Jejunojejunal Intussusception in

an case of post Roux en Y Hepatico

Jejunostomy

Dr. M. Rajesh Menon

MS Post Graduate
SU1, Prof. R. Vasuki’s unit
Assts: Dr. A.K. Kalpana Devi, Dr. P.S. Arun and Dr. Washington

Department of General Surgery

KMCH- Chennai
Case presentation
 15 year old student,
 Vague abdominal discomfort and Pain around the
umbilicus for 5 days
 Nausea and Vomiting since 3 days
 Not passed stools for 2 days
 Low grade fever since last day
Past history
 Diagnosed to have Type 1 choledochol cyst
 Operated at 3 months
 Roux – en –Y hepaticojejunostomy done

 Post op – un evenful
 Normal mile stones
 But was small for age
On examination
 Dehydrated
 PR_ 96/mt
 BP_110/70 mm Hg
 CVS and RS- NAD
 P/A: mild abdonimal distention
 No VGP/VIP, hernial orifices free
 Soft abdomen with tenderness in Left hypochondrium
 No evidence of free fluid clinically
 BS- present
 Perineum normal.
 PR: normal tone with fecal staining
Investigations
 CBC_ showed mild leukocytosis
 RFT, electrolytes and LFT- normal
 X rays: distended small bowel loops
 USG: dilated small bowel with minimal free fluid.
 Plain CT: post Roux en Y HJ status with dilated jejunal
loops with minimal free fluid- duodenal herniation
suspected.
 Advised CECT
Management
 RTA, CBD, I/O Chart and AG girth chart
 IV Fluids as per body weight
 Antibiotics and Pain killers
 Continuous monitoring

 Patient showed improvement.

 Passed flatus and watery stools
 Encouraged fluids on 2nd day
3nd day of admission
 Patient pain increased and developed fever

 General Condition deteriorated with increased abd

distention
 Able to palpate a mass over the left hypochodrium and
lumbar region
 CECT final report awaited
CECT
Further management
 SGE opinion sought
 By the time the lump on the left side of the abdomen
disappeared
 Patient condition improved
 They suggested conservative management
 Review sos
After couple of days
 Patient felt increasing pain with vomiting
 With mild abdominal distention
 No mass palpable

 Decided for a Diagnostic laparoscopy in consultation with

SGE
Per Op findings
Findings on D lap
 Dilated HJ segment till distal JJ loop
 Multiple adhesions and bands
 Previous anastomosis grossly dilated
 It was possible to replicate the Intussusception
 Duodenal herniation could not be ruled out

 Decided to proceed with exploratory laparotomy

Laparotomy findings
 HJ segment looped beneath the liver with gross dilatation
till distal JJ loop
 Clearly visible constriction band
 Multiple adhesions around (in the vicinity of old
anastomosis)
Procedure done
 Adhesiolysis
 Resection of the dilated bowel segment
 New HJ, GJ and JJ was refashioned
Post op period
 Immediate post op uneventful
 Started orals on 4th day.
 Discharged on 8th POD.
 Patient was doing well on first follow up visit.
Roux-en Y Hepaticojejunostomy
Discussion- Intussusceptions
 Presentation 3 months to 3 years
 Often antegrade, and illeocecal
 Idiopathic Precedes viral infection
 In children, meckels diverticulum
 Associated with polyps, foreign
body, periappendicitis, bleeding,
intestinal duplication etc.
 Hydrostatic reduction, air anaema
 If recurrent or unsuccessful,
surgical intervention
 (b) Target sign: it indicates
(a) Illustration of retrograde hyperemia of mucosa, muscularis,
intussusception. and serosa with
submucosal edema.
Retrograde Intussusceptions
 Usually following RnY gastro or hepaticojejunostomy

 No known cause

 Damage to the MMC pathways implicated

 Distal jejunum is separated from Duodenum
 Ectopic pace maker potential
 Another cause? anastomotic site induced like suture line,
adhesions, inflammatory edema, dysmotility
Surgical management
 (a) manual reduction of the intussusception,
 (b) revision of the anastomosis
 (c) anchoring of the efferent limb to the parietal
peritoneum or suturing together of the efferent and
afferent limbs after reduction of intussusception
 (d) a new gastrojejunostomy, ideally using a Roux-en-Y
reconstruction
 (e) If gangrenous, resection and revision of anastomosis
provides the correct treatment.
Conclusion
 Intussusception can follow RNY Gastric or Hepatico
Jejunostomy
 Disorganized peristalsis or multiple pace maker setters
 Clinical picture is vague.
 CT is diagnostic
 No major role for conservative management
 Surgery – resection and refashioning
References:

[1] Jian-Fang Li, Dan-Dan Lai, Zhi-Hong Lin, Tian-Ye Jiang, Ai-Min Zhang, Jian-Feng Dai,
Comparison of the long-term results of Roux-en-Y gastric bypass and sleeve gastrectomy for
morbid obesity, Surg. Laparosc. Endosc. Percutan.

[2] Oliver Varban, Ali Ardestani, Dan Azagury, David B. Lautz, Ashley H. Vernon, Malcolm K.
Robinson, Ali Tavakkoli, Resection or reduction? The dilemma of managing retrograde
intussusception after Roux-en-Y gastric bypass, Surg. Obes. Relat. Dis. 9.5 (2013) 725–730

[3] Loic Daellenbach, Michel Suter, Jejunojejunal intussusception after Roux-en-Y gastric
bypass: a review, Obes. Surg. 21.2 (2010) 253–263 (Web.).

[4] M.P. Hocking, D.M. McCoy, S.B. Vogel, J.V. Kaude, C.A. Sninsky, Antiperistaltic and
isoperistaltic intussusception associated with abnormal motility after Roux-en-Y gastric bypass:
a case report, Surgery 110 (1991) 109–112.

[5] Baolien Nguyen Tu, Keith A. Kelly, Motility disorders after Roux-en-Y gastrojejunostomy,
Obes. Surg. 4.3 (1994) 219–226 (Web.).

[6] K.B. Jones, Biliopancreatic limb obstruction in gastric bypass at or proximal to the
jejunojejunostomy: a potentially deadly, catastrophic event, Obes. Surg. 6 (1996) 485–493.

[7] L.H. Karlstrom, N.J. Soper, K.A. Kelly, S.F. Phillips, Ectopic jejunal pacemakers and
enterogastric reflux after Roux gastrectomy: effect of intestinal pacing, Surgery 106 (1989)
486–495.

[8] S.C. Simper, J.M. Erzinger, R.D. McKinlay, S.C. Smith, Retrograde (reverse) jejunal
intussusception might not be such a rare problem: a single group's experince of 23 cases.
Dr. M. Rajesh Menon