Jejunal Intussusception Following Small Bowel Bypass for Morbid Obesity GENE B. STARKLOFF, M.D., F.A.C.S.,* ROBERT A. SHIVELY, M.D.,t JOHN G. GREGORY, M.D.t In 600 patients who have undergone small bowel bypass for the treatment of morbid obesity, we have encountered three patients who developed intussusception in the bypassed intestine. Diagnosis in these cases has been difficult but in two patients with surgical marker clips applied to the transected fixed jejunum as well as to the adjacent mesocolon, diagnosis was made easier by the radiographic finding of separation of these clips. Clinical symptoms are difficult to evaluate and valuable time may be wasted before a diagnosis is arrived at. Once a diagnosis is made, operation with either reduction or resection of the area of intussusception should be carried out with refixation of the bowel to the mesocolon and reapplication of surgical marker clips. These marker clips are of great value in the diagnosis of intussusception occurring in the bypassed loop.
I NTUSSUSCEPTION OF THE bypassed small intestine after intestinal bypass performed for morbid obesity occurs despite efforts to prevent it by fixation of the small intestine. When intussusception occurs,'2 the diagnosis is difficult and operative correction is frequently delayed until a palpable mass and signs of peritoneal irritation have developed. Frequently, spontaneous reduction of the intussuscipiens occurs and symptoms subside, only to reoccur. Physical examination usually does not delineate the intussusception, unless a palpable mass is present. Barium x-rays of the incontinuity intestinal tract are normal. Patients with no positive physical, laboratory or radiographic findings, who repeatedly complain of cramp-like abdominal pain, sometimes associated with vomiting, are often relegated to a category that are encountered in postoperative intestinal shunt patients whose symptoms are psychogenic. This is particularly true in those patients in whom intussusception occurs early in the postoperative period when massive abdominal girth tends to invalidate examination and masks appreciation Submitted for publication: August 11, 1976. * Clinical Professor of Surgery. t Resident, Department of Surgery. t Professor of Urology, Chief Section of Urology. Reprint requests: Gene B. Starkloff, M.D., Department of Surgery, Saint Louis University Hospitals, 1325 South Grand Boulevard, Saint Louis, Missouri 63104.
From the Department of Surgery Saint Louis University Hospitals, Saint Louis University School of Medicine
of localized tenderness or the presence of a mass. Intussusception in the bypassed jejunum has been frequently mentioned but seldom described.6'7 This report describes our experience with three cases and demonstrates that the entity can occur despite vigorous efforts to prevent it, that it can occur several years postoperatively, and that the diagnosis can be made more easily if silver clips are used to mark the attachment of the small bowel to the mesentery. Our experience includes 600 patients who have had small bowel bypass procedures for morbid obesity. The operations have been either end-to-side, utilizing 14 inches of jejunum joined to ileum 4 inches from the ileo-cecal junction,3 or end-to-end, with the anastomosis of 12 inches of jejunum to 8 inches of terminal ileum.4 In this group of patients, drainage of the proximal closed segment was accomplished by anastomosis of the ileum to either the left transverse colon or the sigmoid. In all patients the transected and closed distal jejunum was attached to the mesentery of the left transverse colon by silk sutures. These seromuscular sutures were placed in the closed jejunal end and deeply in the colonic mesentery to the left of the middle colic vessels. Since November 1972 we have used silver clips as surgical markers, one on the closed jejunum and one adjacent to it on the colonic mesentery at the site of fixation. It is our feeling that, if plain abdominal film should show that these silver clips are separated from the original position, the attachment of the closed jejunum to the mesentery was no longer intact and that intussusception was probable if suggestive symptoms were present. This has proved to be the case in our experience. In the period November 1970 to May 1976 we have encountered three cases of intussusception. The case histories are included in some detail to emphasize the prolonged course and difficulty in diagnosis of this unusual entity.
