a large obstructing colonic malignancy with possibly widespread peritoneal deposits. In order to determine whether a palliative operation was appropriate, an emergency CT scan with intravenous contrast was performed the following morning. Interestingly the CT scan showed a proximal duodenal and small bowel dilatation (Figure 1) due to a large proximal small bowel intussusception creating a 7cm mass on the left side of the abdomen. The mass was described as complex with concentric layers of fat, soft tissue and enhancing mucosa which in the axial plane conferred a ‘target mass’ appearance and in the coronal plane (Figure 2) could be described as a ‘pseudo kidney’. The small bowel affected appeared oedematous and thickened although the mucosa appeared viable, suggested by good contrast enhancement. In addition, there was a small volume of free fluid in the upper abdomen and pelvis and a small collection of fluid adjacent to the gastro-oesophageal junction above the oesophageal hiatus and adjacent to the fundus of the stomach. It showed no evidence of colonic malignancy or peritoneal deposits but confirmed the presence of a large incisional hernia containing both small and large bowel. Based on the clinical and radiological findings, an exploratory laparotomy was performed and a small bowel intussusception was identified just distal to her retrocolic Roux-en-Y jejunojejunostomy. The intussusception appeared to be in a retrograde fashion. Although the bowel involved was oedematous, the intussusception was easily reduced. The Roux-en-Y loops were examined and no obvious palpable intraluminal lesions or lead point other than the anastomosis could be identified. The bowel loops appeared viable and therefore no resection was required. It was also decided that the risk of resection and reconstruction of her Roux-en-Y would probably outweigh its benefit. The previously noted areas of palpable lumpiness on her abdomen were
found to be her non-absorbable suture materials along the margins of her previous hernia mesh repair. The patient developed basal atelectasis on her first post-operative day, but had no other complications. Her bowel activity returned fully on her fourth post-operative day and she was discharged from hospital seven days after her operation. The patient remained symptom free four months after her operation.
122 |
DISCUSSION This case has demonstrated another unusual cause of abdominal mass in an elderly patient. Adult intussusception accounts for only approximately 5% of all cases of intussusception, with the vast majority occurring in paediatric cases.1 Although adult intussusception is rare, it has been demonstrated that various types of small bowel bypass may predispose adults to intussusception. Hence, it requires a high index of suspicion to make a prompt diagnosis. Furthermore, mortality from intussusception is around 10% but can be as high as 50% if treatment if delayed.10 There are three recognised types of intussusception; antegrade, retrograde and combined. The retrograde intussusception following a Roux-en-Y procedure was found to be uncommon as the incidence rate has been reported to be 1 in 600 in one retrospective study.10 However, it was found to be the the most common type following some forms of gastric bypass surgery and accounts for about 80% of all cases.11 Retrograde intussusception was first described by John Hunter in 1789 and defined as ‘an invagination of the intussusceptum in an antiperistaltic or proximal direction as opposed to the usual peristaltic or distal direction’.12 There are a number of hypotheses concerning intussusception in patients after gastric bypass surgery; a) the suture line acts as a lead point, b) hyperperistalsis of the excluded segment telescopes the bowel, and c) accumulation of intraluminal fluid in the excluded segment forces the invagination. However, there are still
the royal colleges of surgeons of edinburgh and ireland
© 2008 Surgeon 6; 2: 121-123
no data available to support any of the above theories.4,7,8 The case presented here shows a typical clinical manifestation for the acute onset type of intussusception. However, it has been reported that chronic onset can occur.11-13 In the chronic onset type, patients can present with recurrent episodes of vague abdominal pain precipitated by eating. This can, therefore, be confused with the diagnosis of mesenteric angina. A number of different radiological modalities have been described to aid the diagnosis of intussusception. These include plain film, angiography, radioactive isotope studies, barium studies, abdominal ultrasound and CT scan.14-17 Although barium studies are both diagnostic and therapeutic in children with presumed intussusception, CT scan with contrast has been shown to be the most reliable method to diagnose intussusception in adults.1,18 CT often reveals a target pattern with an intraluminal soft tissue mass (Figure 2), which can be seen with bowel intussusceptions. Since over 60% of adult cases are associated with gastrointestinal malignancy, it has been advocated that all patients with enteric lesions should undergo resection without reduction. However, for patients who previously had gastric surgery and the lead point is thought to be either the suture line or adhesion, resection is not always necessary.1 Defective motor function and myoelectric activity have been shown in the Roux limb in patients with Roux-en-Y anastomosis.19-20 It has therefore been suggested that performing two long side-to-side anastomoses instead of end-to-side or end-to-end, or plicating both anastomoses several centimetres along the antimesenteric borders would minimise the risk of recurrence.9,19 CONCLUSION Intussusception rarely occurs in adults. It can present with a variety of symptoms ranging from acute to chronic in nature. Contrast CT scan is the most useful pre-operative diagnostic technique but the ultimate treatment of adult intussusception is surgical. As the number of bariatric gastric bypass procedures continues to rise, a high index of suspicion of intussusception must be employed when dealing with patients who have previously undergone some form of gastric bypass procedure.
