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Intussusception after Roux-en-Y gastric bypass
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Original article
Intussusception after Roux-en-Y gastric bypass Derek Stephenson, M.D., Rena C. Moon, M.D., Andre F. Teixeira, M.D., Muhammad A. Jawad, M.D., F.A.C.S.* Department of Bariatric Surgery, Orlando Regional Medical Center & Bariatric and Laparoscopy Center, Orlando Health, Orlando, Florida Received September 23, 2013; accepted January 13, 2014
Abstract
Background: Jejuno-jejunal (J-J) intussusception is a rare complication after Roux-en-Y gastric bypass (RYGB). Prompt diagnosis is critical as it may lead to obstruction and bowel necrosis, but clinical presentation is nonspecific. A definitive treatment plan has not been established with intussusception after RYGB. The aim of our study was to describe clinical presentation and outcomes of treatment in patients with intussusception after RYGB. Methods: Out of 3022 patients who underwent laparoscopic RYGB between January 2003 and January 2013, 12 (0.4%) patients presented with intussusception after RYGB. A retrospective review of a prospectively collected database was performed. Results: Of the 12 patients, 11 (91.7%) presented with left or right upper quadrant abdominal pain as their chief complaint, and 1 (8.3%) presented with persistent nausea and vomiting. Diagnosis was made by computed tomographic scan (n ¼ 1) or intraoperative findings (n ¼ 11) at a mean period of 24.9 ⫾ 26.0 months (range 3–85) after laparoscopic RYGB. Seven (58.3%) patients were treated only with reduction, 2 (16.7%) with resection and revision of J-J anastomosis, the remaining 3 (25.0%) underwent imbrication/plication of the J-J anastomosis. Only 1 (8.3%) patient, who was treated by reduction, returned with subsequent finding of recurrent intussusception at 9 months. All patients did well at a mean follow-up of 12.7 ⫾ 16.4 months (range 1–47). Conclusion: While reduction alone of the intussusception is safe and effective, there is a risk of recurrence, and imbrication of the J-J anastomosis may be a more effective means of treatment. (Surg Obes Relat Dis 2014;]:00–00.) r 2014 American Society for Metabolic and Bariatric Surgery. All rights reserved.
Keywords:
Intussusception; Complications; Imbrication; Reduction; Gastric bypass; Revision
Despite increasing and developing surgical options, laparoscopic Roux-en-Y gastric bypass (LRYGB) remains the most commonly performed bariatric surgery in this country [1]. As the number of these procedures increases, we create a large population of specialized patients with long-term potential complications that must be monitored. This can include complications such as malnutrition, biliary *
Correspondence: Muhammad A. Jawad, M.D. Medical Director, Department of Bariatric Surgery, Orlando Regional Medical Center & Bariatric and Laparoscopy Center, Orlando Health, 89 W Copeland Dr, 1st Floor, Orlando, FL. E-mail: [email protected]
issues, and intestinal obstruction; included in this list is intestinal intussusception [2,3]. Intussusception is an uncommon etiology of bowel obstruction in the general population more commonly seen in pediatric patients [3–5]. In adults, estimated incidence of the condition has historically been as low as 1/1,000,000 population/year [1,3,4]. However, while still relatively rare, this condition is increasingly being noted in postbypass bariatric patients [6,7]. The result of this is that bariatric surgeons are likely to increasingly encounter this condition and must be able to diagnose and treat it appropriately. The purpose of our study was to identify the presentation of intussusception in postbypass bariatric patients and an
http://dx.doi.org/10.1016/j.soard.2014.01.026 1550-7289/r 2014 American Society for Metabolic and Bariatric Surgery. All rights reserved.
