Jejunojejunal Intussusception Following Roux-en-Y Gastrectomy for Gastric Adenocarcinoma

Abstract

Jejunojejunal intussusception is an exceptionally rare but potentially serious complication following Roux-en-Y gastrectomy, with an estimated incidence of 0.4%–0.64%. It most often occurs at the jejunojejunal anastomosis, typically in a retrograde fashion, due to postoperative motility disturbances. Although most cases occur within 2 years postoperatively, delayed presentations several years after surgery can pose diagnostic challenges. We report the case of an 81-year-old male who presented 6 years after D2 subtotal gastrectomy with Roux-en-Y reconstruction for gastric adenocarcinoma and high-grade neuroendocrine tumor. The patient developed acute-onset, severe colicky abdominal pain with vomiting and distension. Contrast-enhanced computed tomography revealed a “bowel-within-bowel” configuration at the jejunojejunal anastomosis, consistent with intussusception and distal ischemia. Diagnostic laparoscopy confirmed the diagnosis, and due to gangrenous changes in the distal afferent jejunal loop, an open resection with reconstruction of the jejunojejunal anastomosis and gastrojejunostomy was performed. The patient’s postoperative recovery was uneventful. This case underscores the importance of maintaining clinical suspicion for intussusception in postgastrectomy patients presenting with acute abdomen, even years after surgery. Early imaging, timely diagnosis, and individualized surgical intervention are essential to prevent morbidity and ensure favorable outcomes.

INTRODUCTION

Jejunojejunal intussusception is an exceedingly rare complication following Roux-en-Y gastrectomy, with an estimated incidence of 0.64%, yet it can lead to significant morbidity if unrecognized.[1,2] It most commonly occurs at the jejunojejunal anastomosis and often presents in a retrograde fashion, likely due to postoperative alterations in intestinal motility or mucosal hypertrophy.[2,3] Although most cases present within the first 2 years postoperatively, delayed presentations may occur even several years after surgery, posing diagnostic challenges.

Patients typically present with sudden-onset, severe abdominal pain, nausea, vomiting, and oral intolerance.[4] Contrast-enhanced computed tomography (CT) is the diagnostic modality of choice, often revealing the characteristic “target” sign indicative of telescoping bowel segments.[5] Prompt recognition is critical, as delayed diagnosis can result in bowel obstruction or necrosis.[6] Surgical management remains the definitive treatment, with resection and reanastomosis of the affected segment associated with the lowest recurrence rates.[7]

We report a rare case of jejunojejunal intussusception occurring 6 years after Roux-en-Y gastrectomy for gastric adenocarcinoma. This case highlights the importance of clinical vigilance, timely imaging, and individualized surgical intervention in the management of delayed postgastrectomy complications, contributing valuable insight to the limited literature on this condition.

CASE REPORT

An 81-year-old male with a history of D2 subtotal gastrectomy with Roux-en-Y reconstruction for moderately differentiated gastric adenocarcinoma and a high-grade neuroendocrine tumor in January 2019 presented to the emergency department in March 2025 with sudden-onset, severe colicky abdominal pain of 6 h duration. The pain was associated with multiple episodes of nausea and vomiting, progressive abdominal distension, and oral intolerance.

On physical examination, the abdomen was distended with hyperactive bowel sounds and tenderness in the epigastric and left hypochondriac regions. Laboratory investigations revealed leukocytosis with a left shift. Contrast-enhanced abdominal CT demonstrated a large hypodense filling defect approximately 38 cm distal to the gastrojejunostomy, measuring 6.8 cm × 8.7 cm × 10.7 cm, with a “bowel-within-bowel” appearance consistent with intussusception at the jejunojejunal anastomosis [Figure 1].

Figure 1.

Contrast-enhanced abdominal computed tomography scan showing a large hypodense filling defect with the “bowel-within-bowel” appearance at the jejunojejunal anastomosis, consistent with intussusception

The proximal duodenum and jejunum were mildly dilated, and the distal portion of the intussusceptum showed poor wall enhancement and fluid content, suggestive of ischemia.

A diagnostic laparoscopy confirmed the intussusception at the jejunojejunal anastomosis. Noninvasive reduction was unsuccessful, necessitating conversion to an open surgical approach. During exploratory laparotomy, the distal afferent jejunal loop was found to be gangrenous [Figure 2], and the affected segment was resected.