Copyright © 8 May 2007
REFERENCES 1. Azar T, Berger D Adult intussusception. Ann Surg 1997; 226: 135-38 2. Loizou MC, Koundourakis SS, Kollias VD et al. Jejunojejunal intussusception after Roux-en-Y gastrojejunostomy: a rare cause of postoperative bowel obstruction in an adult. Eur J Surg 1994; 160: 451-52 3. Denath F, Kweka E. Retrograde intussusception of the bypassed duodenojejunal segment after Rouxen-Y gastrectomy: computed tomography ndings. Can Assoc Radiol J 1991; 42: 135-38 4. Duane T, Wohlgemuth S, Rufn K. Intussusception after Roux-en-Y gastric bypass. Am Surg 2000; 66(1): 82-4 5. Majeski J, Fried D. Retrograde intussusception after roux-en-Y gastric bypass surgery. Imag Surg 2004; 199(6): 988-89
© 2008 Surgeon 6; 2: 121-123
6. Ozdogan M, Hamaloglu E, Ozdemir A, Ozenc A. Antegrade jejunojejunal intussusception after Rouxen-Y oesophagojejunostomy as an unusual cause of postoperative intestinal obstruction: report of a case. Surg Today 2001; 31: 355-57 7. Nelson R, Williams L, Bombeck T. A unique late mechanical complication of jejunoileal bypass. Dis Col Rect 1985; 28: 738-40 8. Miller D. Intussusception of the by-passes segment after jejunoileal by-pass for obesity. Am J Gastroenterol 1979; 72: 434-40 9. Whipple OC, Stringer EF, Senkowski CK, Hartley M. Retrograde intussusception of the efferent limb after a pancreaticojejunostomy. Am Surg 2003; 69(4): 353-55 10. Goverman J, Greenwald M, Gellman L, Gadaleta D. Antiperistaltic (retrograde) intussusception after Roux-en-Y gastric bypass. Am Surg 2004; 70(1): 67-70 11. Waits J, Beart R. Jejunogastric intussusception. Arch Surg 1980; 115: 1449-52 12. Mason L., Williams R, Marshburn E. Retrograde jejunogastric intussusception following gastrectomy. Arch Surg 1960; 81: 485-91 13. Caudell W, Lee CJ. Acute and chronic jejunogastric intussusception. N Eng J Med 1955; 21: 359-63 14. Lande A, Schechter L, Bole P. Angiographic diagnosis of small intestinal intussusception. Radiology 1977; 122: 691-93 15. Duszynski D, Anthone R. Jejunal intussusception demonstrated by tc99m pertechnetate and abdominal scanning. Am J Roentgenol 1970; 109: 729-32 16. Montali G, Croce F, De Pra L, Solbiati L. Intussusception of the bowel: a new sonographic pattern. Br J Radiol 1983; 56: 621-23 17. Bar-Ziv J, Solomon A, Computed tomography in adult intussusception. Gastrointest Radiol 1991; 16: 264-66 18. Gayer G, Apter S, Hofmann C et al. Intussusception in adults: CT diagnosis. Clin Radiol 1998; 53: 53-7 19. 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 20. Mathias J, Fernandez A, Sninsky CA et al. Nausea, vomiting, and abdominal pain after Roux-en-Y anastomosis: motility of the jejunal limb. Gastroenterology 1985; 88: 101-7
the royal colleges of surgeons of edinburgh and ireland |
123