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effective means of treatment with low recurrence and postoperative complications. Methods After institutional review board approval and following the Health Insurance Portability and Accountability Act guidelines, the authors performed a retrospective chart review of a prospectively maintained database of all patients who underwent a LRYGB during the time span of January 1, 2003 to January 31, 2013. From this group, all patients with an intraoperatively confirmed diagnosis of small intestinal intussusception were eligible for this study. Data points collected included demographic information, time to presentation from original surgery, interval weight loss, calculated as change in body mass index (BMI), chief presenting symptoms, and any admissions for recurrence. Operative notes were reviewed for primary treatments administered and any combined procedures performed. Patient charts were reviewed for all postoperative followups to identify any delayed complications or recurrences. Surgical technique
F1
F2
A standardized technique was used for the initial bypass in all patients. In this technique, we create a vertical gastric pouch using a linear stapler, Echelon Endopath 45 and 60 (Ethicon Endo–surgery, Somerville, NJ). Either the greater omentum is then transected or a window is created to allow tension free gastrojejunal anastomosis. The ligament of Treitz is identified and a 50-cm biliopancreatic limb is created with a firing of the linear stapler leaving the mesentery intact. The efferent limb is then measured out to from 75 to 100 cm after which the jejuno-jejunal (J-J) anastomosis is created. The biliopancreatic limb is brought next to the efferent jejunal loop and stay sutures placed in a side-to-side fashion. An enterotomy is made in both limbs and anastomosis created with the linear stapler. The enterotomy edges are elevated with further stay sutures and then closed with 2 separate firings of the stapler. The Roux limb is brought up antecolic antegastric to the gastric pouch, and the gastrojejunal anastomosis is created in a similar manner. Both anastomosis staple lines are over sewn, and the J-J mesenteric defect as well as the Peterson’s defect is suture closed. A draining gastrostomy tube is placed in the remnant stomach and a drain is placed. Three main operative techniques were used to treat the intussusception (Fig. 1). Reduction involved manual release of noted intussusception, inspection of bowel, and no further intervention. Anastomotic revision consisted of resection of the jejuno-jejunostomy followed by stapled reanastomosis of afferent and efferent limbs in a method similar to the surgical technique described above for the initial bypass. Imbrication/plication consisted of suture plication of the jejuno-jejunostomy (Fig. 2). Using a
Fig. 1. Laparoscopic presentation of jejuno-jejunal intussusception after gastric bypass.
running suture, the dilated bowel was imbricated along the staple line narrowing the size of the common channel. The decision of which procedure each patient received was based on surgeon intraoperative clinical judgment. These decisions were based on the degree of dilation noted at the J-J anastomosis, with more invasive procedures, such as revision, used for more dilated bowel. Procedures were performed laparoscopically in all cases, and no patient was converted to open procedure.
Results During the 10 years included in our study period, 3022 patients underwent LRYGB at our institution. From this group 12 (0.4%) patients were intraoperatively confirmed to have a small bowel intussusception, all occurring at the J-J anastomosis. All patients underwent either manual reduction, imbrication or revision of the anastomosis. Of these 12 patients, 11 (92%) were female. Mean age at the time of diagnosis was 39.2 ⫾ 9.6 years (range 25–58). Average BMI at time of initial bypass procedure was 47.0 ⫾ 4.4 kg/m2 (range 40.2–53.6) with mean BMI at time of presentation being 31.1 ⫾ 4.3 kg/m2 (range 25.2– 38.9). This resulted in an average interval drop in BMI of 15.8 ⫾ 2.6 kg/m2 (range 10.6–21.4), mean percentage of excess weight loss of 64.8 ⫾ 12.3% (range 46.3–84.1) at a mean period of 24.9 ⫾ 26.0 months (range 3–85) after the bypass procedure. Eleven (91.7%) out of 12 patients presented with chief complaint of upper quadrant abdominal pain, and 1 patient (8.3%) had chief complaint of persistent nausea and vomiting. Preoperative diagnoses varied somewhat with 4 patients diagnosed with gallbladder related disease (biliary dyskinesia, cholecystitis), 1 with dilated blind limb, and 1 with umbilical hernia. Two patients were given the diagnosis of intussusception with the remaining 4 given diagnosis of abdominal pain otherwise unspecified. Of the 2 patients preoperatively identified with possible intussusception, 1 diagnosis was based on preoperative computed tomography (CT) scan with the other based on clinical suspicion.
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Fig. 2. Illustration of the imbrication of jejuno-jejunal intussusception technique. (A) Dilated jejuno-jejunal anastomosis after reduction of intussusception. (B) Suture imbrication at the anastomotic staple line. (C) Continuation of running suture to imbricate bowel at staple line. (D) Complete imbrication of jejunojejunal anastomosis with new narrowed common channel.
There were 3 different surgical approaches to the intussusception itself once recognized. Seven (58.3%) patients were treated only with reduction, 2 (16.7%) with resection and revision of J-J anastomosis, the remaining 3 (25.0%) underwent imbrication/plication of the J-J anastomosis. Only 1 (8.3%) of the 12 patients returned to our facility with subsequent finding of recurrent intussusception. This patient had been treated with reduction of intussusception at her prior surgery. The recurrence occurred 9 months after the initial procedure. During this span, the patient had an additional 3.7 kg of weight loss resulting in a drop of 1.4 kg/m2 in BMI. The recurrence was treated with resection and revision of the J-J anastomosis. No further recurrences have been noted. In addition to the primary intervention for the intussusception, 7 patients had 1 or multiple other procedures performed during the surgery. This consisted of 4 cholecystectomies, 1 hiatal hernia repair, 1 umbilical hernia repair, and 4 revisions of dilated/elongated blind limbs.
