Intussusceptions with Small Bowel Obstruction Following Roux-en-Y Gastric Bypass Surgery

by Wasef Abu-Jaish, MD, FACS; Vaia Sigounas, MD; and Bryan Brown, MS-III

Drs. Abu-Jaish and Sigounas are from the University of Vermont College of Medicine, Fletcher Allen Health Care, Minimally Invasive and Bariatric Surgery, Burlington, Vermont. Mr. Brown is a third-year medical student at University of Vermont College of Medicine.

Funding: No funding was provided.
Disclosures: The authors report no conflicts of interest relevant to the content of this article.

Bariatric Times. 2013;10(12):20–23.

ABSTRACT
Roux-en-Y gastric bypass is the most common bariatric procedure performed for severe obesity, and it is not uncommon to have complications. Intussusception is a rare, yet potentially fatal, complication after Roux-en-Y gastric bypass, increasing risk for bowel ischemia and perforation. Here, we present two case reports of middle-aged women years after surgery without the typical signs and symptoms of intussusception. Both patients were diagnosed using imaging and dignosis was confirmed with exploratory laparoscopy/laparotomy. The first patient appeared to have viable bowel during her first exploratory laparotomy, in which the bowel was simply was reduced. She recurred three weeks later and was taken back for a second exploratory laparotomy, resection of previous jejunojejunostomy, and restoration by a side-to-side jejunostomy. The second patient had resection of previous jejunojejunostomy, and the gastrointestinal tract was restored by a side-to-side functional end-to-end jejuno-jejunostomy and by a side-to-side jejunojejunostomy. These cases illustrate the importance of high suspicion of intussusception in patients after Roux-en-Y gastric bypass presenting with acute or recurrent obstructive symptoms, early radiological evaluation, early involvement with bariatric surgery team, and prompt surgical intervention by laparoscopy or laparotomy.

INTRODUCTION
Roux-en-Y gastric bypass (RYGB) is the most common bariatric procedure performed for severe obesity.[1] Complications are not uncommon, and the evaluation for gastrointestinal symptoms and abdominal pain can be difficult. Small bowel obstruction (SBO) is a recognized complication of RYGB, most commonly caused by internal hernia. Intussusception occurs rarely in adults and accounts for 1 to 5 percent of all SBOs. When it does occur, it is usually due to a benign or malignant lead point. Intussusception is a rare cause of obstruction after RYGB. Over the last several years, patients with a distant past surgical history of open or laparoscopic RYGB have been presenting with intussusception at the jejunojejunostomy without an identifiable lead point.

In this article, we describe two such patients who were transferred to our hospital within two months of each other. These patients did not present with the typical signs and symptoms of intussusceptions, such as currant jelly stools, abdominal mass, or peritonitis. Instead, they presented years after surgery with nonspecific abdominal pain, nausea, and vomiting.[2]

Case # 1
The patient was a 49-year-old female who initially presented to an outside hospital with 24 hours of acute, chronic, severe abdominal pain that began as postprandial pain and increased in intensity with coinciding nausea and nonbilious vomiting. An acute abdominal series was suspicious for obstruction and internal hernia. The patient was transferred to our hospital for further management, including computed tomography (CT) scan. (Figure 1). Her past surgical history included laparoscopic RYGB for morbid obesity five years earlier. Her BMI when she presented to our clinic was 18kg/m2. In addition to undergoing RYGB, she had an appendectomy, hysterectomy, and salpingo-oophorectomy. Upon arrival, her vital signs were stable and the abdominal exam showed tenderness in mid-abdomen with voluntary guarding and rebound. White blood cell (WBC) count was elevated to 15,000. After targeted resuscitation, she was taken to the operating room for repair of a suspected incarcerated internal hernia by the general surgery team. Instead of finding an internal hernia during exploratory laparotomy, 30cm of volvulized small bowel was found intussuscepted into a massively dilated jejunojejunostomy. When the intussusception was reduced, the previously dusky small bowel “pinked up” as blood flow returned. The bowel appeared viable and no plication or additional operative action was taken. Over the next few days, bowel function returned, and the patient was discharged home. Three weeks later, the patient returned to the general surgery out-patient clinic with similar, but milder abdominal symptoms.

She was re-admitted to the hospital under the care of the bariatric surgery team with provisional diagnosis of partial small bowel obstruction due to chronic intermittent intussusception with dehydration, electrolyte abnormalities, and malnutrition. Fluid resuscitation, electrolyte replacement, and total parenteral nutrition were started. The upper GI showed a massively dilated Roux limb, and a narrowed proximal common channel.
After multiple conversations with the patient and her family, she returned to the operating room for possible revision of the jejunojejunostomy or reversal of the RYGB. In the operating room, an exploratory laparotomy with extensive lysis of adhesions and decompression of the dilated small bowel was performed. Under direct visualization, the common channel had extensive intraperitoneal adhesions with multiple constrictive adhesive bands and was found to be intussuscepted in retrograde fashion. The Roux limb, biliary limb, and gastric remnant were significantly dilated. Also, there was patchy ischemia and necrosis in the biliary limb proximal to the jejunojejunostomy, 10cm distal to the ligament of Treitz (Figure 2).

