What is the treatment approach for intussusception in an adult with a gastric bypass?

Treatment of Intussusception in Adults with Gastric Bypass

Surgical intervention is the recommended treatment for intussusception in adults with gastric bypass, with laparoscopic or open surgical approach determined by the patient's hemodynamic status. 1, 2

Diagnostic Approach

• CT scan is the preferred imaging modality for diagnosing intussusception in post-bariatric surgery patients
• Key CT findings that suggest need for surgical intervention:
  • Intussusception length >9 cm
  • Diameter >4.5 cm
  • Presence of a lead point
  • Evidence of bowel obstruction 3

Treatment Algorithm

Initial Management

• Immediate IV fluid resuscitation
• Nasogastric tube insertion for decompression
• Anti-emetics as needed
• Foley catheter placement to monitor urine output 2

Surgical Management

1. Surgical approach selection:

   • Laparoscopic approach for hemodynamically stable patients
   • Open surgery for unstable patients 1, 2

2. Intraoperative decision-making:

   • Assess bowel viability using visual inspection or indocyanine green fluorescence angiography
   • If viable bowel: Gentle manual reduction of intussusception (high risk of recurrence)
   • If non-viable bowel: Resection of the affected segment with creation of a new anastomosis 1
   • If jejuno-jejunostomy involved: Reconstruction of the anastomosis 1

3. Additional techniques to prevent recurrence:

   • Resection of the invaginated segment (treatment of choice to prevent recurrence) 1
   • Consider anchoring techniques such as:
     • Noble enteropexy
     • Anchoring efferent limb to surrounding structures (parietal peritoneum) 1

Special Considerations

• Delay in surgical intervention beyond 48 hours is associated with significantly increased mortality 1
• Retrograde (anti-peristaltic) intussusception is the most common form after laparoscopic Roux-en-Y gastric bypass 1
• In complex cases with recurrent intussusception, consider reversal of gastric bypass or conversion to sleeve gastrectomy (requires multidisciplinary evaluation by experienced bariatric surgeons) 1

Types of Intussusception After Gastric Bypass

• Type I: Afferent loop intussusception (antegrade)
• Type II: Efferent loop intussusception (retrograde) - most common
• Type III: Combined form 1

Pitfalls and Caveats

• Endoscopic reduction alone is associated with high recurrence rates and should be avoided as definitive treatment 1
• Symptoms may be vague and non-specific, leading to delayed diagnosis
• Consider intussusception in any post-bariatric surgery patient presenting with abdominal pain, nausea, or vomiting 4, 5
• Intussusception is a rare but serious complication after Roux-en-Y gastric bypass, requiring prompt surgical consultation 6