Abstract
Background: Retrograde intussusception of the small bowel is extremely rare. We experienced four cases of retrograde jejunojejunal intussusception that needed emergency surgery. The aim of the present report was to expand awareness of retrograde jejunojejunal intussusception as an urgent complication following gastrectomy.
A 59-old-year male, 73-old-year male, 78-year-old male and 79-year-old female were transferred to our Institute complaining of abdominal pain and bloody vomiting. All patients had history of gastrectomy with Roux-en-Y or Billroth II method reconstruction. Computed tomography showed small bowel intussusception and we performed emergency laparotomy. Intraoperative findings revealed deeply invaginating analis jejunum into the anastomosis region and two of the patients underwent bowel resection due to severe ischemic damage. Three of the patients had good postoperative courses, however, one patient unfortunately died from sepsis resulting from intestine necrosis. Therefore, retrograde jejunojejunal intussusception after gastrectomy should be considered as an urgent complication after gastrectomy.
There is potential for various complications after gastrectomy in both the early and late postoperative periods, such as postoperative bleeding, anastomotic leakage, adhesive ileus or dumping syndrome. Herein we report our four cases of retrograde jejunojejunal intussusception as an urgent complication following gastrectomy in the late postoperative period.
Case Reports
Patient 1. A 59-year-old male was transferred to our Institute complaining of abdominal pain and bloody vomiting. He had undergone total gastrectomy with a Roux-en-Y reconstruction method for gastric cancer 3 years earlier and had a previous history of intussusception half a year earlier. Enhanced computed tomography (CT) revealed a lamellar structure arranged in a concentric circle and suggested a retrograde intussusception of the small bowel (Figure 1). The patient underwent emergency laparotomy. During surgery, retrograde jejunojejunal intussusception was found (Figure 2) and the intussusception was approximately 15 cm in length from 15 cm more anal to the jejunojejunal anastomotic region, widening to 7 cm. There was no evident of necrotic intestine after manual reduction, so bowel resection was not performed. Postoperative esophagogastroduedenoscopy revealed no mass in the presenting portion of the intussusception. No recurrence of the intussusception has been observed during follow-up.
Patient 2. A 73-year-old male with abdominal pain was transferred to our Institute and diagnosed with jejunojejunal intussusception and intestinal ileus with an enhanced CT. He had experienced similar symptoms six times previously. He had undergone distal gastrectomy with Billroth II method reconstruction and Braun's anastomosis 37 years earlier. Intraoperative findings showed the retrograde jejunojejunal intussusception at the efferent loop without a tumor at the presenting portion and mild edematous changes without necrosis. Therefore, manual reintegration without bowel resection was performed. After discharge, the patient had recurrent symptoms twice and received conservative treatments, on each occasion.
Computed tomographic (CT) images showing retrograde jejunojejunal intussusception in patient 1. Analis jejunum had invaginated into the afferent loop through jejunojejunal anastomotic region. A: Axial CT images. White arrowhead indicates the jejunojejunal anastomotic region. B: Coronal CT images. White arrowheads indicate the presenting portion and black arrows indicate the retrograde invaginating analis jejunum.
Patient 3. A 77-year-old male presented to the Emergency Department due to abdominal pain and bloody vomiting. He had undergone distal gastrectomy with Billroth II method reconstruction and Braun's anastomosis. He had never experienced similar symptoms. Enhanced CT indicated jejunojejunal intussusception and dilatation of the proximal jejunum. He underwent emergency surgery and analis jejunum invaginating into the site of Braun's anastomosis, widening to 10 cm, was found. Bowel resection of the necrotic jejunum and re-reconstruction of Billroth II method were performed. He had not yet suffered a relapse at the time of writing.