Mean number of postoperative clinic visits was 3.5 ⫾ 3.1 times (range 1–8) per patient; with average total postoperative follow-up time of 12.7 ⫾ 16.4 months (range 1– 47). During this time, no delayed complications have been noted. Discussion Small-intestinal intussusception is a relatively rare condition in the adult population, and is equally so in the postgastric bypass bariatric population [1]. However, due to the unique anatomic changes in this population, a specific etiology of J-J anastomosis intussusception is being increasingly noted [1,2,7,8]. So far no definitive etiology or direct cause has been elicited as a mechanism for this finding [2,6–8]. Reviews of current literature note hypothesis including a combination of rapid weight loss leading to mesenteric thinning, and disruption of intestinal pacemakers
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resulting in retrograde peristalsis [1,6,9]. Along with the lack of understanding of the etiology of this condition, there is also a lack of standardized treatment [2]. Current surgical options range on a large spectrum from less invasive simple reduction, to full resection and revision of the bowel anastomosis. Along with each of these options, there remains an unknown amount of recurrence and delayed complications [1]. In this study, we attempted to review patients presenting with intussusception after LRYGB and determine a pattern of presentation. We also purposed to review the various surgical treatments we have been performing for this condition, and assess for any complications or outcome data that may trend toward a preferred method. In reviewing the demographic characteristics of our population, 11 of the 12 patients (91.6%) were of female gender. This finding fits with trends reported in current literature showing a disproportionate number of female patients compared with the total bypass pool [4]. In relation to age, our population trended toward the early 40’s with mean age of 39.2 at time of diagnosis. A previous review of similar patients found a slightly younger median age of 35.5 and questioned whether there was any age component to this process [1]. However, with an age range spanning from early 20’s to late 50’s and a total bariatric patient population lacking more elderly patients, our data set is unable to verify this trend, and shows no noticeable age correlation. Our patients showed significant weight loss at the time of presentation with a mean percentage of excess weight loss of 64.8%. This coincides with the hypothesis that weight loss resulting in mesenteric thinning causes intussusception [1,6,9]. The traditional presentation of patients with intussusception in the general adult population is abdominal pain; often lower abdominal, nausea and vomiting, and bloody stools [4,10]. However, due to the unique anatomy of bariatric patients, this presentation is unlikely to be as common [3,5,7]. A large majority of our patients presented with the chief complaint of upper abdominal pain. As this is a relatively common surgical complaint with a large number of differential diagnoses, it is understandable why few of our patients were preoperatively diagnosed with intussusception. While many of the patients reported left-sided pain, there were still a number with right-sided or epigastric pain. This remains a somewhat unexplained finding, as left-sided abdominal pain due to the more left-sided position of the jejunal-jejunal anastomosis would be expected. Because of this conditions’ often vague presenting symptoms, biliary/ gallbladder related causes and abdominal pain of unknown etiology were the most common diagnoses given, representing a third of cases, respectively. In relation to gallbladder disease, our current practice is to leave in gallbladders at time of initial bypass if there is no evidence of stones or disease on preoperative ultrasound imaging. Patients with preoperative findings, regardless of symptom history, have
cholecystectomy performed at time of surgery. This process leaves a large population of patients with remaining gallbladders after their bypass, and potential for future biliary pathology. In those cases where later gallbladder disease do occur, they have a presentation similar to the population in this study with nonspecific upper abdominal pain that is not necessarily specified to right upper quadrant. Even outside of gallbladder disease, the differential for nonspecific upper abdominal pain in postbypass patients is extensive, with many of the potential processes of significant medical concern. Due to the obstructive nature of intussusception, it would be expected to find signs of acute obstruction with diffuse abdominal pain, progressive nausea and emesis progressing to bowel ischemia and peritonitis [4]. This, however, was not the case in our population. Rather, most patients presented with a slow, prolonged course of similar symptoms of mild abdominal pain. Only 1 of the 12 patients complained of having persistent nausea/vomiting. Some of this could be explained by patients having chronic, possibly intermittent intussusception and obstruction. If this were the case, a higher level of recurrence after reduction could be assumed. Our numbers, however, are too small to exhibit this. Based on the results of this study, patients with postgastric bypass intussusception do not have a clear diagnostic presentation, and a high level of suspicion and concern is needed