What is the appropriate next management for a stable 30‑year‑old female with a confirmed jejuno‑jejunal intussusception and no peritoneal signs?

Management of Jejuno-Jejunal Intussusception in a Stable Adult Patient

This stable 30-year-old female with confirmed jejuno-jejunal intussusception and no peritoneal signs requires exploratory laparoscopy within 12-24 hours, with intraoperative decision-making between reduction alone versus resection with primary anastomosis based on bowel viability and suspicion for a pathological lead point.

Rationale for Surgical Intervention

• Adult intussusception almost always has a pathological lead point (unlike pediatric cases), with malignancy present in up to 10-16% of small bowel intussusceptions, making surgical exploration mandatory even in stable patients 1, 2, 3

• Exploratory laparoscopy should be performed within 12-24 hours in stable patients with confirmed small bowel obstruction and persistent symptoms, as recommended for post-bariatric surgery patients with similar presentations 1

• The patient's lack of improvement despite conservative management for presumed gastroenteritis, combined with radiologic confirmation of intussusception, mandates surgical evaluation rather than continued observation 1

Surgical Approach and Technique

Initial Laparoscopic Exploration

• Begin with diagnostic laparoscopy to assess the entire small bowel, identify the intussusception site, and evaluate bowel viability 1

• Systematically examine from the ileocecal junction proximally toward the jejunum to identify the lead point and extent of involvement 1

Intraoperative Decision Algorithm

If bowel appears viable and no mass/lead point is identified:

• Attempt laparoscopic reduction by gentle manual manipulation 4, 5
• However, reduction alone carries the highest risk of recurrence (up to 30% in some series) and should be avoided if any pathological lead point is suspected 6

If a pathological lead point is identified or suspected:

• Resection of the affected segment with primary anastomosis is recommended as it results in fewer recurrences compared to reduction alone 1
• This is the preferred approach in adult intussusception given the high likelihood of an underlying structural abnormality 4, 6

If bowel viability is questionable:

• Perform limited intestinal resection with primary anastomosis in this hemodynamically stable patient 1
• Resection margins should include all compromised bowel with adequate vascular supply 1

Critical Intraoperative Considerations

• Mandatory histopathological examination of the resected specimen is essential to identify the lead point (inflammatory fibroid polyp, lipoma, Meckel's diverticulum, or malignancy) 1, 2, 3, 4

• Obtain biopsies if reduction without resection is performed, though this approach is not recommended in adult intussusception 2, 3

• Assess the entire small bowel for synchronous lesions or other causes of obstruction (adhesions, additional intussusceptions) 1

• Consider indocyanine green (ICG) fluorescence angiography if available to evaluate bowel perfusion and determine resection margins 1

Why Conservative Management is Inappropriate

• Transient intussusception (self-reducing) is rare in adults and typically an incidental radiologic finding in asymptomatic patients 5

• This patient has persistent symptoms for one month with acute worsening, making spontaneous resolution unlikely 4, 7

• Delay in surgical intervention risks bowel ischemia, perforation, and peritonitis, significantly increasing morbidity and mortality 2, 8, 7

• The normal inflammatory markers and absence of peritonitis indicate early presentation—an optimal window for elective laparoscopic intervention before complications develop 1

Common Pitfalls to Avoid

• Do not attempt reduction alone in adult intussusception without resection, as recurrence rates are unacceptably high and the underlying pathology remains unaddressed 1, 6

• Do not delay surgery for prolonged observation or repeated imaging in a patient with confirmed intussusception and persistent symptoms 1, 3

• Do not assume benign etiology based on age or presentation—malignancy must be excluded histologically in all adult intussusception cases 1, 2, 3

• Do not convert to open surgery prematurely unless laparoscopic visualization is inadequate or the patient becomes unstable 1

Postoperative Management

• Serial clinical examinations every 3-6 hours in the immediate postoperative period to monitor for complications 2, 3

• Advance diet as tolerated once bowel function returns 1

• Await final histopathology to guide any additional treatment if malignancy is identified 1, 2, 3