What is the management approach for a patient with a history of gastric bypass surgery presenting with jejunal and ileal intussusception on computed tomography (CT) scan?

Management of Jejunal and Ileal Intussusception After Gastric Bypass

For a patient with a history of gastric bypass presenting with jejunal and ileal intussusception on CT scan, surgical intervention with resection of the affected segment is recommended as it results in fewer recurrences compared to simple reduction. 1

Diagnostic Approach

When a post-gastric bypass patient presents with symptoms suggestive of small bowel obstruction:

• CT scan is the primary diagnostic tool for identifying intussusception
• Typical CT findings include a "target sign" or "sausage-shaped" mass
• Laboratory tests may show nonspecific inflammatory markers

Management Algorithm

Initial Assessment

1. Evaluate hemodynamic stability
2. Assess for signs of peritonitis or bowel ischemia
   • Fever, tachycardia, severe tenderness, guarding
   • Laboratory markers of inflammation or ischemia

Management Based on Clinical Status

For Hemodynamically Stable Patients:

• Surgical exploration is mandatory within 12-24 hours 1
• Laparoscopic approach is preferred if expertise is available
• Exploration should begin at the ileocecal junction and proceed proximally

For Unstable Patients:

• Immediate surgical exploration without delay
• Consider damage control approach if extensive ischemia is present

Intraoperative Decision Making

Upon identifying the intussusception:

1. Assess bowel viability

   • Evaluate color, peristalsis, mesenteric pulsations
   • Consider ICG fluorescence angiography if available 1

2. Surgical options:

   • Preferred approach: Resection of the affected segment 1
     • This results in fewer recurrences compared to simple reduction
   • Alternative: Simple reduction if bowel is completely viable
     • Higher risk of recurrence with this approach

3. If resection is performed:

   • Create a new anastomosis
   • Consider closure of any mesenteric defects with non-absorbable suture

Rationale for Resection vs. Reduction

While reduction alone may be considered in cases with completely viable bowel, the evidence strongly suggests that resection of the affected segment leads to fewer recurrences 1. Intussusception after gastric bypass is often associated with lead points such as adhesions or ectopic pacemakers that may persist if simple reduction is performed 2, 3.

Post-operative Care

• Monitor for signs of anastomotic leak or recurrent obstruction
• Early mobilization and progressive diet advancement
• Consider second-look laparoscopy if there are concerns about bowel viability

Common Pitfalls to Avoid

1. Delayed diagnosis and intervention - Intussusception can rapidly progress to bowel ischemia
2. Incomplete examination of the bowel - Multiple areas of intussusception may be present
3. Simple reduction without addressing the underlying cause - Higher recurrence rates
4. Failure to assess the entire small bowel - Other causes of obstruction may coexist

Intussusception after gastric bypass is a rare but serious complication that requires prompt surgical intervention. While some cases report successful laparoscopic reduction without resection 4, 5, the strongest evidence supports resection of the affected segment to prevent recurrence 1.