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at the site of
anchoring. One month later, July 1972, the patient readmitted with crampy left upper quadrant pain which spontaneously subsided. The patient was readmitted December 1973 and April 1974, both admissions were for intermittent cramplike abdominal pain without nausea or vomiting. On these admissions the physical examination, with the exception of hepatomegaly, was negative. Blood counts, urinalysis, serum amalase determinations were all normal. Barium enema, upper gastrointestinal series and intravenous pylograms were all negative. Because of the hepatomegaly, the patient underwent percutaneous liver biopsy which showed fatty infiltration of the liver. The pain spontaneously subsided on each of these admissions and the patient was discharged 'improved'. During January 1975 the patient was seen in the Outpatient Department on two occasions with abdominal pain, with normal physical and laboratory findings. The patient was hospitalized with persistent symptoms and an abdominal mass was found in the left upper quadrant. On January 29, 1975 the patient was explored and found to have a massive intussusception of the excluded jejunum (Fig. 1). The mass was resected, the transected end of the jejunum was closed and was anchored to the left transverse mesocolon in the manner previously described, and silver marker clips were applied to it. The patient has had no further was
complaints. FIG. 1. Operative photograph of intussusception of proximal end of bypassed jejunum.
Case Reports Case 1. A 48 year old female had an end-to-side jejunal-ileal bypass in June 1972. The transected closed jejunum was anchored to the transverse mesocolon. Silver marker clips were not applied
FIG. 2. Plain radiograph abdomen
showing
wide
separation of two surgical marker clips. An additional marker
the
clip
area
can
be
seen
in
of the tied stain-
less steel wire sutures. This represents the site of
the jejunal-ileal tomosis.
anas-
Case 2. A 19 year old female had a jejunal-ileal end-to-end small bowel bypass with ileo transverse colic anastomosis in May 1975. Care was taken to suture the jejunal stump to the transverse mesocolon and to mark the site with silver marker clips. On August 10, 1975 the patient presented herself with abdominal pain. Blood counts, electrolytes and serum diastase were all normal and the patient was discharged with a diagnosis of viral gastroenteritis. The patient was next seen on February 18, 1976 and was hospitalized with a 6 months' history of intermittent cramp-like abdominal pain, associated with nausea and vomiting, and spontaneous relief from
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April 1977
FIG. 3. Wide separation of surgical marker clips occurring in patient found to have intussusception. The surgical marker clip on the right and low in the photograph overlying the vertebra bodies represents the anastomotic site.
the pain usually after the vomiting. The pain would occur every 4 to 6 days and last three to four hours. It was interesting that immediately following vomiting and relief of pain, the patient would be hungry and would be able to eat a normal meal. Physical examination on admission revealed a questionable mass in the upper quadrant on the left above the umbilicus. There was some tenderness in this area. Blood counts, serum amalase determinations and electrolytes were all within normal limits. Plain ab-
FIG. 4. Intraoperative photograph of large intussusception of proximal jejunum in the bypassed segment.
dominal radiograph revealed wide separation of the previously placed surgical markers (Fig. 2). It was the feeling that this patient probably had jejunal intussusception in the bypassed segment of jejunum. This was confirmed at operation. The intussusception was reduced and the reduced closed jejunum was anchored to the transverse mesocolon. The patient has remained well. Case 3. A 37 year old male was operated upon July 5, 1973. He had an end-to-side jejunal-ileal bypass. The jejunal stump was sutured to the transverse mesocolon and silver marker clips were applied to the jejunum and the adjacent mesocolon. On January 16, 1974 the patient was hospitalized with a renal calculus and in November 1974 had a Ureterolithotomy. In March and April 1975 he was hospitalized with left nephrolithiasis. His next hospitalization was on April 14, 1975 because of urinary retention and he subsequently passed a left renal calculus. At this hospitalization the patient complained of crampy left upper quadrant pain which he stated was different from the pain associated with the renal calculus. In September 1975 he was hospitalized twice where investigation of his abdominal pain failed to reveal the cause. On October 9, 1975 the patient was again admitted with cramp-like abdominal pain and nausea without vomiting and no etiology was determined. On March 8, 1976 he was seen complaining of cramp-like abdominal pain and nausea without vomiting. In light of the previous experience, plain radiography of the abdomen was at last obtained. Separation of the silver marker clips was demonstrated (Fig. 3), a questionable mass was present in the left upper quadrant above and to the left of the umbilicus. This mass, in conjunction with the radiographic findings, prompted celiotomy with a preoperative diagnosis of jejunal intussusception (Fig. 4). At operation the intussuscepted area was resected and silver marker clips were reapplied. Since operation the patient has been free of complaints.