Patient 4. A 78-year-old female was transferred to our Emergency Department for bloody vomiting since the previous day, aspiration and signs of shock. She had undergone distal gastrectomy with Billroth II method reconstruction and Braun's anastomosis 6 years earlier, but had never experienced manifestation associated with intussusception. Enhanced CT showed intussusception and strangulated ileus, therefore emergency surgery was performed and revealed the analis jejunum deeply invaginating into the site of Braun's anastomosis, widening to 7 cm. Since it was impossible to reduce the intussusception manually, bowel resection including the site of intussusception and Roux-en-Y reconstruction was performed. The excised specimen showed intestinal necrosis. Unfortunately, the patient died of sepsis resulting from intestine necrosis.
Discussion
The characteristics of our four patients are summarized in Table I. They had all undergone gastrectomy with Roux-en-Y (patient 1) or Billroth-II (patient 2, 3 and 4) method reconstruction. Intraoperative findings showed the analis jejunum deeply invaginating into the anastomotic region and no obvious palpable tumor at the presenting point in any of the cases. Patients 3 and 4 had evidence of intestinal necrosis and needed to undergo bowel resection. Patients 1 and 3 are still alive without recurrence; however, the patients twice experienced recurrences that were treated with conservative therapy. Unfortunately, patient 4 died from sepsis involving the necrotic intestine.
Intestinal intussusception in adult patients accounts for 1% of all bowel obstructions and intussusception after gastrectomy accounted for 1.2%-4.1% of all intussusceptions in adults (1, 2). Many of these cases of intussusception after gastrectomy were associated with Billroth II or Roux en Y method reconstructions and patients with Billroth I method reconstruction were rare. In addition, patients with Braun anastomosis had a threefold higher occurrence rate than those without Braun anastomosis. Moreover, a recent report about bariatric surgery revealed that 0.4% of patients who underwent laparoscopic Roux en Y gastric bypass experienced obstruction at jejunojejunostomy (3).
The most widely accepted mechanism of intussusception is intestinal spasm, which means that the contracted intestinal ring-shaped muscle induced invagination into the nearby relaxed intestine (4). Other mechanisms were also indicated as follows: helminth aberration and fibrous adhesion, anastomotic hypersize, excessive behavior of the efferent loop, submucosal bowel edema (2, 5). In cases of retrograde jejunojejunal intussusception, it is difficult to determine the definitive mechanism and some mechanisms overlapped and led to development of such a state.
Surgical procedures for retrograde intussusception remain controversial: Which procedure is better, resection or reduction? Although bowel resection and re-reconstruction of anastomosis is clearly required in cases with apparent necrotic or non-reducible intestine, we wonder whether or not we should perform resection when there was no apparent ischemic intestine after manual reduction. Patients with colonic intussusception were recommended bowel resection regardless of ischemia because the majority of them had a malignant lead point. Previous literature showed that the incidence of a lead point within retrograde intussusception after bariatric surgery was 0% and manual reduction had low recurrence compared to resection in their small cohort (5). Moreover, bowel resection had no statistical significant effect in preventing recurrences compared to manual reduction in pediatric intussusception cases (6). Therefore, patients with retrograde intussusception without necessity for resecting the intestine should rather undergo only manual reduction without resection; prospective study, focused on retrograde jejunojejunal intussusception cases, is needed.
Intraoperative findings for patient 1. A: The analis jejunum invaginated into the widely extended jejunojejunal anastomotic region. The dashed line shows the analis jejunum invaginating into the small intestine. B, C: Manual reduction was performed and there was no evidence of necrotic intestine.
Summary of four patients with retrograde jejunojejunal intussusception after gastrectomy.
We report on four cases of retrograde jejunojejunal intussusception after gastrectomy. This retrograde intussusception could have developed into a life-threatening condition, however, early diagnosis and immediate surgical treatment led to good prognoses. Therefore, retrograde jejunojejunal intussusception should be kept in mind as an emergent complication after gastrectomy.
- Received September 22, 2015.
- Revision received October 23, 2015.
- Accepted October 26, 2015.
- Copyright© 2015 International Institute of Anticancer Research (Dr. John G. Delinassios), All rights reserved
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