Laparoscopic Management of Jejuno-jejunal Intussusception Post Laparoscopic Roux-en-Y Gastric Bypass in a Pregnant Patient

Abstract

This case is of a 44-year-old, with a background of NIDDM and BMI 25 with weight of 58 kg, transferred from a district general hospital with severe abdominal pain and vomiting. CT at referring hospital (performed without knowledge of pregnancy status by both patient and clinician) showed intussusception with concomitant small bowel obstruction. Index RYGB was performed in 2016 at referring hospital, with patient weight of 95 kg and BMI 42 pre-operatively. For this operation, the length of bilio-pancreatic limb was 45 cm, length of alimentary limb was 120 cm, and size of jejuno-jejunal anastomosis was 6 cm (created using TriStapler Gold 60 mm). Common limb length as a routine is not measured at time of primary operation. There was a 3-year duration between index RYGB and presentation with intussusception. Initial diagnostic laparoscopy demonstrated a distended gastric remnant and dilated bilio-pancreatic limb with a widened jejuno-jejunal anastomosis. Upon reduction of retrograde small bowel intussusception, a segment of small bowel immediately beyond jejuno-jejunal anastomosis was nonviable. In view of non-viable small bowel, a decision was made to undertake resection of jejuno-jejunal anastomosis followed by restoration of intestinal continuity. Small bowel mesentery was divided using harmonic scalpel and ligaclips. Restoration of intestinal continuity was achieved by joining alimentary limb to common channel limb with a side-to-side stapled anastomosis and closure of lateral defect with 2–0 vicryl suture. Prior to joining bilio-pancreatic limb to common channel, a small enterotomy is made to allow decompression of distended small bowel, thus precluding need to decompress gastric remnant separately with a gastrostomy tube. In total, 2 L of gastric content were released. This enterotomy was then used for creation of new jejuno-jejunal anastomosis. The gastric remnant remained viable throughout the operation. The bilio-pancreatic limb is joined to common channel with side-to-side stapled anastomosis and again, closure of lateral defect with 2–0 vicryl. Jejuno-jejunal hernial defect was closed with 0 Ethibond. Petersen’s defect was closed at index operation and was patent during revision surgery — this was checked and confirmed intra-operatively. The resected specimen retrieved in endoscopic bag. Following creation of new RYGB, the length of biliopancreatic limb was 45 cm, length of alimentary limb was 100 cm, size of jejuno-jejunal anastomosis was 4.5 cm (created using Tri-Stapler Gold 45 mm), and length of common limb was 150 cm. Total operative time was 195 min. Key Points 1. It is important for clinicians to consider intussusception as a differential diagnosis in patients presenting with small bowel obstruction with a history of previous RYGB. 2. Assessing viability of small bowel intra-operatively is essential, and it is important to proceed to resection if clinically indicated 3. As per SAGES guidelines, the use of laparoscopic surgery in pregnancy is safe and provides patients with the same benefit over open surgery as with a non-pregnant patient.