Discussion Intussusception in the normal bowel is characterized by symptoms of bowel obstruction-cramp-like ab-
Vol. 185.9 NO. 4
JEJUNAL INTUSSUSCEPTION
389
FIG. 5. Adjacent surgical marker clips in a patient with an intestinal bypass without symptoms or findings suggestive of intussusception. This represents the normal postoperative appearance on radiograph.
dominal pain, distention and vomiting. Frequently in children and occasionally in adults there is coincident passage of bloody stools containing mucous. In patients who have undergone small intestinal shunting, since the closed jejunum is bypassed, there is no bowel obstruction; therefore, no distention. Nausea and vomiting may occur and is probably reflex in nature. The only symptom may be crampy abdominal pain, particularly to the left and above the umbilicus. It should be noted that intussusception of bypassed jejunum may be a late complication5, occurring one to two years after small bowel bypass. Each of our patients had intermittent episodes suggesting recurrent obstruction with spontaneous reduction. Two had associated vomiting and one had bloody stools. None had significant changes in the number or character of their stools. Until the final episode leading to diagnosis and treatment, all three patients were seen multiple times, with normal physical, laboratory and radiologic examinations. Two of the patients were referred for psychiatric consultation, with the feeling that their complaints were entirely functional and that organic complaints had been ruled out by laboratory, radiographic and physical examinations. At the time of diagnosis two patients had left upper quadrant masses and all three had crampy pain. In the two patients who had silver marker clips placed at the
time of surgery, the plain radiograph of the abdomen showed separation of the clips. It is our feeling that the placement of silver marker clips is a most valuable adjunct and will enable the diagnosis of intussusception to be made earlier. The entity ofjejunal intussusception of the bypassed segment is one in which diffuse, vague complaints are the rule and a high index of suspicion is necessary to make the diagnosis promptly. Since cramp-like abdominal pain is the only common denominator and because cramp-like abdominal pain, due to intestinal gas, occurs so frequently in the bypass patient, it is suggested that any patient with persistent cramp-like pain have plain radiographs of the abdomen to determine the position of the marker clips. Close approximation of the surgical marker clips in a patient without intussusception is illustrated in Fig. 5. We have found, upon reexploration of bypass patients, instances where the jejunal stump was no longer anchored to the transverse colon, but without evidence of intussusception or past symptoms suggestive of it. When we have encountered this, we have refixed the transected jejunum to the mesocolon and applied new markers. Once the diagnosis of jejunal intussusception is made, resection or surgical reduction of the intussuscepted segment should be carried out. We are at the present time directing our atten-
390
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STARKLOFF, SHIVELY AND GREGORY
tion to more secure fixation of the transected jejunal stump on the mesocolon in order to prevent future occurrences of intussusception. This is accomplished by deeper placement of sutures in the mesocolon and the use of five anchoring sutures. Summary Three cases of jejunal intussusception, following jejunal-ileal bypass for morbid obesity, are presented and the difficulty in diagnosis is elucidated. Attention is directed to the importance of the clinical suspicion in the face of crampy abdominal pain and the separation of silver marker clips in the postoperative bypass patient. The importance of silver marker clips in making a diagnosis is emphasized.
References 1. Tanga, M. R., Waddell, W. G., and Wellington, J. I.: Jejunal Intussusception: A Complication of Small Bowel Bypass for Intractable Obesity. Can. J. Surg. 13:168- 169, 1970. 2. Kaufmann, Welden: Intussusception-A Late Complication of Small Bowel Bypass for Obesity. JAMA 202:1147-1148, 1967. 3. Payne, J. H. and Dewind, I. T.: Surgical Treatment of Obesity. Am. J. Surg. 118:141-147, 1969. 4. Scott, H. W., Jr., Law, D. H.4 , Sandstead, H. H., et al.: Jejunoileal Shunt in the Surgical Treatment of Morbid Obesity. Ann. Surg. 171:770-782, 1970. 5. Starkloff, G. B., Donovan, J. F., Ramach, K. R., and Wolfe, B. M.: Metabolic Intestinal Surgery, Arch. Surg. 110: 652-657, 1975. 6. Swenson and Oberst: Pre- and Post-operative Care of the Patient with Intestinal Bypass for Obesity. Am. J. Surg. 129(3):225-228, 1975. 7. Editorial: Operations for Obesity. Br. Med. J. 4:247, 1971.
