* 3rd General Surgery Clinic, University of Medicine and Pharmacy Craiova, Romania* 3rd General Surgery Clinic* 2nd Medical Clinic
Introduction
Jejunogastric intussusception (JGI) is an extremely rare complication of stomach surgery, following the gastrojejunostomy (GJS), gastric resection type Billroth II and, exceptionally, the GJS with " a-la Roux" Y loop that may appear any time after surgical intervention, ranging from 6 days to 20 years (1). While in children it is idiopathic, being the second cause of surgical emergence after the acute apendicitis, in adults it is secondary to a previous pathological condition (2). The early diagnosis and the immediate surgical intervention are mandatory because mortality is more than 50% if the intervention is made in more than 48 hours after admission (1).
Case report
Young female, 32 years old, who had been operated 12 years ago for a gastroduodenal disease that she didn't know many details about. She presented severe pain in the superior abdominal segment posteriorly iradiated, incoercible
nausea followed by hematemesis that had started few hours before. The clinical examination showed: patient with
moderate weight deficit, agitated, pale teguments, intense sweat, tachicardic, unable to find an antialgic position; abdomen with xifo-umbilical median scar, flat, swelling out temperately in epigastrium, painful in the superior segment where a soft, imprecise and relatively motile tumour was delimited. The biological explorations and the simple abdominal radiography are completed by an echography that shows a well-vascularized large-sized tumour along the projection area of the stomach that couldn't be defined as being intra- or retrogastric. We applied gastric suction,
perfusions with antispastics, antisecretives and pain killers, without influencing the symptomatology. The emergence endoscopy presented a huge intragastric tumour that was bleeding diffusely on the whole area and couldn't be
surpassed with the endoscope. Because the hematemesis and the permanent intense pain, not even influenced by mialgin, dominated the clinical image, a surgical intervention was made and we noticed: moderate adherent process in the supramesocolic segment but with no trace of the previous intervention at the level of stomach or duodenum. The
stomach presented a soft, motile and large-sized tumour; the examination of the posterior side of the stomach revealed a transmesocolic GJS and the efferent loop was retrogradely invaginated (Fig. 1, 2). An anterior gastrotomy was made: the surface of the tumour was a congested jejunal mucous membrane bleeding diffusely and the general aspect confirmed the JGI (Fig. 3, 4). We succeeded in reducing it, the invaginated loop of 50-55 cm. being viable (Fig. 5, 6). The endo- and extraluminal examination of the stomach and duoden showed no modification. For that reason the anastomosis was eliminated and instead of it we made minimal enterectomy with termino- terminal entero- enterostomy as well as prior and subsequent gastroraphy. The evolution was simple and the patient left the hospital after a week.
Discussion
If the first GJS was made in 1881 by Woeffler and the first gastric resection followed by GJS, in 1885, by Billroth, only in 1914 Bozzi reported the first JGI after GJS and only after 25 years, in 1940, Lundberg reported the first JGI after Billroth II resection (1,2). The cases presented, under 200, isolated or in very small series, have as a structure 13 JGI after GJS to 1 after Billroth II resection.
Although such interventions are quite frequent only 70 cases have been reported in MEDLINE for the last 30 years and Mayo Clinic has reported only 16 well-documented cases for the last 72 years (1, 2, 3, 4).
In 1940, at the proposal of Shackman, three anatomic types were described: type I, anterograde, regarding the afferent loop; type II, retrograde, regarding the efferent loop; type III, combined, regarding both loops (6). Type II is the most frequent (80%), the other two being present in about 10% cases each. (1, 2, 3, 4). The case presented
herein is of type II.
From the clinical point of view the JGI has two forms: acute- fulminating and chronic- intermittent (7). In the acute form, the strangling of the invaginated loop is characterized by atrocious pain in the epigastrium, posteriorly iradiated, incoercible nausea followed by hematemesis; when the abdomen was examined, in 50% of cases, a soft, relatively motile and extremely painful tumour mass in the epigastrium was felt. So, by summing up the described symptoms and signs we obtained a triad characteristic to the acute
JGI: epigastric pain with sudden admission, incoercible vomiting followed by hematemesis and tumoral epigastric mass in a patient with GJS. This typical picture was absolutely identical with the reported case. In the chronic form, the symptomatology is similar but more discrete and improves spontaneously, belonging rather to the postgastrectomy syndrom.
The causes of JGI haven't been completely cleared up and understood so far. Lots of factors were held responsible: long afferent loop, jejunal spasms with abnormal motility, gastric atony if associated to vagotomy, sudden increase of intraabdominal pressure and retrograde peristaltis. This approach, in the case of type II JGI, seems to have been accepted by many authors (1, 2, 3, 4, 5).
The certainty exploration for an early diagnosis is the endoscopy but it must be made by a professional inured to the characteristic image of the invaginated loop (8).
We could as well talk about the eso-gastric barium
passage, abdominal CT-scan and ultrasonography but all these are non-characteristic and may delay the surgical intervention.
For the case reported, the explorations - although
suggestive for the diagnosis- together with the symptomatology and the emergence laparotomy led to the decision of saving the invaginated and intragastric strangled loop. Most reported cases were not diagnosed before surgery even if they underwent complete examinations (7).
The surgical treatment aims at solving the acute complication and at finding a method for relapse prevention. We may start by reducing the invagination: if the loop is viable we may fix either it or the meso to the parietal peritoneum or mesocolon, we may eliminate it if not justified (such was the case reported) or we may transform it in a new GJS,
ideally using a Roux-en-Y reconstruction or Pean-Billroth I; loop resection, if not viable, and a new reconstruction as in previous cases (1, 2, 3, 4, 5, 6, 7, 8).
The relapses after surgical reduction were very rare, only three cases having been reported by Hamilton (1923), Hublin (1951) and Douglas (1954).
Conclusions
An exceptional complication of gastric surgery, JGI may appear any time after JGS. The acute form is an emergence asking for an early diagnosis and immediate intervention.
The triad epigastric pains- incoercible vomiting
followed by hematemesis- epigastric tumour in a patient operated for a gastroduodenal disease is obviously suggestive for the diagnosis.
The high digestive endoscopy is the elective exploration for the diagnosis but it must be made by an experienced professional able to recognize the image.
The options for the therapeutic conduct after reducing the invaginated loop and evaluating its viability are meant either to fix the loop to the adjacent structures or to
eliminate or change the GJS; the ideal situation would be T-T Pean-Billroth I gastroduodenostomy or GJS, using a Roux-en-Y reconstruction.
References
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