Antegrade Jejunal Intussusception at the Bilopancreatic Limb Jejunojejunostomy After Laparoscopic Distal Gastrectomy With Roux‐en‐Y Reconstruction: A Case Report

ABSTRACT

Jejunal intussusception is a rare but potentially serious complication of gastric surgery, typically involving the gastrojejunostomy or alimentary limbs. A 75‐year‐old woman underwent laparoscopic distal gastrectomy with D1+ lymphadenectomy and Roux‐en‐Y reconstruction for early‐stage gastric cancer. Postoperatively, she developed intermittent vomiting every 10 days without identifiable triggers and was managed conservatively. However, transient jejunal intussusception involving the bilopancreatic limb was later identified at the jejunojejunal site. Although the intussusception resolved spontaneously, her symptoms persisted. Laparoscopic reoperation revealed mild bulging at the jejunojejunostomy site and a bilopancreatic limb measuring approximately 40 cm, considerably longer than the intended 25 cm. The segment was resected and reconstructed in the antiperistaltic direction using a 25‐cm limb. Postoperatively, the patient's symptoms resolved completely. Even minor intraoperative misjudgment of bilopancreatic limb length may lead to functional complications such as intussusception. Awareness of this rare complication can help guide surgical decision‐making and postoperative management, ultimately improving patient outcomes.

1. Introduction

Jejunal intussusception is a rare but clinically significant complication of gastric surgery. It accounts for less than 5% of bowel obstructions in adults and is most frequently observed after bariatric surgery or oncologic gastrectomy with Roux‐en‐Y (RY) or Billroth II reconstruction [1]. Intussusception typically occurs at the gastrojejunostomy or within the alimentary limb. However, intussusception at the bilopancreatic limb jejunojejunostomy is exceedingly rare.

In this report, we present a rare case of antegrade intussusception at the bilopancreatic limb jejunojejunostomy site occurring after laparoscopic distal gastrectomy with RY reconstruction for early‐stage gastric cancer.

2. Case Presentation

A 75‐year‐old woman was referred to our department for the treatment of early‐stage gastric cancer. She was diagnosed with a type 0–IIc lesion on the lesser curvature of the middle stomach, histologically confirmed as poorly differentiated adenocarcinoma and clinically staged as cT1bN0M0, Stage I. She underwent laparoscopic distal gastrectomy with D1+ lymphadenectomy and RY reconstruction. The gastrojejunostomy was performed using a functional end‐to‐end anastomosis with an Endo GIA Tri‐Staple Purple 60 stapler (Medtronic). The jejunojejunostomy was constructed in the antiperistaltic direction a side‐to‐side anastomosis with an Endo GIA Tri‐Staple Camel 45 stapler (Medtronic), with the internal diameter of the anastomosis adjusted to approximately 30 mm. The biliopancreatic limb length was measured at approximately 25 cm from the ligament of Treitz, and Petersen's defect was routinely closed with a continuous non‐absorbable 3–0 V‐Loc (Medtronic) suture to prevent internal herniation. After discharge, she experienced intermittent episodes of vomiting approximately every 10 days without identifiable triggers or consistent patterns. During these episodes, she was managed conservatively with intravenous fluids and antiemetic therapy, which temporarily alleviated her symptoms. Although the vomiting recurred intermittently, her oral intake and nutritional status remained largely stable, and conservative management was continued. A contrast‐enhanced CT scan was subsequently performed as part of routine postoperative oncologic surveillance, during which transient jejunojejunal intussusception at the biliopancreatic limb anastomosis was incidentally detected (Figure 1A,B). Because this finding was considered a possible cause of her persistent vomiting, reoperation was recommended, and the patient opted to proceed with surgical intervention.

FIGURE 1.

Diagnostic evaluation of jejunal intussusception. (A) Computed tomography image showing jejunojejunal intussusception at the bilopancreatic limb (arrow). (B) Schematic illustration of antegrade intussusception at the bilopancreatic limb, with the jejunum telescoping distally through the anastomosis.

During the laparoscopic reoperation, no definitive signs of intestinal intussusception were observed; however, mild bulging at the jejunojejunostomy site was noted (Figure 2A). Notably, the actual biliopancreatic limb length from the ligament of Treitz measured approximately 40 cm, significantly longer than the intended 25 cm. Following an 8‐cm laparotomy, the previous jejunojejunal anastomosis (Roux Y‐limb anastomosis) was resected. First, the elevated jejunal limbs were anastomosed end‐to‐end using a hand‐sewn full‐thickness Gambee technique with 4–0 PDS. Next, the alimentary limb was anastomosed approximately 30 cm distal to the gastrojejunostomy site in the antiperistaltic direction using an Endo GIA Tri‐Staple Camel 45 stapler, creating an anastomotic diameter of roughly 25 mm. The entry hole was closed with a hand‐sewn full‐thickness Gambee suture with 4–0 PDS. The final length of the biliopancreatic limb was adjusted to 25 cm. The operation lasted 131 min, with an estimated blood loss of 12 mL. The patient's postoperative course was uneventful, and she was discharged on postoperative day 10. During a six‐month follow‐up period, she remained free of vomiting, without symptom recurrence.

FIGURE 2.