I NTUSSUSCEPTION OF THE bypassed small intestine after intestinal bypass performed for morbid obesity occurs despite efforts to prevent it by fixation of the small intestine. When intussusception occurs,'2 the diagnosis is difficult and operative correction is frequently delayed until a palpable mass and signs of peritoneal irritation have developed. Frequently, spontaneous reduction of the intussuscipiens occurs and symptoms subside, only to reoccur. Physical examination usually does not delineate the intussusception, unless a palpable mass is present. Barium x-rays of the incontinuity intestinal tract are normal. Patients with no positive physical, laboratory or radiographic findings, who repeatedly complain of cramp-like abdominal pain, sometimes associated with vomiting, are often relegated to a category that are encountered in postoperative intestinal shunt patients whose symptoms are psychogenic. This is particularly true in those patients in whom intussusception occurs early in the postoperative period when massive abdominal girth tends to invalidate examination and masks appreciation Submitted for publication: August 11, 1976. * Clinical Professor of Surgery. t Resident, Department of Surgery. t Professor of Urology, Chief Section of Urology. Reprint requests: Gene B. Starkloff, M.D., Department of Surgery, Saint Louis University Hospitals, 1325 South Grand Boulevard, Saint Louis, Missouri 63104.
From the Department of Surgery Saint Louis University Hospitals, Saint Louis University School of Medicine
of localized tenderness or the presence of a mass. Intussusception in the bypassed jejunum has been frequently mentioned but seldom described.6'7 This report describes our experience with three cases and demonstrates that the entity can occur despite vigorous efforts to prevent it, that it can occur several years postoperatively, and that the diagnosis can be made more easily if silver clips are used to mark the attachment of the small bowel to the mesentery. Our experience includes 600 patients who have had small bowel bypass procedures for morbid obesity. The operations have been either end-to-side, utilizing 14 inches of jejunum joined to ileum 4 inches from the ileo-cecal junction,3 or end-to-end, with the anastomosis of 12 inches of jejunum to 8 inches of terminal ileum.4 In this group of patients, drainage of the proximal closed segment was accomplished by anastomosis of the ileum to either the left transverse colon or the sigmoid. In all patients the transected and closed distal jejunum was attached to the mesentery of the left transverse colon by silk sutures. These seromuscular sutures were placed in the closed jejunal end and deeply in the colonic mesentery to the left of the middle colic vessels. Since November 1972 we have used silver clips as surgical markers, one on the closed jejunum and one adjacent to it on the colonic mesentery at the site of fixation. It is our feeling that, if plain abdominal film should show that these silver clips are separated from the original position, the attachment of the closed jejunum to the mesentery was no longer intact and that intussusception was probable if suggestive symptoms were present. This has proved to be the case in our experience. In the period November 1970 to May 1976 we have encountered three cases of intussusception. The case histories are included in some detail to emphasize the prolonged course and difficulty in diagnosis of this unusual entity.
386
Vol. 185
. No. 4
JEJUNAL INTUSSUSCEPTION
387
at the site of
anchoring. One month later, July 1972, the patient readmitted with crampy left upper quadrant pain which spontaneously subsided. The patient was readmitted December 1973 and April 1974, both admissions were for intermittent cramplike abdominal pain without nausea or vomiting. On these admissions the physical examination, with the exception of hepatomegaly, was negative. Blood counts, urinalysis, serum amalase determinations were all normal. Barium enema, upper gastrointestinal series and intravenous pylograms were all negative. Because of the hepatomegaly, the patient underwent percutaneous liver biopsy which showed fatty infiltration of the liver. The pain spontaneously subsided on each of these admissions and the patient was discharged 'improved'. During January 1975 the patient was seen in the Outpatient Department on two occasions with abdominal pain, with normal physical and laboratory findings. The patient was hospitalized with persistent symptoms and an abdominal mass was found in the left upper quadrant. On January 29, 1975 the patient was explored and found to have a massive intussusception of the excluded jejunum (Fig. 1). The mass was resected, the transected end of the jejunum was closed and was anchored to the left transverse mesocolon in the manner previously described, and silver marker clips were applied to it. The patient has had no further was
complaints. FIG. 1. Operative photograph of intussusception of proximal end of bypassed jejunum.