The patient underwent resection of the prior jejunojejunostomy with 20cm of the biliary limb resected, leaving 10cm; 40cm of the Roux limb was resected, leaving 20cm distal to the gastrojejunostomy; and 50cm of the proximal common channel was resected. The gastrointestinal tract was restored by a primary two-layered hand-sewn, side-to-side jejunojejunostomy of the remaining Roux limb to the distal jejunum, and by a primary two-layered hand-sewn, side-to-side jejunojejunostomy 40cm from the gastrojejunostomy with a 10cm biliary limb. In addition to this, the patient underwent cholecystectomy for acalculus cholecystitis and gastric tube (GT) placement for decompression of the gastric remnant and postoperative enteral feeding. Postoperatively, she did well and tolerated the post-gastric bypass diet and her symptoms resolved. She was discharged on supplement GT enteral feeding. At the subsequent office visit, her nutritional status showed marked improvement, she gained eight pounds and was symptom free. Once her oral intake increased, and the vitamins, trace elements, and hemogram returned to normal levels, the GT was removed 12 weeks postoperatively.

Case # 2
A 42-year-old woman presented to an outside hospital with a six-day history of severe abdominal pain, nausea, and vomiting. She had presented to their emergency room several times in one week, and an initial CT scan had been read as negative for any pathology. However, when she was re-imaged, her second CT scan showed intussusception at the jejunojejunostomy with proximal small bowel dilation to the level of the gastric remnant. She was transferred to our institution for further management. (Figure 3).

Seven years prior to her presentation to our clinic, she underwent open RYGB for morbid obesity. She also had an appendectomy, cholecystectomy, right oophorectomy, ovarian cystectomy, bladder surgery, and chronic pain related to interstitial cystitis. On examination, the patient was nontoxic but in severe distress from excruciating abdominal pain. She stated that she had never had so much pain and that pain medication did nothing to control it. Her vital signs were stable, and she did not have fever, tachycardia, or hypotension. Her abdomen was diffusely tender to palpation and she had guarding but no rebound. Her WBC was 8,000 with a normal differential. After she was fluid resuscitated, the patient was taken to the operating room where diagnostic laparoscopy confirmed the diagnosis of intussusception at the jejunojejunostomy. Intraoperative findings demonstrated a retrograde intussusception at the jejunojejunostomy with dilated Roux, biliary limb, and gastric remnant, but without ischemia or perforation. Intraoperative esophagogastroduodenoscopy (EGD) was performed and showed a normal gastric pouch and nondilated gastrojejunostomy. No marginal ulcer or gastro-gastric fistula were identified. The jejunojejunostomy was resected, and the gastrointestinal tract was restored by a primary two-layer, hand-sewn anastomosis between the remaining of both Roux and biliary limb to the distal jejunum, leaving behind 100cm of Roux limb and a 15cm of biliary limb. A gastrostomy tube was placed to decompress the gastric remnant. Postoperatively, the patient recovered well, advanced to a regular diet, and was discharged home several days later (Figure 4 ). Six weeks later, the GT was removed and the patient experienced no gastrointestinal symptoms.

Discussion
The development of an intussusception is a potential complication after RYGB and carries the risk of bowel ischemia and perforation. Its diagnosis can be difficult because the presenting signs, symptoms, and physical and radiologic examination findings can be vague, nonspecific, and/or nondiagnostic. The clinical presentation can vary from very unclear and intermittent symptoms to a dramatic acute abdomen secondary to small bowel necrosis or perforation.

Intussusception, obstruction caused by the telescoping of one piece of bowel into an adjacent piece of bowel, causes approximately one percent of small bowel obstructions in the adult population.[3] In adult intussusception, the lead point is frequently a benign or malignant neoplasm.[4] A number of case reports have been published over the past few years describing intussusception without an identifiable lead point in patients with a history of open or laparoscopic Roux-en-Y gastric bypass.[5]

The jejuno-jejunostomy is the most frequently affected area, and one hypothesis for the occurrence of these intussusceptions is that altered motility in the Roux limb is responsible for the intussusceptions, rather than the presence of a mass.[6] Other suggested theories include the staple/suture line serving as a lead point, focal nodular hyperplasia, the development of ectopic myoelectric pacemakers in the Roux limb, and derangements in the migratory motor complex.[5] There may also be a relationship between a large amount of weight loss and intussusceptions, perhaps due to thinning out of the mesentery.[7]

Here, we described two patients who presented years after surgery with nonspecific abdominal pain, nausea, and vomiting. The source of obstruction was identified using imaging, including acute abdominal series and CT scan. As has been previously reported, target signs, sausage-shaped mass in the jejunojejunostomy, and a dilated excluded stomach are suggestive of intussusception in post-RYGB patients.[8] The diagnosis was confirmed during exploratory laparoscopy/laparotomy. In Case #1, after the intussusception was relieved and the viable affected bowel left in place, intussusception recurred a month later, requiring surgical resection of the jejunojejunostomy.

A recently published study by Simper et al reported that two out of two patients operatively managed with simple reduction for RYGB-related intussusception at their institution had recurrent intussusception, suggesting that plication or resection of dilated, viable bowel may be the most reasonable course of action under these circumstances.[9] A second paper by Menzo et al illustrates that while plication of the common channel to the biliopancreatic limb decreases recurrence of intussusceptions to 40 percent, resection and reconstruction of the jejunostomy may ultimately be necessary to resolve the patient’s symptoms.[10]

Conclusion
Intussusception after RYGB is a rare and potentially fatal complication and must be considered in patients presenting with acute or recurrent intermittent obstructive symptoms. The management should include high suspicion of such a condition, early radiological evaluation by CT of the abdomen and pelvis, early consultation with or referral to bariatric surgery, and prompt surgical intervention by laparoscopy or laparotomy.

References
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6.    Hocking MP, McCoy M, et al. Antiperistaltic and isoperistaltic intussusception associated with abnormal motility after Roux-en-Y gastric bypass: a case report. Surgery. 1991;110:109–112.
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Category: Case Series, Past Articles