ADULT RETROGRADE INTUSSUSCEPTION...Rea, JD. et al. Approach to Management of Intussusception in...

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ADULT RETROGRADE INTUSSUSCEPTION Brian Tiu Richmond University Medical Center September 3, 2015 www.downstatesurgery.org

Transcript of ADULT RETROGRADE INTUSSUSCEPTION...Rea, JD. et al. Approach to Management of Intussusception in...

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ADULT RETROGRADE INTUSSUSCEPTION

Brian Tiu Richmond University Medical Center

September 3, 2015

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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

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CASE PRESENTATION • PMHx: fibroids

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

• Medications: multivitamin

• NKDA

• 5 pack year smoking history

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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

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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

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Presenter
Presentation Notes
rescuscitated
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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

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OUTLINE

• pathophysiology

• diagnosis

• treatment

• retrograde intussusception

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EPIDEMIOLOGY

• adult intussusception - only 5% of all cases

• 1-5% of intestinal obstructions in adults

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TYPES

• enteric

• ileocolic/ileocecal

• colonic

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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
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• 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

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Presenter
Presentation Notes
lipoma, carcinoid, polyps, adenoCa
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Presenter
Presentation Notes
any lesion in the bowel wall or irritant in the lumen that alters the normal peristaltic pattern may initiate invagination
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Presenter
Presentation Notes
pellet = lead point Pacman = edge of intussusceptum ghost are proximal bowel
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SIGNS & SYMPTOMS

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

• strangulation - peritonitis, ↓UOP, fever, tachycardia

• ↓K, ↑Cr, leukocytosis, lactic acidosis

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RADIOLOGY

• plain film

• sonography

• CT scan

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

target sign

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Presenter
Presentation Notes
plain - non specific, sometimes you may see a sausage-shaped soft tissue density outlined by air.
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CT SCAN target sign

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

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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
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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

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

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HOW CAN WE RESOLVE THIS?

• No lead point

• “Roux stasis syndrome”

• ectopic pacemakers

• waves collide in jejunum

• retrograde peristalsis

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FINDINGS www.downstatesurgery.org

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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

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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

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• 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

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