in the course of their workup and diagnosis. If it is suspected, CT scan of abdomen remains the most appropriate imaging study [1,6,11]. In most of our patients, an attempt was made at a nonrevisional procedure. This has potential benefits such as preserving bowel length, and avoiding new anastomoses and the resultant risks that come with them such as leak and bleeding. The potential risk from these more conservative measures is an increase in recurrence, as previous studies have shown nonrevision, especially reduction only, to have a higher rate of recurrence [1]. In our group, the overall rate of recurrence was low with only 1 case, representing 8%, but this case did occur in a patient that received reduction only. No recurrences were noted in the group of patients that received imbrication. This has potential importance, as this technique could be a middle ground option between reduction and revision. Whereas reduction may not be enough of an active intervention, leading to recurrence, imbrication may be a more effective nonrevisional means of relieving current, and preventing subsequent, J-J intussusception. Other nonrevisional techniques have been described in the literature, such as pexy of the biliopancreatic limb to the common channel. One published case using this technique noted apparent intraoperative success in treating the intussusception. The patient did have persistence of symptoms, and despite no visual signs of recurrence on return to operating room had anastomotic revision performed [12]. No such cases were found in our group of
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patients that received anastomotic imbrication as described in this study. Our study does have the limitations of not having numbers large enough to truly determine the recurrence rate of imbrication, and follow-up for any delayed complications needs to be monitored even further into the future. However, this method appeared safe and effective in our study population and should be an option considered in future cases of intussusception depending on intraoperative findings. Although still relatively rare, there has been, and will likely continue to be, a number of patients presenting with intussusception after gastric bypass surgery, specifically at the jejunojejunostomy. These patients present a potential diagnostic and therapeutic difficulty for the surgeon caring for them. Symptoms are often vague and at times mild; leading to confusion with other processes, but the potential morbidity from an intussusception related obstruction should not be ignored. Due to the large differential of diagnosis fitting this presentation a high level of suspicion must be held, and investigation supplemented with imaging such as abdominal CT when available. Once diagnosed, there is still no consensus choice for the optimal treatment of this condition. Conclusion We propose that while reduction alone of the intussusception is safe and effective, there is a risk of recurrence, and imbrication of the J-J anastomosis may be a more effective means of treatment. This also maintains the benefits of avoiding potential anastomotic complications that may be seen with revision. Our data does show that revision with resection is also a reliable and effective option with low recurrence, and in cases of bowel ischemia remains the standard.
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Disclosures The authors have no commercial associations that might be a conflict of interest in relation to this article. References [1] Daellenbach L, Suter M. Jejunojejunal intussusception after roux-en-y gastric bypass: a review. Obes Surg 2011;21:253–63. [2] Varban O, Ardestani A, Azagury D, et al. Resection or reduction? The dilemma of managing retrograde intussusception after Roux-en-Y gastric bypass. Surg Obes Relat Dis 2012 May 18 [epub ahead of print]. [3] O’Connor DB, Ryan R, O’Malley D, Macdermott E. Retrograde intussusception 5 years after Roux-en-Y gastric bypass for morbid obesity. Ir J Med Sci 2012;181:419–21. [4] Lindor RA, Bellolio MF, Sadosty AT, Earnest F 4 th, Cabrera D. Adult intussusception: presentation, management, and outcomes of 148 patients. J Emerg Med 2012;43:1–6. [5] McKay R. Ileocecal intussusception in an adult: the laparoscopic approach. JSLS 2006;10:250–3. [6] Singla S, Guenthart BA, May L, Gaughan J, Meilahn JE. Intussusception after laparoscopic gastric bypass surgery: an underrecognized complication. Minim Invasive Surg 2012;2012:464853. [7] Simper SC, Erzinger JM, McKinlay RD, Smith SC. Laparoscopic reversal of gastric bypass with sleeve gastrectomy for treatment of recurrent retrograde intussusception and Roux stasis syndrome. Surg Obes Relat Dis 2010;6:684–8. [8] Boudourakis LD, Divino C, Nguyen S. Retrograde intussusception seven years after a laparoscopic Roux-en-Y gastric bypass. J Minim Access Surg 2013;9:82–3. [9] Pande R, Fraser I, Harmston C. Emergency presentation of retrograde intussusception as a late complication of gastric bypass. Ann R Coll Surg Engl 2012;94:e116–7. [10] Ashurst J, Kane B. Jejunojejunal intussusception after Roux-en-Y gastric bypass. Am J Emerg Med 2013;31:452.e3–e5. [11] Rose M, Richards WO. Laparoscopic longitudinal jejunectomy for intussusception after gastric bypass. Am Surg 2012;78:E308–10. [12] Lo Menzo E, Stevens N, Kligman M. Plication followed by resection for intussusception after laparoscopic gastric bypass. Surg Obes Relat Dis 2010;6:563–5.
