Retrograde Jejunojejunal Intussusception With Perforation After Sleeve-to-Roux-en-Y Gastric Bypass (RYGB) Conversion: A Case Report

Jejunojejunal (JJ) intussusception is a rare late complication of Roux-en-Y gastric bypass (RYGB).Most cases are retrograde, meaning the common channel telescopes backward into the JJ anastomosis.The best surgical treatment is still debated: simple reduction, reduction with fixation, or resection with a new anastomosis.We report a 69-year-old woman who had a sleeve gastrectomy 10 years earlier, converted to RYGB about two years later because of reflux.She presented with abdominal pain that woke her from sleep and radiated to the back, with recent diarrhea and no vomiting or fever.She had leukocytosis (14.5 x 10 3 /µL) with normal Creactive protein (CRP) and a lactate of 2.2 mmol/L.An abdominal radiograph showed air-fluid levels, and a nasogastric tube drained coffee-ground content.Computed tomography (CT) then showed dilated proximal small bowel and a suspected intussusception at the JJ anastomosis, without free air.Laparoscopy was converted to laparotomy because the intussusception could not be reduced laparoscopically.About 90 cm of the common channel had telescoped retrogradely into the JJ anastomosis.The bowel was congested but viable.A 1 cm perforation was found in the common channel, 10 cm distal to the anastomosis.The Petersen space and the JJ mesenteric defect were both open.We reduced the intussusception, repaired the perforation primarily, closed both mesenteric defects, and fixed the common channel to the biliopancreatic limb and the mesenteric root.We chose not to resect because the bowel was viable, the involved segment was long (about 90 cm), and the biliopancreatic and alimentary limbs were markedly dilated close to the ligament of Treitz.Recovery was uneventful, and the patient was discharged on postoperative day 6.At two months, she was well, with no recurrence or complaints.This case shows that intussusception after RYGB can present with few signs of perforation, even when the bowel is perforated.In selected patients with viable bowel, reduction with fixation and primary repair is a reasonable alternative to resection.