Figure 2.

Intraoperative photograph showing the gangrenous distal afferent jejunal loop prior to resection

A new jejunojejunal anastomosis and gastrojejunostomy were created [Figure 3], and a surgical drain was placed at the site.

Figure 3.

Intraoperative view after resection, showing the newly created gastrojejunostomy and jejunojejunal anastomosis

The patient had an uneventful postoperative course, with gradual return of bowel function and tolerance of oral intake. He was discharged in stable condition, and follow-up in the outpatient setting revealed no complications. The surgical drain was removed successfully.

DISCUSSION

Roux-en-Y gastrectomy is a widely performed procedure for gastric malignancies, combining restrictive and malabsorptive elements by creating a small gastric pouch and rerouting the small intestine. The jejunojejunal anastomosis connects the biliopancreatic limb to the alimentary limb, allowing ingested food to mix with bile and pancreatic secretions distal to the gastric pouch.[8,9] Although intussusception is a well-recognized complication in pediatric populations, it is rare in adults and even more uncommon following Roux-en-Y gastrectomy, accounting for 5% of all cases of intussusception and almost 1%–5% of bowel obstruction.[10] It most frequently occurs at the jejunojejunal anastomosis, often in a retrograde fashion, and is thought to result from postoperative alterations in intestinal motility, mucosal hypertrophy, or abnormal peristalsis.[2,3,11]

Clinically, patients typically present with acute abdominal pain, nausea, vomiting, and oral intolerance. Most reported cases of postgastrectomy intussusception present within the first 2 years after surgery; however, delayed presentations, sometimes several years postoperatively, have been documented.[3,10] In our patient, the intussusception occurred 6 years after Roux-en-Y gastrectomy, representing an unusually delayed onset. Contrast-enhanced CT is the imaging modality of choice, demonstrating the characteristic “target” sign and allowing assessment of bowel viability.[2,12] In this case, CT revealed a large jejunojejunal intussusception with distal ischemia [Figure 1], which was confirmed intraoperatively [Figure 2].

Management strategies for jejunojejunal intussusception vary depending on intraoperative findings and bowel viability. While some cases may be treated by reduction alone or in combination with enteropexy, resection of the affected segment with reconstruction is generally associated with the most favorable outcomes and the lowest recurrence rates, reported around 22%.[13] Previously reported cases often involved smaller intussusceptums that could be reduced without resection,[14,15] whereas our patient had a large ischemic segment necessitating resection and reconstruction of both the jejunojejunal anastomosis and gastrojejunostomy [Figure 3]. This highlights the spectrum of severity and the importance of individualized surgical management.

This case underscores several key points for clinical practice. First, intussusception can occur as a delayed complication, even years after Roux-en-Y gastrectomy. Second, prompt imaging with CT is essential for diagnosis and surgical planning. Third, the presence of bowel ischemia mandates timely resection to prevent morbidity. Finally, awareness of this rare entity is critical for clinicians evaluating postoperative patients with acute abdominal symptoms, as early recognition and appropriate intervention significantly improve outcomes. By comparing our experience with previously reported cases, this report contributes valuable insight into the presentation, management, and potential complications of jejunojejunal intussusception after Roux-en-Y gastrectomy.

CONCLUSION

Jejunojejunal intussusception is a rare but potentially serious complication following Roux-en-Y gastrectomy. Although most cases occur within the first 2 years postoperatively, delayed presentations, as seen in our patient 6 years after surgery, can occur. Clinicians should maintain a high index of suspicion in postoperative patients presenting with acute abdominal pain, nausea, vomiting, or oral intolerance. Contrast-enhanced CT is the diagnostic modality of choice, and prompt surgical intervention, including resection and reanastomosis when ischemia is present, is essential to prevent morbidity. This case highlights the importance of early recognition, timely imaging, and individualized surgical management in optimizing patient outcomes following delayed post-gastrectomy intussusception.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form, the patient has given his consent for his images and other clinical information to be reported in the journal. The patient understands that name and initials will not be published, and due efforts will be made to conceal identity, but anonymity cannot be guaranteed.

Conflicts of interest

There are no conflicts of interest.

Funding Statement

Nil.