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Original article
Intussusception after Roux-en-Y gastric bypass Derek Stephenson, M.D., Rena C. Moon, M.D., Andre F. Teixeira, M.D., Muhammad A. Jawad, M.D., F.A.C.S.* Department of Bariatric Surgery, Orlando Regional Medical Center & Bariatric and Laparoscopy Center, Orlando Health, Orlando, Florida Received September 23, 2013; accepted January 13, 2014
Abstract
Background: Jejuno-jejunal (J-J) intussusception is a rare complication after Roux-en-Y gastric bypass (RYGB). Prompt diagnosis is critical as it may lead to obstruction and bowel necrosis, but clinical presentation is nonspecific. A definitive treatment plan has not been established with intussusception after RYGB. The aim of our study was to describe clinical presentation and outcomes of treatment in patients with intussusception after RYGB. Methods: Out of 3022 patients who underwent laparoscopic RYGB between January 2003 and January 2013, 12 (0.4%) patients presented with intussusception after RYGB. A retrospective review of a prospectively collected database was performed. Results: Of the 12 patients, 11 (91.7%) presented with left or right upper quadrant abdominal pain as their chief complaint, and 1 (8.3%) presented with persistent nausea and vomiting. Diagnosis was made by computed tomographic scan (n ¼ 1) or intraoperative findings (n ¼ 11) at a mean period of 24.9 ⫾ 26.0 months (range 3–85) after laparoscopic RYGB. Seven (58.3%) patients were treated only with reduction, 2 (16.7%) with resection and revision of J-J anastomosis, the remaining 3 (25.0%) underwent imbrication/plication of the J-J anastomosis. Only 1 (8.3%) patient, who was treated by reduction, returned with subsequent finding of recurrent intussusception at 9 months. All patients did well at a mean follow-up of 12.7 ⫾ 16.4 months (range 1–47). Conclusion: While reduction alone of the intussusception is safe and effective, there is a risk of recurrence, and imbrication of the J-J anastomosis may be a more effective means of treatment. (Surg Obes Relat Dis 2014;]:00–00.) r 2014 American Society for Metabolic and Bariatric Surgery. All rights reserved.
Keywords:
Intussusception; Complications; Imbrication; Reduction; Gastric bypass; Revision
Despite increasing and developing surgical options, laparoscopic Roux-en-Y gastric bypass (LRYGB) remains the most commonly performed bariatric surgery in this country [1]. As the number of these procedures increases, we create a large population of specialized patients with long-term potential complications that must be monitored. This can include complications such as malnutrition, biliary *
Correspondence: Muhammad A. Jawad, M.D. Medical Director, Department of Bariatric Surgery, Orlando Regional Medical Center & Bariatric and Laparoscopy Center, Orlando Health, 89 W Copeland Dr, 1st Floor, Orlando, FL. E-mail: [email protected]
issues, and intestinal obstruction; included in this list is intestinal intussusception [2,3]. Intussusception is an uncommon etiology of bowel obstruction in the general population more commonly seen in pediatric patients [3–5]. In adults, estimated incidence of the condition has historically been as low as 1/1,000,000 population/year [1,3,4]. However, while still relatively rare, this condition is increasingly being noted in postbypass bariatric patients [6,7]. The result of this is that bariatric surgeons are likely to increasingly encounter this condition and must be able to diagnose and treat it appropriately. The purpose of our study was to identify the presentation of intussusception in postbypass bariatric patients and an
http://dx.doi.org/10.1016/j.soard.2014.01.026 1550-7289/r 2014 American Society for Metabolic and Bariatric Surgery. All rights reserved.
