Retrograde jejunojejunal intussusception in a pregnant female after laparoscopic Roux-en-Y gastric bypass

Retrograde jejunojejunal intussusception in a pregnant female after laparoscopic Roux-en-Y... Adult intussusception is a rare complication after laparoscopic Roux-En-Y gastric bypass (LRYGB) surgery. Incidence of intussusception is on the rise as the demand of bariatric surgeries is increased to treat morbid obesity. Among the bariatric surgeries, LRYGB gastric bypass results in significantly higher weight loss with thinning of the mesentery resulting in increased risk for intussusception. Majority of intussusception cases after gastric bypass have been reported in non- pregnant patients. We report a case of retrograde jejunojejunal intussusception in 6 weeks pregnant female following lap- aroscopic gastric bypass, which was diagnosed with abdominal magnetic resonance imaging and managed successfully with resection and revision of the anastomosis. including white blood cell count, serum chemistry, urinalysis BACKGROUND and liver function tests were all within normal limits. Laparoscopic Roux-En-Y gastric bypass (LRYGB) is one the most Abdominal ultrasound confirmed intrauterine pregnancy. surgical procedures performed worldwide to treat morbid obes- Magnetic resonance imaging revealed intussusception of small ity and associated co-morbidities. Intussusception is a rare bowel with close loop obstruction (Figs. 1 and 2). Following ini- complication that is reported status post-LRYGB. The incidence tial resuscitation, emergent laparoscopy was performed which of intussusception after LRYGB is 0.1 to 0.3% of the cases [1]. confirmed the diagnosis. Intra-operatively significantly dilated Intussusception is the prolapsing of a proximal segment of loop of jejunum approximately 20 cm in length was noticed bowel (intussesceptum) into the lumen of the distal segment close to the jejuno-jejunostomy with retrograde telescoping of (intussuscipiens). the jejunum (Fig. 3). At that time decision was made to covert to open laparotomy with resection of irreducible intussuscep- tion and reconstruction of jejuno-jejunostomy (Fig. 4). Post- CASE PRESENTATION operative course was uneventful, the patient subsequently A 37-year-old 6 weeks pregnant female status post-LRYGB 2 recovered fully and was discharged home on post-operative years ago presented with 4 hours history of sudden onset of day 4. On follow-up, patient was seen in the clinic and reported epigastric and peri-umblical pain and tenderness, associated doing well and pain free. Patient also was following up with her with nausea and vomiting. Vitals signs were stable. Labs obstetrician to assess the viability of the fetus. Received: March 4, 2018. Accepted: April 25, 2018 Published by Oxford University Press and JSCR Publishing Ltd. All rights reserved. © The Author(s) 2018. This is an Open Access article distributed under the terms of the Creative Commons Attribution Non-Commercial License (http://creativecommons.org/ licenses/by-nc/4.0/), which permits non-commercial re-use, distribution, and reproduction in any medium, provided the original work is properly cited. For commercial re-use, please contact journals.permissions@oup.com Downloaded from https://academic.oup.com/jscr/article-abstract/2018/5/rjy094/4995820 by Ed 'DeepDyve' Gillespie user on 21 June 2018 2 K. Khan et al. Figure 1: Magnetic resonance imaging shows intussusception of small bowel with close loop obstruction (cross section). Figure 4: Gross image showing irreducible