Case Reports Case 1. A 48 year old female had an end-to-side jejunal-ileal bypass in June 1972. The transected closed jejunum was anchored to the transverse mesocolon. Silver marker clips were not applied
FIG. 2. Plain radiograph abdomen
showing
wide
separation of two surgical marker clips. An additional marker
the
clip
area
can
be
seen
in
of the tied stain-
less steel wire sutures. This represents the site of
the jejunal-ileal tomosis.
anas-
Case 2. A 19 year old female had a jejunal-ileal end-to-end small bowel bypass with ileo transverse colic anastomosis in May 1975. Care was taken to suture the jejunal stump to the transverse mesocolon and to mark the site with silver marker clips. On August 10, 1975 the patient presented herself with abdominal pain. Blood counts, electrolytes and serum diastase were all normal and the patient was discharged with a diagnosis of viral gastroenteritis. The patient was next seen on February 18, 1976 and was hospitalized with a 6 months' history of intermittent cramp-like abdominal pain, associated with nausea and vomiting, and spontaneous relief from
388
STARKLOFF, SHIVELY AND GREGORY
Ann. Surg.
April 1977
FIG. 3. Wide separation of surgical marker clips occurring in patient found to have intussusception. The surgical marker clip on the right and low in the photograph overlying the vertebra bodies represents the anastomotic site.
the pain usually after the vomiting. The pain would occur every 4 to 6 days and last three to four hours. It was interesting that immediately following vomiting and relief of pain, the patient would be hungry and would be able to eat a normal meal. Physical examination on admission revealed a questionable mass in the upper quadrant on the left above the umbilicus. There was some tenderness in this area. Blood counts, serum amalase determinations and electrolytes were all within normal limits. Plain ab-
FIG. 4. Intraoperative photograph of large intussusception of proximal jejunum in the bypassed segment.
dominal radiograph revealed wide separation of the previously placed surgical markers (Fig. 2). It was the feeling that this patient probably had jejunal intussusception in the bypassed segment of jejunum. This was confirmed at operation. The intussusception was reduced and the reduced closed jejunum was anchored to the transverse mesocolon. The patient has remained well. Case 3. A 37 year old male was operated upon July 5, 1973. He had an end-to-side jejunal-ileal bypass. The jejunal stump was sutured to the transverse mesocolon and silver marker clips were applied to the jejunum and the adjacent mesocolon. On January 16, 1974 the patient was hospitalized with a renal calculus and in November 1974 had a Ureterolithotomy. In March and April 1975 he was hospitalized with left nephrolithiasis. His next hospitalization was on April 14, 1975 because of urinary retention and he subsequently passed a left renal calculus. At this hospitalization the patient complained of crampy left upper quadrant pain which he stated was different from the pain associated with the renal calculus. In September 1975 he was hospitalized twice where investigation of his abdominal pain failed to reveal the cause. On October 9, 1975 the patient was again admitted with cramp-like abdominal pain and nausea without vomiting and no etiology was determined. On March 8, 1976 he was seen complaining of cramp-like abdominal pain and nausea without vomiting. In light of the previous experience, plain radiography of the abdomen was at last obtained. Separation of the silver marker clips was demonstrated (Fig. 3), a questionable mass was present in the left upper quadrant above and to the left of the umbilicus. This mass, in conjunction with the radiographic findings, prompted celiotomy with a preoperative diagnosis of jejunal intussusception (Fig. 4). At operation the intussuscepted area was resected and silver marker clips were reapplied. Since operation the patient has been free of complaints.