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effective means of treatment with low recurrence and postoperative complications. Methods After institutional review board approval and following the Health Insurance Portability and Accountability Act guidelines, the authors performed a retrospective chart review of a prospectively maintained database of all patients who underwent a LRYGB during the time span of January 1, 2003 to January 31, 2013. From this group, all patients with an intraoperatively confirmed diagnosis of small intestinal intussusception were eligible for this study. Data points collected included demographic information, time to presentation from original surgery, interval weight loss, calculated as change in body mass index (BMI), chief presenting symptoms, and any admissions for recurrence. Operative notes were reviewed for primary treatments administered and any combined procedures performed. Patient charts were reviewed for all postoperative followups to identify any delayed complications or recurrences. Surgical technique
F1
F2
A standardized technique was used for the initial bypass in all patients. In this technique, we create a vertical gastric pouch using a linear stapler, Echelon Endopath 45 and 60 (Ethicon Endo–surgery, Somerville, NJ). Either the greater omentum is then transected or a window is created to allow tension free gastrojejunal anastomosis. The ligament of Treitz is identified and a 50-cm biliopancreatic limb is created with a firing of the linear stapler leaving the mesentery intact. The efferent limb is then measured out to from 75 to 100 cm after which the jejuno-jejunal (J-J) anastomosis is created. The biliopancreatic limb is brought next to the efferent jejunal loop and stay sutures placed in a side-to-side fashion. An enterotomy is made in both limbs and anastomosis created with the linear stapler. The enterotomy edges are elevated with further stay sutures and then closed with 2 separate firings of the stapler. The Roux limb is brought up antecolic antegastric to the gastric pouch, and the gastrojejunal anastomosis is created in a similar manner. Both anastomosis staple lines are over sewn, and the J-J mesenteric defect as well as the Peterson’s defect is suture closed. A draining gastrostomy tube is placed in the remnant stomach and a drain is placed. Three main operative techniques were used to treat the intussusception (Fig. 1). Reduction involved manual release of noted intussusception, inspection of bowel, and no further intervention. Anastomotic revision consisted of resection of the jejuno-jejunostomy followed by stapled reanastomosis of afferent and efferent limbs in a method similar to the surgical technique described above for the initial bypass. Imbrication/plication consisted of suture plication of the jejuno-jejunostomy (Fig. 2). Using a
Fig. 1. Laparoscopic presentation of jejuno-jejunal intussusception after gastric bypass.
running suture, the dilated bowel was imbricated along the staple line narrowing the size of the common channel. The decision of which procedure each patient received was based on surgeon intraoperative clinical judgment. These decisions were based on the degree of dilation noted at the J-J anastomosis, with more invasive procedures, such as revision, used for more dilated bowel. Procedures were performed laparoscopically in all cases, and no patient was converted to open procedure.
Results During the 10 years included in our study period, 3022 patients underwent LRYGB at our institution. From this group 12 (0.4%) patients were intraoperatively confirmed to have a small bowel intussusception, all occurring at the J-J anastomosis. All patients underwent either manual reduction, imbrication or revision of the anastomosis. Of these 12 patients, 11 (92%) were female. Mean age at the time of diagnosis was 39.2 ⫾ 9.6 years (range 25–58). Average BMI at time of initial bypass procedure was 47.0 ⫾ 4.4 kg/m2 (range 40.2–53.6) with mean BMI at time of presentation being 31.1 ⫾ 4.3 kg/m2 (range 25.2– 38.9). This resulted in an average interval drop in BMI of 15.8 ⫾ 2.6 kg/m2 (range 10.6–21.4), mean percentage of excess weight loss of 64.8 ⫾ 12.3% (range 46.3–84.1) at a mean period of 24.9 ⫾ 26.0 months (range 3–85) after the bypass procedure. Eleven (91.7%) out of 12 patients presented with chief complaint of upper quadrant abdominal pain, and 1 patient (8.3%) had chief complaint of persistent nausea and vomiting. Preoperative diagnoses varied somewhat with 4 patients diagnosed with gallbladder related disease (biliary dyskinesia, cholecystitis), 1 with dilated blind limb, and 1 with umbilical hernia. Two patients were given the diagnosis of intussusception with the remaining 4 given diagnosis of abdominal pain otherwise unspecified. Of the 2 patients preoperatively identified with possible intussusception, 1 diagnosis was based on preoperative computed tomography (CT) scan with the other based on clinical suspicion.
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Fig. 2. Illustration of the imbrication of jejuno-jejunal intussusception technique. (A) Dilated jejuno-jejunal anastomosis after reduction of intussusception. (B) Suture imbrication at the anastomotic staple line. (C) Continuation of running suture to imbricate bowel at staple line. (D) Complete imbrication of jejunojejunal anastomosis with new narrowed common channel.
There were 3 different surgical approaches to the intussusception itself once recognized. Seven (58.3%) patients were treated only with reduction, 2 (16.7%) with resection and revision of J-J anastomosis, the remaining 3 (25.0%) underwent imbrication/plication of the J-J anastomosis. Only 1 (8.3%) of the 12 patients returned to our facility with subsequent finding of recurrent intussusception. This patient had been treated with reduction of intussusception at her prior surgery. The recurrence occurred 9 months after the initial procedure. During this span, the patient had an additional 3.7 kg of weight loss resulting in a drop of 1.4 kg/m2 in BMI. The recurrence was treated with resection and revision of the J-J anastomosis. No further recurrences have been noted. In addition to the primary intervention for the intussusception, 7 patients had 1 or multiple other procedures performed during the surgery. This consisted of 4 cholecystectomies, 1 hiatal hernia repair, 1 umbilical hernia repair, and 4 revisions of dilated/elongated blind limbs.
