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Intussusception after Roux-en-Y gastric bypass for morbid obesity
Surgery for Obesity and Related Diseases 4 (2008) 664 – 667
Case report
Intussusception after Roux-en-Y gastric bypass for morbid obesity Juan Lessmann, M.D., Eliana Soto, M.D., Stephen Merola, M.D.* Department of Surgery, New York Hospital Queens, Flushing, New York Received October 12, 2007; accepted December 11, 2007
Obesity is one of the most serious public health concerns today in the United States. Obesity is defined as a body mass index (BMI) of 30 kg/m2. Morbid obesity is defined as a BMI of ⱖ40 kg/m2 or ⬎35 with co-morbidities [1]. Super obesity describes a BMI ⬎50 kg/m2. In the United States, ⬎30% of adults are obese and 2–3% of men and 6 –7% of women are morbidly obese [2]. *Reprint requests: Stephen Merola, M.D., F.A.C.S., Department of Surgery, New York Hospital Queens, 56-45 Main Street, Flushing, NY 11355. E-mail: [email protected]
Roux-en-Y gastric bypass (RYGB) is one of the surgical treatments for morbidly obese patient after other weight loss therapies have failed. RYGB can be done as open or laparoscopic surgery. A sustained weight reduction occurs in all patients, with a mean weight loss of about one third of the body weight [3,4]. Long-term follow-up data have shown that ⬎80% of patients with adult-onset diabetes are cured by RYGB [5,6]. Complications of gastric bypass occur in 3–20% of patients [7] and include anastomotic leak, stricture, pulmonary embolism, and small bowel obstruction. Small
Fig. 1. Abdominopelvic CT scan with oral and intravenous contrast showing small bowel intussusception at mid-small bowel. 1550-7289/08/$ – see front matter © 2008 American Society for Metabolic and Bariatric Surgery. All rights reserved. doi:10.1016/j.soard.2007.12.014
J. Lessmann et al. / Surgery for Obesity and Related Diseases 4 (2008) 664 – 667
bowel obstruction occurs with a reported frequency of .2– 4.5% after laparoscopic RYGB [8]. Most small bowel obstructions after RYGB are due to internal hernias or adhesions. Small bowel intussusception as a cause of obstruction in patients who have undergone gastric bypass is extremely rare. To date, ⬎12 cases have been reported in published studies, including 4 antegrade (isoperistaltic), 5 antiperistaltic, and 2 not specified [9 –13]. All the cases occurred ⬎1 year after RYGB and after significant weight loss. No intussusception cases have been reported after laparoscopic RYGB. We describe 3 cases of intussusception, 1 after open gastric bypass and 2 after laparoscopic gastric bypass. Case reports Case 1 A 44-year-old woman had undergone open gastric bypass 6 years before admission. She had experienced a 130-lb weight loss during that 6-year period. She presented to the emergency department with a 4-hour history of sharp epigastric pain, radiating to the back, along with nausea, but no vomiting. She reported bowel movement 1 day previously. On physical examination, she was afebrile. She was hemodynamically stable. Her abdomen was soft, not distended, but diffusely tender, with guarding over the right lower quadrant. Her white blood cell count was 12,000 cells/mL,
665
with 86% neutrophils. An abdominopelvic computed tomography (CT) scan with oral and intravenous contrast revealed small bowel intussusception at the mid-small bowel (Fig. 1). She underwent emergent laparotomy. At exploration, an intact Roux-en-Y anastomosis was seen, with a large midjejunojejunal intussusception. Resection of the involved bowel was performed with a stapled anastomosis, using a GIA-75 and TA-60 stapler. The patient had an uneventful postoperative course and was discharged home on the fourth postoperative day. Case 2 A 47-year-old woman had undergone laparoscopic RYGB 6 years before presentation. Her weight at the time had been 325 lb; 2 years later she underwent laparoscopic revision of her RYGB because she had experienced weight loss in excess of 210 lb and was severely malnourished. At the second operation, she required placement of a feeding tube because she was unable to tolerate an oral diet. She presented to our emergency room ⬎1 year later with an 18-hour history of diffuse crampy abdominal pain, nausea, and vomiting. On physical examination, she was afebrile, hemodynamically stable, and weighed 138 lb. Her abdomen was soft, not distended, but tender over her right hemiabdomen. No rebound was present. Her white blood cell count was 9000 cells/mL. An abdominopelvic CT scan with oral
Fig. 2. Abdominopelvic CT scan with oral and intravenous contrast showing intussusception at level of jejunojejunal anastomosis, with collapsed distal bowel.
