Intussusception after Gastric Surgery

• Introduction
• Etiology and Pathophysiology
• Clinical Manifestations (Table 1)
• Diagnosis (Table 2)
• Treatment
• Conclusion
• References

Intussusception following gastric surgery is a rare postoperative complication. It may develop in clinical situations following gastroenterostomy, Billroth II gastric surgery with or without Braun anastomosis, or Roux-en-Y gastrojejunostomy. The patients may present with either an acute surgical emergency or with a chronic, relapsing form. The mortality may be up to 50 % in these cases if not treated appropriately, but little is known about the mechanism underlying the condition. Early diagnosis with a high index of suspicion and prompt treatment of the acute form are therefore important. Surgical reduction with laparotomy is mandatory, although definitive corrective and preventative measures have not yet been established.

Introduction

Intussusception can be defined as the invagination of a segment of the gastrointestinal tract into the lumen of an adjacent segment. Intussusception is uncommon in adults, in whom it accounts for only 5 % of cases and only 1 % of cases of intestinal obstruction [1]. Postoperative intussusception in adults is considered to be an extremely rare clinical entity, although it has recently been reported as a complication after gastric surgery [2]. Postoperative jejunogastric intussusception was first described in a patient with gastrojejunostomy in 1914 by Bozzi [3]. Fewer than 200 cases of postoperative intussusception have been reported in the English-language literature since then [2] [4] [5] [6] [7] [8] [9] [10] [11] [12] [13] [14] [15] [16] [17]. The reported incidence is under 0.1 % in patients who undergo gastric resection [9]. However, early diagnosis and prompt surgical intervention are mandatory due to the high mortality rate. Physicians treating patients with a medical history of gastric surgery should be aware of this clinical entity in order to avoid fatal consequences.

To review the topic of intussusception after gastric surgery, a PubMed search was conducted using several terms, including “jejunogastric intussusception,” “jejunojejunal intussusception,” “postoperative intussusception,” and “gastric surgery or resection.” The English-language literature was reviewed, and the results with regard to the pathophysiology, clinical manifestations, diagnosis, and treatment of the condition are presented below.

Etiology and Pathophysiology

In contrast to other types of intussusception in adults, which usually have a clear etiology, definite anatomic or pathologic causes are rarely found in cases following gastric surgery [6] [8] [9]. Intussusception can occur at any time after gastric surgery, varying from 6 days to 18 years postoperatively, with an average of 6 years in the acute form and from 5 days to up to 14 years in the chronic form [6].

The condition usually develops after gastrojejunostomy, although it may occur following Roux-en-Y gastrojejunostomy, esophagojejunostomy, or even partial or total gastric resection [2]. The risk of intussusception after gastrojejunostomy is as high as 13 times the risk of gastrectomy with Billroth II anastomosis [17]. The diameter of the stoma varies from 2 to 5 cm, and the invaginated segment of the jejunum can extend from 4 cm to 2 m [6]. The most common type of intussusception after gastric surgery is retrograde jejunogastric [8]. Anatomically, jejunogastric intussusception can be classified into five types:

• Afferent limb intussusception (type I)

• Efferent limb intussusception (type IIa)

• Efferent-efferent intussusception (type IIb)

• A combination of types I and II (type III)

• Intussusception through a Braun side-to-side jejunojejunal anastomosis (type IV) [10] [11].

Type II represents approximately 80 % of all cases. Types I and III make up about 10 %, and type IV is rare. Among these, type III usually presents as an early complication, and most cases are diagnosed within only a few days after surgery [9]. Cases of jejunojejunal or jejunoduodenal intussusception have been exceptionally reported in patients with total gastrectomy. Only one case of the duodenogastric type was found, in a patient with Billroth I gastrectomy [18].