intussusception at the jejuno- jejunostomy. DISCUSSION Among the bariatric surgeries, LRYGB results in significantly Figure 2: Magnetic resonance imaging shows intussusception of small bowel higher weight loss. As weight loss occurs, fear of complications with close loop obstruction (coronal view). can arise. Post-LRYGB weight loss leads to thinning of the mes- entery resulting in increased risk for intussusception [2]. The cause of telescoping of the intestine and prolapsing into one another and developing intussusception after gastric bypass is not clear. Some research suggests dysmotility as a cause of intussusception in post-gastric bypass patients [1]. As reported by Simper et al. after LRYGB that 0.1–0.3% of patients will get intussusception. Most intussusceptions are retrograde, but can be anterograde and located at the jejunojejunal anastomosis, which acts as the lead point [3]. Patients who are not pregnant, retrograde intussusception is more common [4]. After LRYGB intussusception is rare especially in pregnancy but if it does occur, it accounts for 5% of all intestinal obstruc- tions [5]. Pregnant patients continue to lose weight after LRYGB surgery, it also improves their fertility. Index of suspicion for intussusception should be high in post-gastric bypass pregnant patients presenting with acute onset abdominal pain. In order to rule out intussusception a good history and physical exam along with ultrasound and magnetic resonance imaging (MRI) should be considered early in pregnant patients. The best imaging diagnostic test for intussusception is CT scan, however in pregnant patients it should only be done when the benefit outweighs the risks. Delay in the diagnosis can result in fatal outcome. MRI shows pseudokidney sign, with hypoechoic bowel wall mimicking the renal cortex and hyperechoic mesen- tery mimicking the renal fat in patients with intussusception. Once diagnosis of intussusception is made, next step is to per- form diagnostic laparoscopy and reduce intussuscepted bowel. Figure 3: Gross specimen showing resected; irreducible intussusceptions. In other cases, if the intussusception is not reduced Downloaded from https://academic.oup.com/jscr/article-abstract/2018/5/rjy094/4995820 by Ed 'DeepDyve' Gillespie user on 21 June 2018 Retrograde jejunojejunal intussusception in a pregnant female 3 laparoscopy, conversion to laparotomy and resection and revi- 2. Al-Sabah S, Christou N. Intussusception after laparoscopic sion of the anastomosis should be performed. Roux-en-Y gastric bypass. Surg Obes Relat Dis 2008;4:205–9. 3. Perdue PW, Johnson HW, Stafford PW. Intestinal obstruction complicating pregnancy. Am J Surg 1992;164:384–8. CONFLICT OF INTEREST STATEMENT 4. Singla S, Guenthart BA, May L, Gaughan J, Meilahn JE. None declared. Intussusception after laparoscopic gastric bypass surgery: an underrecognized complication. Minim Invasive Surg 2012; 2012:464853. REFERENCES 5. Simper S, Erzinger J, McKinlay R, Smith S. Retrograde 1. Goverman J, Greenwald M, Gellman L, Gadaleta D. (reverse) jejunal intussusception might not be such a rare Antiperistaltic (retrograde) intussusception after Roux-en-Y problem: a single group′s experience of 23 cases. Surg Obes gastric bypass. Am Surg 2004;70:67–70. Relat Dis 2008;4:77–83. Downloaded from https://academic.oup.com/jscr/article-abstract/2018/5/rjy094/4995820 by Ed 'DeepDyve' Gillespie user on 21 June 2018 http://www.deepdyve.com/assets/images/DeepDyve-Logo-lg.png Journal of Surgical Case Reports Oxford University Press