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J. Lessmann et al. / Surgery for Obesity and Related Diseases 4 (2008) 664 – 667
Fig. 3. Abdominopelvic CT scan with oral and intravenous contrast showing a small bowel intussusception at jejunojejunostomy, with proximal bowel dilation consistent with small bowel obstruction.
and intravenous contrast revealed intussusception at the level of the jejunojejunal anastomosis, with collapsed distal bowel (Fig. 2). She underwent emergent laparotomy. At exploration, some dilation of the small bowel was seen at the level of jejunojejunal anastomosis; however, no intussusception was visualized. The patient had an uneventful postoperative course and was discharged home on the fifth postoperative day.
the jejunojejunostomy, with proximal bowel dilation consistent with a small bowel obstruction (Fig. 3). She underwent emergent laparotomy. At exploration, an intact jejunojejunal anastomosis was seen, with a large jejunojejunal intussusception, 5 cm distal to the jejunojejunal anastomosis. The intussusception was reduced; the bowel was viable. The patient had an uneventful postoperative course. A postoperative small bowel series reported no abnormalities.
Case 3 A 58-year-old woman had undergone laparoscopic gastric bypass 3 years before admission. She had experienced a 120-lb weight loss during the 3 years. She presented to our emergency department with a 6-hour history of sharp epigastric-left upper quadrant pain and multiple episodes of vomiting. On physical examination, she was afebrile and was hemodynamically stable. Her abdomen was soft, not distended, but with left upper quadrant tenderness. Her white blood cell count was 14,000 cells/mL with 81% neutrophils. An abdominopelvic CT scan with oral and intravenous contrast revealed a small bowel intussusception at
Discussion The clinical presentation of intussusception in adults is variable; the most common symptoms include vague abdominal pain, nausea, and vomiting. The physical findings include abdominal tenderness or peritoneal irritation. A high index of suspicion is needed in the bariatric patient. CT of the abdomen is essential in these patients. Early recognition and intervention is mandatory to avoid a delay in the diagnosis and potential adverse outcomes. Severe abdominal pain in a postbariatric surgical patient might warrant surgical exploration even with negative CT findings.
J. Lessmann et al. / Surgery for Obesity and Related Diseases 4 (2008) 664 – 667
Treatment of small bowel intussusception is surgical, either by laparoscopy or laparotomy. The intussusception should be reduced, if possible; otherwise, the bowel should be resected. It is not clear why patients who have undergone gastric bypass develop intussusception, but different theories have been proposed. Duane et al. [12] suggested that the suture lines might act as a lead point. Motility studies have shown that Roux-en-Y constructions in general have a high incidence of dysmotility disorders secondary to ectopic Rouxlimb pacesetters, which can manifest as nausea, bloating, and postprandial abdominal pain [9]. The cause of intussusception after RYGB remains unclear but seems to be multifactorial, involving a lead point (suture lines, adhesions, and lymphoid hyperplasia), motility disturbances, and aberrant intestinal pacemakers [14]. Disclosures The authors claim no commercial associations that might be a conflict of interest in relation to this article. References [1] Buchwald H, Buchwald JN. Evolution of operative procedures for the management of morbid obesity 1950 –2000. Obes Surg 2002;12:705–17. [2] Brolin RE. Bariatric surgery and long-term control of morbid obesity. JAMA 2002;288:2793– 6.
