Retrograde intussusception after bariatric surgery: How rare?

Letters to the Editor

Dear Bariatric Times Editor:
I recently read Dr. Hildago’s article—coauthored by you and published in the February issue of Bariatric Times—entitled “Small Bowel Complications after Malabsorptive Procedures: Internal Hernias, Obstructions, and Intussusceptions.”[1] I had several comments I wanted to make and hope you don’t mind my sharing them with you.

My major criticism is directed toward the section of the article dedicated to discussing intussusception. The authors stated that there have only been eight cases reported to date when, in fact, there has been a considerably larger number of cases reported over the past few years. Our group reported on 23 of our own patients with retrograde intussusception (RINT) at the ASMBS meeting in San Diego in 2007. At the time, I found 21 patients with RINT in the literature. Since then, we have added to our experience and now have seen at least 39 patients with documented RINT, including five patients who had resection of their RINT segments and have had recurrences despite resection. I hope to report our treatments of these patients at this year’s IFSO meeting in Paris, France, if our abstract is accepted.

The truth is, there has been an ever increasing number of these reports, including two reports in the March 2009 Obesity Surgery journal.[2,3] It seems I cannot pick up any surgical journal or article about complication of gastric bypass surgery (GBP) without the mention of this complication—indicating the importance of recognizing and treating this complication in our patients.

I have taken the liberty of enclosing a copy of our report[4] on RINT with this letter, which can also be accessed online at the journal’s website, and would suggest that this topic be considered in future editions of Bariatric Times and possibly include a discussion of the causes of this condition. While it is not known why patients get RINT, it is our impression that it is a manifestation of roux stasis syndrome, which may also be the route cause of other problematic conditions, such as chronic abdominal pain and late recurrent gastrojejunal ulcers in GBP patients—both of which do not seem to have other clear, plausible causes. While I cannot prove this, I would be very interested in hearing other opinions and would look forward to such a discussion.

Again, I hope I have not offended anyone with sharing these observations, but when I read your article I felt there was a missed opportunity to educate surgeons on this problem of RINT and to continue the dialogue on the most appropriated treatment and possible causes. I look forward to possibly seeing more on the topic in the future.

Sincerely,

Steven C. Simper, MD, FACS
Rocky Mountain Associated Physicians, Salt Lake City, Utah

Dear Dr. Simper:
Thank you for your letter and comments. I am impressed with your series and would like to invite your group to contribute an article on this topic. Chronic and intermittent abdominal pain is a serious problem after gastric bypass surgery and, though I always think of intussusception as a possible cause, I must acknowledge that I was able to diagnose one only a handful of times. I would be very interested in your experience on how to diagnose and treat this unusual complication of Roux-en-Y GBP.

Our magazine is meant to be an open forum for all our colleagues treating bariatric patients and your letter has enriched our journal and article.

I am looking forward to your contribution.

Best regards,

Raul J. Rosenthal, MD, FACS
Clinical Editor, Bariatric Tines

REFERENCES
1.    Hildago, Ramirez, Rosenthal, Szomstein. Small bowel complications after malabsorptive procedures: internal hernias, obstructions, and intussusceptions. Bariatric Times. 2009;6(3):1,26–29.
2.    Vila M, Ruíz O, Belmonte M, et al. Changes in lipid profile and insulin resistance in obese patients after Scopinaro biliopancreatic diversion. Obes Surgery. 2009;19(3):299–306.
3.    Ramos AC, Galvão Neto MP, de Souza YM, et al. Laparoscopic duodenal-jejunal exclusion in the treatment of type 2 diabetes mellitus in patients with BMI<30kg/m2 (LBMI). Obes Surgery. 2009;19(3):307–312.
4.    Simper SC, Erzinger JM, McKinlay RD, Smith SC. Retrograde (reverse) jejunal intussusception might not be such a rare problem: a single group’s experience of 23 cases. Surg Obes Relat Dis. 2008;4(2):77–83.

Category: Letters to the Editor, Past Articles