Mean number of postoperative clinic visits was 3.5 ⫾ 3.1 times (range 1–8) per patient; with average total postoperative follow-up time of 12.7 ⫾ 16.4 months (range 1– 47). During this time, no delayed complications have been noted. Discussion Small-intestinal intussusception is a relatively rare condition in the adult population, and is equally so in the postgastric bypass bariatric population [1]. However, due to the unique anatomic changes in this population, a specific etiology of J-J anastomosis intussusception is being increasingly noted [1,2,7,8]. So far no definitive etiology or direct cause has been elicited as a mechanism for this finding [2,6–8]. Reviews of current literature note hypothesis including a combination of rapid weight loss leading to mesenteric thinning, and disruption of intestinal pacemakers
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resulting in retrograde peristalsis [1,6,9]. Along with the lack of understanding of the etiology of this condition, there is also a lack of standardized treatment [2]. Current surgical options range on a large spectrum from less invasive simple reduction, to full resection and revision of the bowel anastomosis. Along with each of these options, there remains an unknown amount of recurrence and delayed complications [1]. In this study, we attempted to review patients presenting with intussusception after LRYGB and determine a pattern of presentation. We also purposed to review the various surgical treatments we have been performing for this condition, and assess for any complications or outcome data that may trend toward a preferred method. In reviewing the demographic characteristics of our population, 11 of the 12 patients (91.6%) were of female gender. This finding fits with trends reported in current literature showing a disproportionate number of female patients compared with the total bypass pool [4]. In relation to age, our population trended toward the early 40’s with mean age of 39.2 at time of diagnosis. A previous review of similar patients found a slightly younger median age of 35.5 and questioned whether there was any age component to this process [1]. However, with an age range spanning from early 20’s to late 50’s and a total bariatric patient population lacking more elderly patients, our data set is unable to verify this trend, and shows no noticeable age correlation. Our patients showed significant weight loss at the time of presentation with a mean percentage of excess weight loss of 64.8%. This coincides with the hypothesis that weight loss resulting in mesenteric thinning causes intussusception [1,6,9]. The traditional presentation of patients with intussusception in the general adult population is abdominal pain; often lower abdominal, nausea and vomiting, and bloody stools [4,10]. However, due to the unique anatomy of bariatric patients, this presentation is unlikely to be as common [3,5,7]. A large majority of our patients presented with the chief complaint of upper abdominal pain. As this is a relatively common surgical complaint with a large number of differential diagnoses, it is understandable why few of our patients were preoperatively diagnosed with intussusception. While many of the patients reported left-sided pain, there were still a number with right-sided or epigastric pain. This remains a somewhat unexplained finding, as left-sided abdominal pain due to the more left-sided position of the jejunal-jejunal anastomosis would be expected. Because of this conditions’ often vague presenting symptoms, biliary/ gallbladder related causes and abdominal pain of unknown etiology were the most common diagnoses given, representing a third of cases, respectively. In relation to gallbladder disease, our current practice is to leave in gallbladders at time of initial bypass if there is no evidence of stones or disease on preoperative ultrasound imaging. Patients with preoperative findings, regardless of symptom history, have
cholecystectomy performed at time of surgery. This process leaves a large population of patients with remaining gallbladders after their bypass, and potential for future biliary pathology. In those cases where later gallbladder disease do occur, they have a presentation similar to the population in this study with nonspecific upper abdominal pain that is not necessarily specified to right upper quadrant. Even outside of gallbladder disease, the differential for nonspecific upper abdominal pain in postbypass patients is extensive, with many of the potential processes of significant medical concern. Due to the obstructive nature of intussusception, it would be expected to find signs of acute obstruction with diffuse abdominal pain, progressive nausea and emesis progressing to bowel ischemia and peritonitis [4]. This, however, was not the case in our population. Rather, most patients presented with a slow, prolonged course of similar symptoms of mild abdominal pain. Only 1 of the 12 patients complained of having persistent nausea/vomiting. Some of this could be explained by patients having chronic, possibly intermittent intussusception and obstruction. If this were the case, a higher level of recurrence after reduction could be assumed. Our numbers, however, are too small to exhibit this. Based on the results of this study, patients with postgastric bypass intussusception do not have a clear diagnostic presentation, and a high level of suspicion and concern is needed in the course of their workup