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[3] Brolin RE, Kenler HA, Gorman JH, Gody RP. Long-limb gastric bypass in the superobese: a prospective randomized study. Ann Surg 1992;215:387–95. [4] Sugerman HJ, Kellun JM, Engle KM, et al. Gastric bypass for treating superobesity. Am J Clin Nutr 1992;55:560S–566S. [5] Livingston EH. Obesity and its surgical management. Am J Surg 2002;165:155– 60. [6] Pories WJ, Swanson MS, MacDonald KG, et al. Who would have thought it? An operation proves to be the most effective therapy for adult-onset diabetes mellitus. Ann Surg 1995;222:339 –50. [7] Capella JF, Capella RF. The weight reduction operation of choice: vertical banded gastroplasty or gastric bypass? Am J Surg 1996;171: 74 –9. [8] Newer techniques in bariatric surgery for morbid obesity. BCBS Technology Evaluation Center Report 2003;18:1–37. [9] Hocking MP, McCoy DM, Vogel SB, Kaude JV, Sninsky CA. Antiperistaltic and isoperistaltic intussusception associated with abnormal motility after Roux-en-Y gastric bypass: a case report. Surgery 1991;110:109 –12. [10] Goverman J, Greenwald M, Gellman L, Gadaleta D. Antiperistaltic (retrograde) intussusception after Roux-en-Y gastric bypass. Am Surg 2004;70:67–70. [11] Bocker J, Vasile J, Zager J, Goodman E. Intussusception: an uncommon cause of postoperative small bowel obstruction after gastric bypass. Obes Surg 2004;14:116 –9. [12] Duane TM, Wohgemuth S, Ruffin K. Intussusception after Rouxen-Y gastric bypass. Am Surg 2000;66:82– 4. [13] Majeski J, Fried D. Retrograde intussusception after Roux-en-Y gastric bypass surgery. J Am Coll Surg 2004;199:988 –9. [14] Edwards MA, Grinbaum R, Ellsmere J, Jones DB, Schneider B. Intussusception after Roux-en-Y gastric bypass for morbid obesity: case report and literature review of rare complications. Surg Obes Relat Dis 2006;2:483–9.
Case report
Intussusception after Roux-en-Y gastric bypass for morbid obesity Juan Lessmann, M.D., Eliana Soto, M.D., Stephen Merola, M.D.* Department of Surgery, New York Hospital Queens, Flushing, New York Received October 12, 2007; accepted December 11, 2007
Obesity is one of the most serious public health concerns today in the United States. Obesity is defined as a body mass index (BMI) of 30 kg/m2. Morbid obesity is defined as a BMI of ⱖ40 kg/m2 or ⬎35 with co-morbidities [1]. Super obesity describes a BMI ⬎50 kg/m2. In the United States, ⬎30% of adults are obese and 2–3% of men and 6 –7% of women are morbidly obese [2]. *Reprint requests: Stephen Merola, M.D., F.A.C.S., Department of Surgery, New York Hospital Queens, 56-45 Main Street, Flushing, NY 11355. E-mail: [email protected]
Roux-en-Y gastric bypass (RYGB) is one of the surgical treatments for morbidly obese patient after other weight loss therapies have failed. RYGB can be done as open or laparoscopic surgery. A sustained weight reduction occurs in all patients, with a mean weight loss of about one third of the body weight [3,4]. Long-term follow-up data have shown that ⬎80% of patients with adult-onset diabetes are cured by RYGB [5,6]. Complications of gastric bypass occur in 3–20% of patients [7] and include anastomotic leak, stricture, pulmonary embolism, and small bowel obstruction. Small
Fig. 1. Abdominopelvic CT scan with oral and intravenous contrast showing small bowel intussusception at mid-small bowel. 1550-7289/08/$ – see front matter © 2008 American Society for Metabolic and Bariatric Surgery. All rights reserved. doi:10.1016/j.soard.2007.12.014
J. Lessmann et al. / Surgery for Obesity and Related Diseases 4 (2008) 664 – 667
