Overview
Definition:
Jejunojejunal intussusception post-Roux-en-Y Gastric Bypass (RYGB) is a rare but serious complication characterized by the telescoping of one segment of the jejunum into an adjacent segment
In the context of RYGB, this typically involves the afferent limb intussuscepting into the efferent limb or vice-versa, often at the sites of enteroenterostomy or jejunojejunostomy.
Epidemiology:
Intussusception is a recognized complication after RYGB, with reported incidence rates varying from 0.04% to 2.5%
It can occur acutely in the early postoperative period or, more commonly, as a chronic or intermittent issue months to years after bariatric surgery
The exact prevalence is difficult to ascertain due to underreporting or misdiagnosis of milder, intermittent forms.
Clinical Significance:
This complication poses a significant threat due to the risk of bowel ischemia, perforation, and peritonitis, leading to high morbidity and mortality if not promptly recognized and managed
Understanding its pathophysiology, clinical presentation, and management is crucial for all bariatric surgeons and surgical residents preparing for DNB and NEET SS examinations.
Clinical Presentation
Symptoms:
Colicky abdominal pain, often severe and intermittent
Nausea and vomiting, which may become feculent in cases of complete obstruction
Abdominal distension
Passage of blood or mucoid stool, sometimes described as "currant jelly" stool, though this is more typical of pediatric intussusception and less common in adults post-RYGB
Palpable abdominal mass, sometimes described as sausage-shaped
Fever and signs of systemic toxicity in cases of strangulation or perforation.
Signs:
Tenderness on abdominal palpation, which may be localized or diffuse depending on the extent of ischemia
Guarding and rebound tenderness in advanced cases
A palpable abdominal mass may be present
Signs of dehydration and shock (tachycardia, hypotension) may be seen in patients with severe complications.
Diagnostic Criteria:
There are no strict diagnostic criteria for jejunojejunal intussusception post-RYGB
Diagnosis is primarily clinical, supported by imaging findings
Key features include a history of RYGB surgery, recurrent or persistent abdominal pain, and characteristic imaging findings suggestive of intussusception at the gastrojejunostomy or jejunojejunostomy sites.
Diagnostic Approach
History Taking:
Detailed history focusing on the timing and nature of abdominal pain post-RYGB
Inquire about any prior episodes of similar pain
Assess for associated symptoms like nausea, vomiting, and bowel habit changes
Ask about diet and any recent changes
Red flags include sudden onset of severe, unrelenting pain, feculent vomiting, or hemodynamic instability.
Physical Examination:
A thorough abdominal examination is paramount
Palpate for masses and assess for tenderness, guarding, and rebound
Auscultate bowel sounds
they may be hyperactive initially and then absent in obstruction
Assess for signs of dehydration and shock.
Investigations:
Abdominal X-ray may show signs of bowel obstruction like dilated loops of bowel and air-fluid levels, but is often non-specific for intussusception
Ultrasound can be helpful, visualizing a target or donut sign representing the intussuscepted bowel
CT scan of the abdomen with intravenous contrast is the imaging modality of choice, demonstrating the characteristic "target sign" or "currant jelly" sign of intussusception and assessing for bowel wall thickening, ischemia, or perforation
Laboratory tests include CBC (leukocytosis, anemia), electrolytes, renal function tests, and liver function tests
Lactic acid levels can indicate ischemia.
Differential Diagnosis:
Other causes of abdominal pain post-RYGB, including marginal ulcers, internal hernias, adhesions, staple line leaks, and pancreatitis
Differentiate from other types of bowel obstruction
Early diagnosis is key to avoid surgical delays.
Management
Initial Management:
Immediate resuscitation with intravenous fluids and electrolyte correction
Nasogastric tube decompression to relieve vomiting and distension
Pain management with analgesics
Prompt surgical consultation is mandatory.
Surgical Management:
Surgery is generally indicated for confirmed or highly suspected jejunojejunal intussusception post-RYGB, especially in the presence of signs of ischemia or obstruction
The primary goal is reduction of the intussusception and assessment of bowel viability
Techniques include manual reduction and, if reduction is difficult or there is concern for ischemia, resection of the involved segment with re-anastomosis
Consideration of revision of enteroenterostomy or gastrojejunostomy may be necessary
Laparoscopic approaches are feasible for stable patients, but conversion to open laparotomy may be required.
Supportive Care:
Aggressive fluid management
Nutritional support, often with parenteral nutrition initially if bowel resection and re-anastomosis is performed
Close monitoring of vital signs, urine output, and abdominal examination
Antibiotic prophylaxis and therapy if infection is suspected.
Complications
Early Complications:
Bowel ischemia and necrosis
Bowel perforation
Peritonitis
Sepsis
Anastomotic leak following resection and reconstruction
Wound infection
Deep vein thrombosis and pulmonary embolism.
Late Complications:
Adhesions leading to further bowel obstruction
Stricture formation at the site of anastomosis
Recurrence of intussusception if the underlying cause (e.g., a mobile loop) is not addressed
Nutritional deficiencies
Dumping syndrome.
Prevention Strategies:
Meticulous surgical technique during RYGB, ensuring adequate length of the common channel and appropriate tension-free enteroenterostomy
Careful patient selection and preoperative counseling
Close postoperative monitoring for early signs of complications
Prompt investigation of abdominal pain post-operatively.
Prognosis
Factors Affecting Prognosis:
The prognosis depends heavily on the timeliness of diagnosis and intervention
Patients presenting with early intussusception and viable bowel have a good prognosis
Delayed diagnosis leading to bowel ischemia, perforation, or sepsis significantly worsens the prognosis and increases morbidity and mortality.
Outcomes:
With prompt diagnosis and appropriate surgical management (reduction or resection), most patients can achieve a good outcome
However, complications like extensive bowel resection may lead to short bowel syndrome or malabsorption
Recurrence is possible if the underlying predisposing factor is not rectified.
Follow Up:
Close follow-up is essential after surgical management
This includes monitoring for signs of recurrence, complications of surgery, and ensuring adequate nutritional status
Regular clinical assessment and appropriate investigations are guided by the patient's recovery and any underlying contributing factors.
Key Points
Exam Focus:
Intussusception is a leading cause of intestinal obstruction in infancy, but post-RYGB intussusception is a distinct surgical emergency
Recognize the characteristic "target sign" on CT
Prompt surgical intervention is critical to prevent bowel necrosis.
Clinical Pearls:
Always consider intussusception in a patient with prior RYGB presenting with recurrent, colicky abdominal pain and vomiting, even months or years post-surgery
Intraoperative assessment of bowel viability is paramount if resection is performed.
Common Mistakes:
Delaying diagnosis due to attributing symptoms to common post-bariatric surgery issues like ulcers or dumping syndrome
Underestimating the severity of pain or failing to promptly investigate with advanced imaging
Inadequate intraoperative assessment of bowel viability leading to compromised resection margins.