Discussion Intussusception in the normal bowel is characterized by symptoms of bowel obstruction-cramp-like ab-
Vol. 185.9 NO. 4
JEJUNAL INTUSSUSCEPTION
389
FIG. 5. Adjacent surgical marker clips in a patient with an intestinal bypass without symptoms or findings suggestive of intussusception. This represents the normal postoperative appearance on radiograph.
dominal pain, distention and vomiting. Frequently in children and occasionally in adults there is coincident passage of bloody stools containing mucous. In patients who have undergone small intestinal shunting, since the closed jejunum is bypassed, there is no bowel obstruction; therefore, no distention. Nausea and vomiting may occur and is probably reflex in nature. The only symptom may be crampy abdominal pain, particularly to the left and above the umbilicus. It should be noted that intussusception of bypassed jejunum may be a late complication5, occurring one to two years after small bowel bypass. Each of our patients had intermittent episodes suggesting recurrent obstruction with spontaneous reduction. Two had associated vomiting and one had bloody stools. None had significant changes in the number or character of their stools. Until the final episode leading to diagnosis and treatment, all three patients were seen multiple times, with normal physical, laboratory and radiologic examinations. Two of the patients were referred for psychiatric consultation, with the feeling that their complaints were entirely functional and that organic complaints had been ruled out by laboratory, radiographic and physical examinations. At the time of diagnosis two patients had left upper quadrant masses and all three had crampy pain. In the two patients who had silver marker clips placed at the
time of surgery, the plain radiograph of the abdomen showed separation of the clips. It is our feeling that the placement of silver marker clips is a most valuable adjunct and will enable the diagnosis of intussusception to be made earlier. The entity ofjejunal intussusception of the bypassed segment is one in which diffuse, vague complaints are the rule and a high index of suspicion is necessary to make the diagnosis promptly. Since cramp-like abdominal pain is the only common denominator and because cramp-like abdominal pain, due to intestinal gas, occurs so frequently in the bypass patient, it is suggested that any patient with persistent cramp-like pain have plain radiographs of the abdomen to determine the position of the marker clips. Close approximation of the surgical marker clips in a patient without intussusception is illustrated in Fig. 5. We have found, upon reexploration of bypass patients, instances where the jejunal stump was no longer anchored to the transverse colon, but without evidence of intussusception or past symptoms suggestive of it. When we have encountered this, we have refixed the transected jejunum to the mesocolon and applied new markers. Once the diagnosis of jejunal intussusception is made, resection or surgical reduction of the intussuscepted segment should be carried out. We are at the present time directing our atten-
390
Ann. Surg. * April 1977
STARKLOFF, SHIVELY AND GREGORY
tion to more secure fixation of the transected jejunal stump on the mesocolon in order to prevent future occurrences of intussusception. This is accomplished by deeper placement of sutures in the mesocolon and the use of five anchoring sutures. Summary Three cases of jejunal intussusception, following jejunal-ileal bypass for morbid obesity, are presented and the difficulty in diagnosis is elucidated. Attention is directed to the importance of the clinical suspicion in the face of crampy abdominal pain and the separation of silver marker clips in the postoperative bypass patient. The importance of silver marker clips in making a diagnosis is emphasized.
References 1. Tanga, M. R., Waddell, W. G., and Wellington, J. I.: Jejunal Intussusception: A Complication of Small Bowel Bypass for Intractable Obesity. Can. J. Surg. 13:168- 169, 1970. 2. Kaufmann, Welden: Intussusception-A Late Complication of Small Bowel Bypass for Obesity. JAMA 202:1147-1148, 1967. 3. Payne, J. H. and Dewind, I. T.: Surgical Treatment of Obesity. Am. J. Surg. 118:141-147, 1969. 4. Scott, H. W., Jr., Law, D. H.4 , Sandstead, H. H., et al.: Jejunoileal Shunt in the Surgical Treatment of Morbid Obesity. Ann. Surg. 171:770-782, 1970. 5. Starkloff, G. B., Donovan, J. F., Ramach, K. R., and Wolfe, B. M.: Metabolic Intestinal Surgery, Arch. Surg. 110: 652-657, 1975. 6. Swenson and Oberst: Pre- and Post-operative Care of the Patient with Intestinal Bypass for Obesity. Am. J. Surg. 129(3):225-228, 1975. 7. Editorial: Operations for Obesity. Br. Med. J. 4:247, 1971.