Retrograde jejunojejunal intussusception in a pregnant female after laparoscopic Roux-en-Y gastric bypass

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Published by Oxford University Press and JSCR Publishing Ltd. All rights reserved. © The Author(s) 2018.
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Abstract

Adult intussusception is a rare complication after laparoscopic Roux-En-Y gastric bypass (LRYGB) surgery. Incidence of intussusception is on the rise as the demand of bariatric surgeries is increased to treat morbid obesity. Among the bariatric surgeries, LRYGB gastric bypass results in significantly higher weight loss with thinning of the mesentery resulting in increased risk for intussusception. Majority of intussusception cases after gastric bypass have been reported in non- pregnant patients. We report a case of retrograde jejunojejunal intussusception in 6 weeks pregnant female following lap- aroscopic gastric bypass, which was diagnosed with abdominal magnetic resonance imaging and managed successfully with resection and revision of the anastomosis. including white blood cell count, serum chemistry, urinalysis BACKGROUND and liver function tests were all within normal limits. Laparoscopic Roux-En-Y gastric bypass (LRYGB) is one the most Abdominal ultrasound confirmed intrauterine pregnancy. surgical procedures performed worldwide to treat morbid obes- Magnetic resonance imaging revealed intussusception of small ity and associated co-morbidities. Intussusception is a rare bowel with close loop obstruction (Figs. 1 and 2). Following ini- complication that is reported status post-LRYGB. The incidence tial resuscitation, emergent laparoscopy was performed which of intussusception after LRYGB is 0.1 to 0.3% of the cases [1]. confirmed the diagnosis. Intra-operatively significantly dilated Intussusception is the prolapsing of a proximal segment of loop of jejunum approximately 20 cm in length was noticed bowel (intussesceptum) into the lumen of the distal segment close to the jejuno-jejunostomy with retrograde telescoping of (intussuscipiens). the jejunum (Fig. 3). At that time decision was made to covert to open laparotomy with resection of irreducible intussuscep- tion and reconstruction of jejuno-jejunostomy (Fig. 4). Post- CASE PRESENTATION operative course was uneventful, the patient subsequently A 37-year-old 6 weeks pregnant female status post-LRYGB 2 recovered fully and was discharged home on post-operative years ago presented with 4 hours history of sudden onset of day 4. On follow-up, patient was seen in the clinic and reported epigastric and peri-umblical pain and tenderness, associated doing well and pain free. Patient also was following up with her with nausea and vomiting. Vitals signs were stable. Labs obstetrician to assess the viability of the fetus. Received: March 4, 2018. Accepted: April 25, 2018 Published by Oxford University Press and JSCR Publishing Ltd. All rights reserved. © The Author(s) 2018. This is an Open Access article distributed under the terms of the Creative Commons Attribution Non-Commercial License (http://creativecommons.org/ licenses/by-nc/4.0/), which permits non-commercial re-use, distribution, and reproduction in any medium, provided the original work is properly cited. For commercial re-use, please contact journals.permissions@oup.com Downloaded from https://academic.oup.com/jscr/article-abstract/2018/5/rjy094/4995820 by Ed 'DeepDyve' Gillespie user on 21 June 2018 2 K. Khan et al. Figure 1: Magnetic resonance imaging shows intussusception of small bowel with close loop obstruction (cross section). Figure 4: Gross image showing irreducible intussusception at the jejuno- jejunostomy. DISCUSSION Among the bariatric surgeries, LRYGB results in significantly Figure 2: Magnetic resonance imaging shows intussusception of small bowel higher weight loss. As weight loss occurs, fear of complications with close loop obstruction (coronal view). can arise. Post-LRYGB weight loss leads to thinning of the mes- entery resulting in increased risk for intussusception [2]. The cause of telescoping of the intestine and prolapsing into one another and developing intussusception after gastric bypass is not clear. Some research suggests dysmotility as a cause of intussusception in post-gastric bypass patients [1]. As reported by Simper et al. after LRYGB that 0.1–0.3% of patients will get intussusception. Most intussusceptions are retrograde, but can be anterograde and located at the jejunojejunal anastomosis, which acts as the lead point [3]. Patients who are not pregnant, retrograde intussusception is more common [4]. After LRYGB intussusception is rare especially in pregnancy but if it does occur, it accounts for 5% of all intestinal obstruc- tions [5]. Pregnant patients continue to lose weight after LRYGB surgery, it also improves their fertility. Index of suspicion for intussusception should be high in post-gastric bypass pregnant patients presenting with acute onset abdominal pain. In order to rule out intussusception a good history and physical exam along with ultrasound and magnetic resonance imaging (MRI) should be considered early in pregnant patients. The best imaging diagnostic test for intussusception is CT scan, however in pregnant patients it should only be done when the benefit outweighs the risks. Delay in the diagnosis can result in fatal outcome. MRI shows pseudokidney sign, with hypoechoic bowel wall mimicking the renal cortex and hyperechoic mesen- tery mimicking the renal fat in patients with intussusception. Once diagnosis of intussusception is made, next step is to per- form diagnostic laparoscopy and reduce intussuscepted bowel. Figure 3: Gross specimen showing resected; irreducible intussusceptions. In other cases, if the intussusception is not reduced Downloaded from https://academic.oup.com/jscr/article-abstract/2018/5/rjy094/4995820 by Ed 'DeepDyve' Gillespie user on 21 June 2018 Retrograde jejunojejunal intussusception in a pregnant female 3 laparoscopy, conversion to laparotomy and resection and revi- 2. Al-Sabah S, Christou N. Intussusception after laparoscopic sion of the anastomosis should be performed. Roux-en-Y gastric bypass. Surg Obes Relat Dis 2008;4:205–9. 3. Perdue PW, Johnson HW, Stafford PW. Intestinal obstruction complicating pregnancy. Am J Surg 1992;164:384–8. CONFLICT OF INTEREST STATEMENT 4. Singla S, Guenthart BA, May L, Gaughan J, Meilahn JE. None declared. Intussusception after laparoscopic gastric bypass surgery: an underrecognized complication. Minim Invasive Surg 2012; 2012:464853. REFERENCES 5. Simper S, Erzinger J, McKinlay R, Smith S. Retrograde 1. Goverman J, Greenwald M, Gellman L, Gadaleta D. (reverse) jejunal intussusception might not be such a rare Antiperistaltic (retrograde) intussusception after Roux-en-Y problem: a single group′s experience of 23 cases. Surg Obes gastric bypass. Am Surg 2004;70:67–70. Relat Dis 2008;4:77–83. Downloaded from https://academic.oup.com/jscr/article-abstract/2018/5/rjy094/4995820 by Ed 'DeepDyve' Gillespie user on 21 June 2018

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Journal of Surgical Case ReportsOxford University Press

Published: May 14, 2018

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