Little is known about the mechanism for the condition, although a few possible explanations have been proposed. First of all, functional and mechanical causes should be considered [9]. Functional causes include reverse peristalsis, which is triggered by an anastomosed jejunal loop being irritated by hydrochloric acid, and atonic stomach, caused by vagotomy. When the appearance suggests mechanical causes, a variety of postoperative conditions should be considered [2] [4] [6] [7] [8] [9] [11] [17]:1) adhesions due to laparotomy; 2) shortening of the mesentery of the jejunum; 3) the size of the anastomotic orifice; 4) jejunal stenosis with obstruction; 5) a long afferent limb; 6) increased mobility in the efferent limb; 7) an upper jejunum wider than the distal bowel; 8) other mechanical causes that increase intra-abdominal pressure; and 9) use of long gastrostomy tubes [19]. The cause acknowledged as being the likeliest mechanism involved in types I and II is antegrade or retrograde peristalsis, triggered by hyperacidity; local spasm leads to invagination of either the afferent or efferent loops into the stomach or jejunum [2] [6]. After the initial invagination, peristalsis or reverse peristalsis continues to push the intussuscepting jejunum toward the stoma. One study described antegrade or retrograde intussusception, although these episodes were commonly transient and subclinical [20]. It has been suggested that the mechanism for type III - combined invagination - is different from the others. Gastrospasm or a reduction in pressure due to vomiting is thought to be a primary factor, while intussusception itself is more secondary [6].

As mentioned above, jejunojejunal intussusception is extremely rare after gastrojejunostomy [6] [7]. It occurs commonly following Roux-en-Y anastomosis, but may also develop in situations without a Roux-en-Y anastomosis [12] [14]. Initially, construction of the Roux limb separates at least 40 cm of intestine from the small-bowel pacemaker located in the duodenal bulb. The Roux limb becomes an isolated 40-cm segment of jejunum that is not under adequate myoelectric control. As a result of its isolation, the Roux limb lacks normal myoelectric activity, which is often dysfunctional as it is split and retrograde, and of high amplitude [21]. A study using radionuclide scanning showed that gastric emptying in patients who had undergone vagotomy and Roux-en-Y anastomosis was significantly delayed in the Roux limb [22]. The phenomenon is also influenced by the alternating release of duodenal peptides, which regulate intestinal motility, and by vagotomy [23]. A combination of these etiological factors can result in atony and dilation of the Roux limb, together with reverse peristalsis and subsequently intussusception [12].

Clinical Manifestations (Table [1])

The clinical manifestations vary, depending on the anatomic type of intussusception and whether it is acute or chronic. Clinically, two forms of intussusception after gastric surgery have been recognized: an acute form and a chronic, recurrent form [6]. The acute form presents with the picture of a high degree of intestinal obstruction. It is therefore a surgical emergency that can rapidly progress to peritonitis due to early incarceration and strangulation of the involved bowel (Figure [1]). Most cases of acute intussusception involve the efferent limb [2]. The acute form is clinically characterized by acute, severe colicky upper abdominal pain, followed by nausea and vomiting. The vomitus is initially food-tinged, then bile-tinged, and finally bloody. The blood is usually dark red, but may rarely be brightly red-colored. In acute intussusception with a small stoma, early incarceration and strangulation make the intussuscepted jejunal mucosa edematous and necrotic; this is followed by bleeding, in which spontaneous reduction becomes unlikely [7]. As the jejunal blood supply is compromised by complete obstruction, the emesis becomes bloody. A tender mass may be palpable in the left upper abdomen in approximately 50 % of the cases, and peristalsis may also be observed [8].

By contrast, the chronic form of intussusception can be characterized by recurrent episodes of vague epigastric pain, exacerbated by meals, and in particular by postprandial fullness, with intermittent nausea and vomiting [2]. The pain can persist for 60 - 90 min after meals and is relieved when the intussuscepted bowel reduces spontaneously [11]. Characteristically, the patient feels better when the stomach is empty after vomiting. Hematemesis is rare unless complete obstruction of the intussuscepted bowel occurs [8]. Attacks occur at irregular intervals, and the frequency can vary from daily to several years. The chronic recurrent form may sometimes present acutely, or may result in severe chronic disability, vague abdominal pain, and malnutrition. Clinical manifestations of the chronic form are similar to those of the acute form but milder, more transient, and recurrent. In the chronic form, the afferent limb is more commonly involved, and intermittent intussusception with spontaneous reduction is frequent, particularly in patients with a wide stoma (Figure [2]) [2] [15] [17]. The diagnosis of the chronic form is often difficult to establish, as radiographic and endoscopic examinations are usually carried out during the asymptomatic stage or after reduction of the intussuscepted jejunum [2] [11].

