Snapshots in surgery: small bowel intussusception following ileojejunal bypass.

KEY CLINICAL MESSAGE: Jejunal intussusception is a known complication of ileojejunal bypass surgery for obesity that may present as an acute abdomen. It can be avoided if the jejunum is anchored to the transverse mesocolon intra-operatively.

Questions

What do the Figures1 and 2 demonstrate?

Figure 1

Pre-operative CT imaging (A) Coronal view. (B) Axial view.

Figure 2

Intra-operative findings.

How might it be avoided?

Answer

A 41-year-old woman presented with a 1 year history of generalized spasmodic abdominal pain and nausea without obstructive symptoms. Three years previously, the patient had undergone a laparoscopic vertical sleeve gastrectomy and ileojejunal bypass (proximal jejunum anastomosed to terminal ileum with formation of a distal jejunal roux-en Y loop) for morbid obesity. CT imaging (Fig.1) demonstrated small bowel intussusception and an exploratory laparotomy (Fig.2) confirmed intussusception of the bypassed jejunal segment.

This clinical case highlights that those bariatric patients with persistent vague or nonspecific abdominal pain presenting to hospital should be investigated. Previous bariatric surgery may lead to masking of the signs and symptoms of gastroenteric pathology. These patients may present unusually and be missed if symptoms are ignored [1,2]. Intussusception of the jejunal segment is a reported complication of ileojejunal bypass [1,2] and may be avoided if the jejunum is anchored to the transverse mesocolon intra-operatively [2].