and diagnosis. If it is suspected, CT scan of abdomen remains the most appropriate imaging study [1,6,11]. In most of our patients, an attempt was made at a nonrevisional procedure. This has potential benefits such as preserving bowel length, and avoiding new anastomoses and the resultant risks that come with them such as leak and bleeding. The potential risk from these more conservative measures is an increase in recurrence, as previous studies have shown nonrevision, especially reduction only, to have a higher rate of recurrence [1]. In our group, the overall rate of recurrence was low with only 1 case, representing 8%, but this case did occur in a patient that received reduction only. No recurrences were noted in the group of patients that received imbrication. This has potential importance, as this technique could be a middle ground option between reduction and revision. Whereas reduction may not be enough of an active intervention, leading to recurrence, imbrication may be a more effective nonrevisional means of relieving current, and preventing subsequent, J-J intussusception. Other nonrevisional techniques have been described in the literature, such as pexy of the biliopancreatic limb to the common channel. One published case using this technique noted apparent intraoperative success in treating the intussusception. The patient did have persistence of symptoms, and despite no visual signs of recurrence on return to operating room had anastomotic revision performed [12]. No such cases were found in our group of
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patients that received anastomotic imbrication as described in this study. Our study does have the limitations of not having numbers large enough to truly determine the recurrence rate of imbrication, and follow-up for any delayed complications needs to be monitored even further into the future. However, this method appeared safe and effective in our study population and should be an option considered in future cases of intussusception depending on intraoperative findings. Although still relatively rare, there has been, and will likely continue to be, a number of patients presenting with intussusception after gastric bypass surgery, specifically at the jejunojejunostomy. These patients present a potential diagnostic and therapeutic difficulty for the surgeon caring for them. Symptoms are often vague and at times mild; leading to confusion with other processes, but the potential morbidity from an intussusception related obstruction should not be ignored. Due to the large differential of diagnosis fitting this presentation a high level of suspicion must be held, and investigation supplemented with imaging such as abdominal CT when available. Once diagnosed, there is still no consensus choice for the optimal treatment of this condition. Conclusion We propose that while reduction alone of the intussusception is safe and effective, there is a risk of recurrence, and imbrication of the J-J anastomosis may be a more effective means of treatment. This also maintains the benefits of avoiding potential anastomotic complications that may be seen with revision. Our data does show that revision with resection is also a reliable and effective option with low recurrence, and in cases of bowel ischemia remains the standard.
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Disclosures The authors have no commercial associations that might be a conflict of interest in relation to this article. References [1] Daellenbach L, Suter M. Jejunojejunal intussusception after roux-en-y gastric bypass: a review. Obes Surg 2011;21:253–63. [2] Varban O, Ardestani A, Azagury D, et al. Resection or reduction? The dilemma of managing retrograde intussusception after Roux-en-Y gastric bypass. Surg Obes Relat Dis 2012 May 18 [epub ahead of print]. [3] O’Connor DB, Ryan R, O’Malley D, Macdermott E. Retrograde intussusception 5 years after Roux-en-Y gastric bypass for morbid obesity. Ir J Med Sci 2012;181:419–21. [4] Lindor RA, Bellolio MF, Sadosty AT, Earnest F 4 th, Cabrera D. Adult intussusception: presentation, management, and outcomes of 148 patients. J Emerg Med 2012;43:1–6. [5] McKay R. Ileocecal intussusception in an adult: the laparoscopic approach. JSLS 2006;10:250–3. [6] Singla S, Guenthart BA, May L, Gaughan J, Meilahn JE. Intussusception after laparoscopic gastric bypass surgery: an underrecognized complication. Minim Invasive Surg 2012;2012:464853. [7] Simper SC, Erzinger JM, McKinlay RD, Smith SC. Laparoscopic reversal of gastric bypass with sleeve gastrectomy for treatment of recurrent retrograde intussusception and Roux stasis syndrome. Surg Obes Relat Dis 2010;6:684–8. [8] Boudourakis LD, Divino C, Nguyen S. Retrograde intussusception seven years after a laparoscopic Roux-en-Y gastric bypass. J Minim Access Surg 2013;9:82–3. [9] Pande R, Fraser I, Harmston C. Emergency presentation of retrograde intussusception as a late complication of gastric bypass. Ann R Coll Surg Engl 2012;94:e116–7. [10] Ashurst J, Kane B. Jejunojejunal intussusception after Roux-en-Y gastric bypass. Am J Emerg Med 2013;31:452.e3–e5. [11] Rose M, Richards WO. Laparoscopic longitudinal jejunectomy for intussusception after gastric bypass. Am Surg 2012;78:E308–10. [12] Lo Menzo E, Stevens N, Kligman M. Plication followed by resection for intussusception after laparoscopic gastric bypass. Surg Obes Relat Dis 2010;6:563–5.
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