It is sometimes difficult to distinguish between a temporary event caused by heavy belching during endoscopy and an intermittent intussusception. One differentiating criterion is that patients who have a temporary event with heavy belching during endoscopy have not usually experienced obstructive symptoms yet. Endoscopic or radiographic studies may be helpful in rare situations, where they reveal intussusception followed by spontaneous reduction (Figure [2]). In particular, the symptoms of intussusception disappear at the same time as spontaneous reduction. In addition, secondary mucosal changes such as hyperemia, edema, erosions, and a slight bluish discoloration are more common in chronic intussusception than temporary events caused by heavy belching in gastroscopic examinations. Nevertheless, the patient’s previous clinical history should be carefully recorded, as the chronic form of postoperative intussusception is in most cases only diagnosed clinically, by correlating the symptoms with the clinical situation.

Diagnosis (Table [2])

Diagnosis is extremely difficult without a high index of suspicion. Plain abdominal radiography is not diagnostic, but occasionally demonstrates a homogeneous mass in the upper abdomen that is outlined by radiolucent stomach gas or intramural air, with advanced ischemia and necrosis (Figure [3]). Contrast radiography is usually diagnostic in the acute form, but is not helpful in the chronic form, as spontaneous reduction usually occurs [8] [24]. However, in the chronic form, a barium examination may help physicians establish a diagnosis of obstruction (Figure [4]). Typical findings in barium studies are a classic coiled-spring appearance or filling defects parallel to curved lines of intestinal folds within the gastric pouch or enteroanastomotic loop [6]. In chronic intussusception, the radiographic findings differ in that the intussuscepted mass is usually smaller than in the acute form. For the best diagnosis of the condition, the barium studies have to be carried out with the patient lying in a steep Trendelenburg position. With resumption of the erect position, the effect of gravity is usually sufficient to reduce the intussusception [8]. However, the role of contrast radiography studies in decision-making is declining today, as it is not practically helpful in the setting of acute, surgical abdomen, and the condition frequently remains undetected on barium studies.

Transabdominal ultrasonography can be helpful for diagnosing intussusception, particularly in children [25]. The thickest component of the intussusception (the donor loop) is the everted returning limb, which forms the hypoechoic outer ring seen on axial scans together with the thin intussuscipiens (the receiving loop). The center of the intussuscepted bowel contains the entering limb, which is of normal thickness and eccentrically surrounded by the hyperechoic mesentery (the target or bull’s-eye sign). Using color Doppler ultrasonography, it is possible to evaluate whether or not the vasculature in the compressed layer of mesentery between the intussusceptum and intussuscipiens is compromised or not [25].

Upper gastrointestinal endoscopy and abdominal computed tomography are highly diagnostic [15] [17]. Gastroduodenoscopy usually discloses a bulky, lobulated, reddish-bluish mass of the bowel within the lumen of the stomach or enteroanastomotic loop, and occasionally dark red blood [15] [17] [26] [27] [28]. In patients with hematemesis or melena, endoscopy is the procedure of choice for evaluating the causes of upper gastrointestinal bleeding, and if it discloses intussuscepted bowel within the lumen of the stomach or enteroanastomotic loop, endoscopy can be diagnostic (Figure [1], [2]) [17] [27] [28]. Since a jejunogastric intussusception can be misidentified as intragastric clots, meticulous attention is required [27]. The chronic form of intussusception may be undetectable if endoscopy or contrast radiography examinations are conducted during asymptomatic periods (Figure [2]) [8] [11] [24]. In such cases, intussusception can be provoked by jejunal reverse peristalsis and subsequent intussusception, using a jet of water directed toward the anastomosis stoma during the endoscopic procedure [24]. However, there is no diagnostic standard for chronic intussusception, as the examinations are usually carried out during asymptomatic periods. The diagnosis of chronic intussusception therefore needs to be considered in patients with recurrent symptoms of vague abdominal pain and intermittent vomiting that spontaneously subside for long periods after gastric surgery.

Abdominal CT is not only a relatively safe and noninvasive method, but is also useful for evaluating other causes of acute abdomen. Abdominal CT is currently the most useful tool for diagnosing intussusception [29]. Abdominal CT is useful for establishing the level of the obstruction, demonstrating whether or not an associated malignancy is present, and assessing the viability of the intussuscepted bowel [29] [30]. Depending on the time that has elapsed since the intussusception occurred, CT shows various radiographic appearances. The early stage is characterized by the presence of what is known as a target mass, consisting of edematous bowel wall and mesentery within the lumen. As the intussusception progresses, a layering pattern, thickened edematous bowel with loss of the layering pattern, extensive bowel thickening and loss of fascial planes, and subsequently gangrene, perforation, and pneumoperitoneum appear [30]. If the condition is advanced, the CT findings in the chronic form are similar to those in the acute form (Figure [5]).

