adult retrograde intussusception...rea, jd. et al. approach to management of intussusception in...

ADULT RETROGRADE INTUSSUSCEPTION

Brian Tiu Richmond University Medical Center

September 3, 2015

www.downstatesurgery.org

CASE PRESENTATION • 41 yo woman

• presented one day hx abdominal pain, worsening

• nausea/vomiting

• denied flatus/BM two days

• s/p laparoscopic leiomyomectomy, POD#2


CASE PRESENTATION • PMHx: fibroids

• PSHx: RYGB surgery 1999, panniculectomy, plastic surgery for excess skin

• Medications: multivitamin

• NKDA

• 5 pack year smoking history


CASE PRESENTATION • T98.4, BP150/85, P88, R18, O2 sat 99%

• midline scar, dressings over lap port sites, no erythema, tender mostly at RLQ/suprapubic area

CBC 5.9 > 13.1/40.1 < 298; 81% granulocytes

BMP 139 / 3.5 / 108 / 24 / 9 / 0.5 < 77 Ca 7.2

UA negative


*


OR • exploratory laparotomy - previous midline scar

• mild lysis of adhesions

• 20 cm segment retrograde jejunal intussusception 20 cm from R&Y anastomosis

• reduced, no lead point found

• ran the small bowel: anastomosis → cecum


Presenter

Presentation Notes

rescuscitated

POST-OP COURSE • Admitted to the floor

• POD#1 - passed trial of void

• POD#2 - return of bowel function, tolerated clear liquid diet

• POD#3 - regular diet, d/c home

• POD#6 - clinic visit, no issues


OUTLINE

• pathophysiology

• diagnosis

• treatment

• retrograde intussusception


EPIDEMIOLOGY

• adult intussusception - only 5% of all cases

• 1-5% of intestinal obstructions in adults


TYPES

• enteric

• ileocolic/ileocecal

• colonic


Presenter

Presentation Notes

distinction is made between ileocolic and ileocecal ileocolic - ileum telescopes into the colon past a fixed ileocecal valve ileocecal - the valve itself may be the lead point of the intussusception entero-enteric being the most common

• bowel telescopes into an adjacent segment

• obstruction and ischemia to the intussuscepting segment

• 90% associated with pathologic processes

• Tumors act as the lead point in >65% of adult


Presenter

Presentation Notes

lipoma, carcinoid, polyps, adenoCa


Presenter

Presentation Notes

any lesion in the bowel wall or irritant in the lumen that alters the normal peristaltic pattern may initiate invagination


Presenter

Presentation Notes

pellet = lead point Pacman = edge of intussusceptum ghost are proximal bowel

SIGNS & SYMPTOMS

• mechanical obstruction - pain, nausea/vomiting, distention, obstipation

• strangulation - peritonitis, ↓UOP, fever, tachycardia

• ↓K, ↑Cr, leukocytosis, lactic acidosis


RADIOLOGY

• plain film

• sonography

• CT scan


Presenter

Presentation Notes

plain - non specific, sometimes you may see a sausage-shaped soft tissue density outlined by air.

ULTRASOUND

target sign


Presenter

Presentation Notes


CT SCAN target sign


Presenter

Presentation Notes


SURGERY • peritoneal

• hemodynamic instability

• ischemia/necrosis

• long length, wide diameter of the intussusception

• presence of a lead point - high incidence of tumor

• no role for air/contrast enema


Presenter

Presentation Notes

What about the patient with vague abdominal pain, r/o enteritis with short segment intussusception mean length on CT → operatively confirmed AI vs confirmed absent AI 9.6 ± 5.4 cm versus 3.8 ± 2.1 cm, P < 0.0001 mean diameter on CT → operatively confirmed AI vs confirmed absent 4.8 ± 1.6 cm versus 3.2 ± 0.8 cm, P = 0.004) concluded length, diameter, lead point, obstruction

EN BLOC RESECTION • high incidence of underlying malignancy

• inability to differentiate malignant vs benign pre- or intra-operatively

• theoretical risk of intra-luminal seeding, venous embolization

• anastomotic complications


Presenter

Presentation Notes

selective approach to small bowel intussusception vs resection of colonic 2° to ↑risk of malignancy

RETROGRADE INTUSSUSCEPTION

• association with gastric bypass surgery

• largest case series: 23 (10 years, >15,000 patients)

• proximal end acts as the intussuscipiens

• distal end is the intussuseptum


HOW CAN WE RESOLVE THIS?

• No lead point

• “Roux stasis syndrome”

• ectopic pacemakers

• waves collide in jejunum

• retrograde peristalsis


FINDINGS www.downstatesurgery.org

CONCLUSIONS OF THE STUDY

• ? Resection and reconstruction of the involved anastomosis

• uncut Roux-en-Y

• early surgery for peritonitis or obstruction

• recurrence can occur regardless of intervention


SUMMARY • intussusception represents a small

percentage of patients presenting with SBO

• surgery indicated peritonitis, hemodynamic instability, ischemia/necrosis, long length/wide diameter of the intussusception, lead point

• suspect retrograde intussusception with RYGB


• Marinas, A. et al. Intussusception of the bowel in adults: A review. World Journal of Gastroenterology. Jan 2009. 15(4): 407-411

• Simeone, DM. et al. Chapter 48. Ileus and Bowel Obstruction. Greenfield’s Surgery: Scientific Principles and Practice - 5th Ed. Philadelphia, PA. Lippincott Williams & Wilkins. 2011

• Simper, SC. et al. Retrograde (reverse) jejunal intussusception might not be such a rare problem: a single group’s experience of 23 cases. Surgery for Obesity and Related Diseases. 2008. (4) 77–83

• Rea, JD. et al. Approach to Management of Intussusception in Adults: A New Paradigm in the Computed Tomography Era. Nov 2007. (73): 1098-1105

• Yakan, S. et al. Intussusception in adults: Clinical characteristics, diagnosis and operative strategies. World Journal of Gastroenterology. Apr 2009. 15(16): 1985-1989


adult retrograde intussusception...rea, jd. et al. approach to management of intussusception in...

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