2-Case presentation
A 19-year-old woman with a BMI of 47 (137 kg weight and 172 cm height) underwent classic gastric bypass surgery. The procedure was done in a standard method with 5 ports. Gastric pouch was created by three 60 mm Endo-GI purple staplers, gastrojejunal anastomosis was about 2 cm with an alimentary limb of 130 cm, and a biliopancreatic limb of 70 cm. Peterson and jejunojejunal defects closed completely.
Diet was started for her the next day, and she was discharged the second day after surgery in a stable condition with instructions to have regular post-op follow-ups. She weighed 109 kg and 93 kg at three and six months post-operation follow-ups, respectively. Iron deficiency anemia was detected in routine lab tests, and iron supplements were prescribed for her. Following her six-month follow-up, she presented with low-intensity colicky abdominal pain episodes after food ingestion that were resolved spontaneously after a few minutes. However, she neglected the painful episodes as they were self-limited.
Nine months after the surgery, she was admitted to the hospital due to 2 episodes of massive fresh bloody vomitting and abdominal pain (worse than her previous pains). Her vital signs were stable upon admission and she had a low intense colic pain in the left upper quadrant without tenderness. She was scheduled for an upper gastrointestinal endoscopy which showed a marginal ulcer at the site of the anastomosis without active bleeding. The next day her abdominal pain worsened and upper abdominal tenderness developed during her physical examination. Her laboratory data showed elevated white blood cells from 8500 /micL to 12000 /micL and a decreased hemoglobulin concentration from 11 gr/dl to 10.5 gr/dl. An abdominal and pelvic computed tomography (CT) scan with contrast was done, which showed distention in a small bowl lumen with a target sign (Figures 1,2 and 3).
With suspicion of intestinal obstruction and intussusception, the patient underwent laparotomy. Her surgical findings were retrograde intussusception of the common channel at the jejunojejunal anastomosis site with severe edema of the small intestine, which made bowel reduction impossible due to intestinal patchy necrosis. Consequently, the beginning of the common channel and the jejunojejunal anastomosis site was resected, and anastomosis of the alimentary limb to the common channel and the biliopancreatic limb to common channel was re-established in a side to side manner.