Recurrent intussusception in a gastric bypass patient with incidental Meckel's diverticulum: A case report.

Most cases of intussusception in adults are secondary to a pathologic condition that serves as a lead point. Intussusception has been reported in the bariatric literature, typically due to intussusception of the jejunojejunostomy. However, other causes of intussusception should be considered, including a Meckel's diverticulum (MD). Simple diverticulectomy or segmental resection is the preferred treatment since the malignancy rate is low. We present an interesting case of a patient with past surgical history of open Roux-en-Y gastric bypass who presented with intussusception. Intraoperatively, an MD was encountered and treated with diverticulectomy. 4 months later, she re-presented with recurrent intussusception and was subsequently taken back to the operating room for revision of her jejunojejunostomy. The postoperative course was uncomplicated.

INTRODUCTION

Nearly 90% of the cases of intussusception in adults are secondary to a pathologic condition that serves as a lead point.[1] Although Meckel's diverticulum (MD) may cause intussusception and small bowel obstruction, it is usually asymptomatic and found incidentally during surgery. It occurs in 1-3% of the general population, and typically is found within 100 cm of the ileocecal valve.[2] Simple diverticulectomy or segmental resection is preferred for the small bowel since the malignancy rate is low.[34] We present an interesting case of a patient with past surgical history of open Roux-en-Y gastric bypass who presented with recurrent intussusception after diverticulectomy for incidental MD.

CASE REPORT

A 62-year-old female (body mass index 19.9 kg/m2) with past surgical history of open Roux-en-Y gastric bypass in 1993 presented to the emergency department with abdominal pain for 1-day. The pain was located in the epigastrium and radiated to the pelvis. She denied vomiting but was nauseated. Her last bowel movement and flatus were 2 days prior. A computed tomography (CT) scan was obtained which revealed dilatation of the biliary limb of the Roux-en-Y gastric with abrupt small bowel tapering in the region of the jejunojejunal anastomosis where there was evidence of small bowel-small bowel intussusception [Figure 1]. She was taken to the operative room for diagnostic laparoscopy. The jejunojejunostomy appeared normal; however, approximately 60 cm proximal to the cecum, an MD with an intussuscepted segment of small bowel was incidentally discovered. The MD was transected with an Endo-GIA stapler, with care taken to avoid narrowing the lumen. She had an uneventful postoperative course and was subsequently discharged home 4 days later. Pathology was consistent with an MD.

Figure 1

Computed tomography abdomen/pelvis with PO/intravenous contrast 7/31/2014

On postoperative day 143, the patient again presented to the emergency room with intermittent abdominal pain for the previous 2 weeks. She reported that the pain felt similar to the previous hospitalization. Repeat CT scan revealed short segment small bowel intussusception in the left upper quadrant. There was no bowel dilatation to suggest obstruction [Figure 2]. She was taken back to the operating room for diagnostic laparoscopy. The jejunojejunostomy was bulbous in appearance and felt to be the cause of the recurrent intussusception. The alimentary limb of the jejunojejunostomy was transected laparoscopically with an Endo-GIA stapler and anastomosed to the jejunum 25 cm distal to the previous connection in a side-to-side fashion using the Endo-GIA stapler. The patient was discharged home on postoperative day 5 tolerating a regular diet. Pathology of the enterectomy was unremarkable.

Figure 2

Computed tomography abdomen/pelvis with PO/intravenous contrast 11/23/2014

DISCUSSION

Bowel intussusception in adults is rare, accounting for 1-5% of all bowel obstructions. In children, the etiology is usually benign and can be safely and effectively managed with pneumatic or hydrostatic reduction in 80% of cases. In contrast, adults are much more likely to have a pathologic cause of intussusception, thereby mandating surgical exploration.[1] MD is a known cause of small bowel intussusception but is more often asymptomatic, occurring in 1-3% of the population.[2] When causing obstruction; however, it should be resected, either via diverticulectomy or bowel resection.[34] Chowbey et al. presented a series of 253 patients undergoing laparoscopy for diagnosis and treatment of recurrent small bowel obstruction. MD was responsible for obstruction in 18 of these patients (7.11%). 10 were managed with diverticulectomy and eight required ileal resection as a definitive treatment.[5]

There are cases presented in the literature describing intussusception in patients with previous bariatric surgery. Daetwiler et al. presented a case of suspected MD causing chronic abdominal pain in a patient who had undergone laparoscopic adjustable gastric banding (LAGB). MD was suspected based on a Tc99 scintigraphy showing tracer enrichment of the terminal ileum. During diagnostic laparoscopy, however, MD was ruled out, and the chronic pain was ultimately determined to be from displaced an LAGB port catheter wrapping around the root of the mesentery.[6] Sohn et al. reported an incidental MD in 1.2% of 427 patients undergoing open Roux-en-Y gastric bypass with routine extirpation of the gallbladder and appendix from July 1994 to June 2006 at a tertiary care hospital.[7]

Our patient had two etiologies for intussusception: MD and a dilated, bulbous jejunojejunal anastomosis from previous Roux-en-Y gastric bypass. Certainly, if no MD was discovered during the initial operation, we feel the appropriate step would have been to revise the jejunojejunal anastomosis. However, given the presence of the MD, the question was whether to resect the MD, and if so, whether to simultaneously revise the jejunojejunal anastomosis. Given the findings of intussusception at the MD we felt this to be the most likely cause of her symptoms. Revising the anastomosis at the same time, thereby creating a fresh anastomosis in addition to the separate staple line along the MD would have increased her risk of postoperative complications. Nonetheless, in retrospect, resecting the MD and revising the jejunojejunal anastomosis, although increasing her risk of postoperative complications, could have prevented the need for a second operation.