bowel obstruction occurs with a reported frequency of .2– 4.5% after laparoscopic RYGB [8]. Most small bowel obstructions after RYGB are due to internal hernias or adhesions. Small bowel intussusception as a cause of obstruction in patients who have undergone gastric bypass is extremely rare. To date, ⬎12 cases have been reported in published studies, including 4 antegrade (isoperistaltic), 5 antiperistaltic, and 2 not specified [9 –13]. All the cases occurred ⬎1 year after RYGB and after significant weight loss. No intussusception cases have been reported after laparoscopic RYGB. We describe 3 cases of intussusception, 1 after open gastric bypass and 2 after laparoscopic gastric bypass. Case reports Case 1 A 44-year-old woman had undergone open gastric bypass 6 years before admission. She had experienced a 130-lb weight loss during that 6-year period. She presented to the emergency department with a 4-hour history of sharp epigastric pain, radiating to the back, along with nausea, but no vomiting. She reported bowel movement 1 day previously. On physical examination, she was afebrile. She was hemodynamically stable. Her abdomen was soft, not distended, but diffusely tender, with guarding over the right lower quadrant. Her white blood cell count was 12,000 cells/mL,
665
with 86% neutrophils. An abdominopelvic computed tomography (CT) scan with oral and intravenous contrast revealed small bowel intussusception at the mid-small bowel (Fig. 1). She underwent emergent laparotomy. At exploration, an intact Roux-en-Y anastomosis was seen, with a large midjejunojejunal intussusception. Resection of the involved bowel was performed with a stapled anastomosis, using a GIA-75 and TA-60 stapler. The patient had an uneventful postoperative course and was discharged home on the fourth postoperative day. Case 2 A 47-year-old woman had undergone laparoscopic RYGB 6 years before presentation. Her weight at the time had been 325 lb; 2 years later she underwent laparoscopic revision of her RYGB because she had experienced weight loss in excess of 210 lb and was severely malnourished. At the second operation, she required placement of a feeding tube because she was unable to tolerate an oral diet. She presented to our emergency room ⬎1 year later with an 18-hour history of diffuse crampy abdominal pain, nausea, and vomiting. On physical examination, she was afebrile, hemodynamically stable, and weighed 138 lb. Her abdomen was soft, not distended, but tender over her right hemiabdomen. No rebound was present. Her white blood cell count was 9000 cells/mL. An abdominopelvic CT scan with oral
Fig. 2. Abdominopelvic CT scan with oral and intravenous contrast showing intussusception at level of jejunojejunal anastomosis, with collapsed distal bowel.
666
J. Lessmann et al. / Surgery for Obesity and Related Diseases 4 (2008) 664 – 667
Fig. 3. Abdominopelvic CT scan with oral and intravenous contrast showing a small bowel intussusception at jejunojejunostomy, with proximal bowel dilation consistent with small bowel obstruction.
and intravenous contrast revealed intussusception at the level of the jejunojejunal anastomosis, with collapsed distal bowel (Fig. 2). She underwent emergent laparotomy. At exploration, some dilation of the small bowel was seen at the level of jejunojejunal anastomosis; however, no intussusception was visualized. The patient had an uneventful postoperative course and was discharged home on the fifth postoperative day.
the jejunojejunostomy, with proximal bowel dilation consistent with a small bowel obstruction (Fig. 3). She underwent emergent laparotomy. At exploration, an intact jejunojejunal anastomosis was seen, with a large jejunojejunal intussusception, 5 cm distal to the jejunojejunal anastomosis. The intussusception was reduced; the bowel was viable. The patient had an uneventful postoperative course. A postoperative small bowel series reported no abnormalities.