Intussusception after gastric surgery should be differentiated from other more common conditions that have similar symptoms, such as marginal ulcer, anastomotic leakage, adhesive bands, internal herniation, volvulus, pancreatitis, postoperative adynamic ileus, intestinal ischemia, primary malignant tumor of the small bowel, esophagitis, and dumping syndrome. If the patient presents with hematemesis, other conditions causing upper gastrointestinal bleeding, such as peptic ulcer, Mallory-Weiss syndrome, and recurrent malignant tumor, should be carefully excluded [2] [6] [16].

Treatment

The treatment of postoperative intussusception after gastric surgery remains controversial and should be individualized for each patient [2] [11]. Various surgical techniques, including simple manual reduction of the jejunal intussusceptum, resection of the intussusceptum, depending on the viability of the bowel, revision of the anastomosis, and take-down of the anastomosis, have been used [2] [6] [7] [8] [9] [11]. Until recently, there has been no standard curative and preventative measure. It is, however, clear that surgical intervention should be carried out as soon as possible to avoid more severe complications, such as bowel perforation, and to reduce the mortality (Figure [6]). Generally, the surgical mortality rate in acute intussusception increases in proportion to the interval between the onset of symptoms and laparotomy. According to reports, the mortality is less than 10 % if surgery is carried out within 48 h after the onset of symptoms, but as high as 50 % if delayed [4]. When the intussuscepted bowel is reducible and viable at laparotomy, simple reduction alone can be carried out (Figure [7], [8]) [2] [7] [8] [11]. During manual reduction, pushing the mass through the stoma is safer than pulling it from the small-bowel side. If the bowel is nonviable, it should be partially resected.

In the chronic form, elective surgery is usually indicated only in patients who are severely disabled or malnourished due to frequent attacks [2] [8]. However, some authors have argued that surgery should be considered as the primary treatment in all cases of the chronic form, due to the possibility of incarcerated intussusceptum. Indeed, a major risk in the chronic form is that acute incarceration or intestinal infarction may occur. In some reports, almost 70 % of patients with the chronic form developed acute intussusception, requiring emergency surgery [24].

Intussuscepted jejunum can be successfully reduced endoscopically in a few selected cases [31]. Endoscopic management consists of reduction of the intussusception, followed by placement of a feeding tube deep in the efferent limb. This technique allows sufficient time for normal peristalsis to occur, whereas adhesions later help anchor the loop in place [32]. However, other reports have suggested that the procedure should only serve as a temporary measure before surgical correction [33]. Because endoscopic management is not widely accepted and is as yet unproved, it should be reserved for selected cases. Chronic intussusception should be corrected immediately, since 70 % of patients present with acute symptoms requiring emergency surgery, and delayed correction results in increased morbidity and mortality [24].

Many procedures have been recommended to prevent recurrence after reduction, including fixation of the jejunum or mesentery to the surrounding tissues, suturing the mesenteric part of the afferent loop together with the efferent loop, revision of the Billroth II anastomosis to a Billroth I anastomosis, and narrowing of the gastroenterostomy stoma [2] [7] [8] [11] [16] [17]. In 1892, Braun suggested that the enteroanastomosis between the jejunal loops that provided drainage for the afferent loop was effective in preventing postoperative intussusception after gastric surgery [9]. However, other reports found that what became known as the “Braun anastomosis” was ineffective as a preventative measure. Toumikowski published a series of 29 patients with gastrojejunal intussusception after gastrojejunostomy, nine of whom had had a Braun anastomosis [9]. This method has therefore now been abandoned. Some surgeons advocate gastric resection if the process has been long-standing and if there is a fear of postoperative gastric atony. Take-down of the anastomosis should be considered if previous simple gastrojejunostomy has been performed [2]. Since postoperative intussusception has rarely occurred after Billroth I anastomosis, some authors have argued that take-down of a previous gastroenteric anastomosis, with revision to a Billroth I anastomosis, should be carried out [11]. There are as yet limited data on the long-term follow-up, so that the long-term efficacy of preventative measures is not currently clear [2] [16] [24]. The choice of treatment should therefore be individualized in accordance with anatomic considerations, the patient’s condition, and the operator’s skills.