Intraoperative finding and Roux‐en‐Y reconstruction from reoperation. (A) Intraoperative image showing mild bulging at the jejunojejunostomy site without clear evidence of intussusception. (B) Diagram of the revised reconstruction. A hand‐sewn Gambee anastomosis was performed between the jejunal limbs, and a new anastomosis was created approximately 30 cm distal to the gastrojejunostomy.

3. Discussion

Postoperative jejunal intussusception is a rare but notable complication of RY reconstruction performed for gastric malignancies [2, 3]. Although most reported cases involve the gastrojejunostomy or the alimentary limb, intussusception at the bilopancreatic limb jejunojejunostomy is exceedingly rare [2, 4]. Given this rarity and its often ambiguous symptomatology, heightened clinical awareness is warranted, particularly in patients presenting with intermittent, nonspecific gastrointestinal symptoms [5].

The pathophysiological mechanisms underlying postoperative intussusception remain incompletely elucidated; however, several theories have been proposed. A leading hypothesis suggests that surgical transection disrupts the normal pacemaker activity of the jejunum, resulting in ectopic pacemaker dominance and aberrant peristalsis. This dysregulated motility may predispose the intestine to segmental telescoping [2, 5, 6]. Moreover, intraoperative visualization of reverse peristalsis in a similar context, as reported by Yoshiyama et al., further supports a motility‐driven mechanism [7].

In addition to motility disturbances, technical factors such as excessive alimentary limb length and enlarged anastomotic diameter have been identified as potential contributors to intussusception [3, 6, 7]. In the present case, the bilopancreatic limb, intended to be 25 cm, was found to measure approximately 40 cm during reoperation, indicating an intraoperative miscalculation. This discrepancy was likely attributable to assessing jejunal length using laparoscopic graspers alone, as bowel sagging during laparoscopy can lead to underestimation when traction and tactile feedback are limited. To prevent similar inaccuracies, our current practice is to measure the limb length laparoscopically and then reconfirm it manually through laparotomy before reconstruction. Because an excessively wide anastomotic diameter may contribute to postoperative intussusception, the new jejunojejunostomy was designed with a smaller lumen (approximately 25 mm) using a 45‐mm stapler, and the entry hole was carefully closed with a hand‐sewn full‐thickness Gambee suture to avoid excessive enlargement. The unintentional increase in limb length may have enhanced intestinal mobility, thereby exacerbating dyskinetic peristalsis and facilitating antegrade intussusception. This finding underscores the importance of meticulous intraoperative measurement, particularly during laparoscopic procedures, where spatial orientation is inherently limited [5].

Furthermore, although the laparoscopic approach offers benefits such as reduced postoperative pain and fewer adhesions, this may paradoxically predispose patients to intussusception owing to decreased peritoneal adhesions and increased small bowel mobility. When superimposed on preexisting motility abnormalities, this mobility can create favorable conditions for intussusception [4, 5]. Although closure of the Petersen's defect was performed to prevent internal herniation, this fixation did not involve the jejunojejunostomy site. Therefore, it is unlikely to have influenced biliopancreatic limb mobility or contributed to the development of intussusception.

Accurate diagnosis of postoperative intussusception is frequently delayed because of its transient and nonspecific clinical manifestations. Vomiting may be misattributed to benign postoperative conditions such as dietary intolerance or functional ileus. Although imaging modalities like computed tomography may detect transient intussusception, spontaneous resolution, as observed in this case, can further complicate diagnosis. Notably, even in the absence of overt intraoperative intussusceptive findings, subtle anastomotic bulging and postoperative symptomatic relief after resection support the diagnosis of functional intussusception [4, 7]. In both the initial operation and the reoperation, the jejunojejunostomies were constructed in the antiperistaltic configuration. It is unlikely that peristaltic direction itself played a major role, as similar cases have been reported with isoperistaltic anastomoses. Instead, excessive limb length and abnormal peristaltic activity were the primary contributing factors.

Jejunojejunal intussusception has been reported more frequently (approximately 0.4%) after bariatric RY gastric bypass than after oncologic gastrectomy [8]. This difference may be related to longer limb lengths, increased bowel mobility following weight loss, and altered motility. In contrast, intussusception after RY reconstruction for gastric cancer is extremely rare, with only sporadic case reports published. Thus, jejunojejunostomy performed for gastric cancer does not appear to be more prone to intussusception than that performed for bariatric surgery.

This case highlights several important clinical considerations. First, accurate and reproducible intraoperative measurement of the bilopancreatic limb is essential to minimize technical variability. Second, functional complications may arise even in the absence of clear anatomical abnormalities. Finally, in cases of persistent or unexplained gastrointestinal symptoms following RY reconstruction, early imaging and a low threshold for surgical exploration are recommended. Increased awareness of this rare complication and its potential underlying mechanisms can inform surgical techniques and postoperative management, ultimately improving patient outcomes.

Author Contributions

Conceptualization, Data curation, Formal analysis: K. Kimura, K. Kato. Writing – original draft: K. Kimura, K. Kato. Writing – review and editing: All authors. All authors read and approved the final manuscript.

Funding

The authors have nothing to report.

Ethics Statement

The authors have nothing to report.

Consent

Informed consent for publication to publish the clinical information and images was obtained from the patient.

Conflicts of Interest

The authors declare no conflicts of interest.

Data Availability Statement

The data that support the findings of this study are available from the corresponding author upon reasonable request.