Background

Patients with Roux-en-Y Gastric Bypass (RYGBP) surgery can suffer bowel obstruction secondary to intussusception of the jejunojejunostomy (JJ) anastomosis. There is no established treatment algorithm. We present a case managed by resection with re-anastomosis, a brief review of literature and propose a treatment algorithm.

Methods

A 41-year-old female who lost 72% of her excess weight after a RYGBP presented with abdominal pain and CT scan findings demonstrating a small bowel obstruction secondary to a JJ intussusception. She underwent diagnostic laparoscopy with anastomotic resection and re-anastomosis. She had an uneventful recovery until diagnosed with intraabdominal abscess POD 14. She underwent IR drainage and recovered with no further sequalae. Review of literature demonstrates variable JJ intussusception incidence of 0.4-5% in post-RYGBP patients, in part due to the vague, transient nature of clinical and radiologic findings. Multiple operative strategies are possible. Ischemia is an absolute indication for resection & re-anastomosis but predisposes to leak, spillage, post-operative abscess. Small bowel plication can predispose to recurrence & required reoperation. Distalization of the Roux limb has also been reported and may offer reduced spillage and recurrence.

Conclusions

Jejunojejunostomy anastomosis intussusception is uncommon but likely underreported. When patients present with obstruction or evidence of ischemia, treatment is urgent surgical reduction and likely resection. We reserve plication for a dilated jejunojejunostomy with recurrent transient intussusception without obstruction or ischemia. Ultimately, choice of operative plan depends on patient's history and intraoperative findings.