Case 3 A 58-year-old woman had undergone laparoscopic gastric bypass 3 years before admission. She had experienced a 120-lb weight loss during the 3 years. She presented to our emergency department with a 6-hour history of sharp epigastric-left upper quadrant pain and multiple episodes of vomiting. On physical examination, she was afebrile and was hemodynamically stable. Her abdomen was soft, not distended, but with left upper quadrant tenderness. Her white blood cell count was 14,000 cells/mL with 81% neutrophils. An abdominopelvic CT scan with oral and intravenous contrast revealed a small bowel intussusception at
Discussion The clinical presentation of intussusception in adults is variable; the most common symptoms include vague abdominal pain, nausea, and vomiting. The physical findings include abdominal tenderness or peritoneal irritation. A high index of suspicion is needed in the bariatric patient. CT of the abdomen is essential in these patients. Early recognition and intervention is mandatory to avoid a delay in the diagnosis and potential adverse outcomes. Severe abdominal pain in a postbariatric surgical patient might warrant surgical exploration even with negative CT findings.
J. Lessmann et al. / Surgery for Obesity and Related Diseases 4 (2008) 664 – 667
Treatment of small bowel intussusception is surgical, either by laparoscopy or laparotomy. The intussusception should be reduced, if possible; otherwise, the bowel should be resected. It is not clear why patients who have undergone gastric bypass develop intussusception, but different theories have been proposed. Duane et al. [12] suggested that the suture lines might act as a lead point. Motility studies have shown that Roux-en-Y constructions in general have a high incidence of dysmotility disorders secondary to ectopic Rouxlimb pacesetters, which can manifest as nausea, bloating, and postprandial abdominal pain [9]. The cause of intussusception after RYGB remains unclear but seems to be multifactorial, involving a lead point (suture lines, adhesions, and lymphoid hyperplasia), motility disturbances, and aberrant intestinal pacemakers [14]. Disclosures The authors claim no commercial associations that might be a conflict of interest in relation to this article. References [1] Buchwald H, Buchwald JN. Evolution of operative procedures for the management of morbid obesity 1950 –2000. Obes Surg 2002;12:705–17. [2] Brolin RE. Bariatric surgery and long-term control of morbid obesity. JAMA 2002;288:2793– 6.
667
[3] Brolin RE, Kenler HA, Gorman JH, Gody RP. Long-limb gastric bypass in the superobese: a prospective randomized study. Ann Surg 1992;215:387–95. [4] Sugerman HJ, Kellun JM, Engle KM, et al. Gastric bypass for treating superobesity. Am J Clin Nutr 1992;55:560S–566S. [5] Livingston EH. Obesity and its surgical management. Am J Surg 2002;165:155– 60. [6] Pories WJ, Swanson MS, MacDonald KG, et al. Who would have thought it? An operation proves to be the most effective therapy for adult-onset diabetes mellitus. Ann Surg 1995;222:339 –50. [7] Capella JF, Capella RF. The weight reduction operation of choice: vertical banded gastroplasty or gastric bypass? Am J Surg 1996;171: 74 –9. [8] Newer techniques in bariatric surgery for morbid obesity. BCBS Technology Evaluation Center Report 2003;18:1–37. [9] Hocking MP, McCoy DM, Vogel SB, Kaude JV, Sninsky CA. Antiperistaltic and isoperistaltic intussusception associated with abnormal motility after Roux-en-Y gastric bypass: a case report. Surgery 1991;110:109 –12. [10] Goverman J, Greenwald M, Gellman L, Gadaleta D. Antiperistaltic (retrograde) intussusception after Roux-en-Y gastric bypass. Am Surg 2004;70:67–70. [11] Bocker J, Vasile J, Zager J, Goodman E. Intussusception: an uncommon cause of postoperative small bowel obstruction after gastric bypass. Obes Surg 2004;14:116 –9. [12] Duane TM, Wohgemuth S, Ruffin K. Intussusception after Rouxen-Y gastric bypass. Am Surg 2000;66:82– 4. [13] Majeski J, Fried D. Retrograde intussusception after Roux-en-Y gastric bypass surgery. J Am Coll Surg 2004;199:988 –9. [14] Edwards MA, Grinbaum R, Ellsmere J, Jones DB, Schneider B. Intussusception after Roux-en-Y gastric bypass for morbid obesity: case report and literature review of rare complications. Surg Obes Relat Dis 2006;2:483–9.