Conclusion

Forms of postoperative intussusception such as jejunogastric, jejunoduodenal, or jejunojejunal intussusception are very rare complications after gastric surgery. The classic pentad of acute postoperative intussusception is sudden-onset epigastric pain, vomiting, hematemesis, a palpable epigastric mass, and a high degree of intestinal obstruction. In patients with a history of gastric surgery, the classic symptoms can alert the physician to the possibility of postoperative intussusception. Endoscopy and abdominal CT are extremely helpful in making a diagnosis. Successful management of postoperative intussusception depends on early diagnosis, adequate resuscitation, and prompt surgical correction. Surgical correction should be considered as soon as possible in the majority of patients.

References

• 1 Azar T, Berger D L. Adult intussusception.  Ann Surg. 1997;  226 134-138
  CrossrefPubMedSearch in Google Scholar
• 2 Waits J O, Beart R W, Charboneau J W. Jejunogastric intussusception.  Arch Surg. 1980;  115 1449-1452
  PubMedSearch in Google Scholar
• 3 Bozzi E. Annotation.  Bull Acad Med. 1914;  122 3-4
  PubMedSearch in Google Scholar
• 4 Shackman R. Jejunogastric intussusception.  Br J Surg. 1940;  27 475-480
  CrossrefPubMedSearch in Google Scholar
• 5 Irons H S Jr, Lipin R J. Jejunogastric intussusception following gastroenterostomy and vagotomy.  Ann Surg. 1955;  141 541-546
  PubMedSearch in Google Scholar
• 6 Foster D F. Retrograde jejunogastric intussusception: a rare cause of hematemesis.  Arch Surg. 1956;  73 1009-1017
  PubMedSearch in Google Scholar
• 7 Salem M H, Coffman S E, Postlethwait R W. Retrograde intussusception at the gastrojejunal stoma.  Ann Surg. 1959;  150 864-871
  PubMedSearch in Google Scholar
• 8 Reyelt W P Jr, Anderson A A. Retrograde jejunogastric intussusception.  Surg Gynecol Obstet. 1964;  119 1305-1311
  PubMedSearch in Google Scholar
• 9 Conklin E F, Markowitz A M. Intussusception, a complication of gastric surgery.  Surgery. 1965;  57 480-488
  PubMedSearch in Google Scholar
• 10 Gundersen S, Cogbill T. Acute jejunogastric intussusception.  Am Surg. 1985;  51 511-513
  PubMedSearch in Google Scholar
• 11 Wheatly M J. Jejunogastric intussusception diagnosis and management.  J Clin Gastroenterol. 1989;  11 452-454
  PubMedSearch in Google Scholar
• 12 Gerst P H, Iyer S, Murthy R M, Albu E. Retrograde intussusception as a complication of Roux-en-Y anastomosis.  Surgery. 1991;  110 717-719
  PubMedSearch in Google Scholar
• 13 O’Dell K B, Gordon R S, Victory C. Acute jejunogastric intussusception: a rare cause of abdominal pain.  Ann Emerg Med. 1992;  21 565-567
  PubMedSearch in Google Scholar
• 14 Loizou M C, Koundourakis S S, Kollias V D. et al . Jejunojejunal intussusception after Roux-en-Y gastrojejunostomy: a rare complication of postoperative bowel obstruction in an adult.  Eur J Surg. 1994;  160 451-452
  PubMedSearch in Google Scholar
• 15 Archimandritis A J, Hatzopoulos N, Hatzinikolaou P. et al . Jejunogastric intussusception presented with hematemesis: a case presentation and review of the literature.  BMC Gastroenterol. 2001;  1 1
  CrossrefPubMedSearch in Google Scholar
• 16 Ren P L, Huang J C, Shin J S. et al . Jejunojejunogastric intussusception: a rare intussusception in an adult patient after gastric surgery.  Gastrointest Endosc. 2002;  56 296-298
  CrossrefPubMedSearch in Google Scholar
• 17 Joshi M A, Jambhulkar M I, Balsarkar D. et al . Jejunogastric intussusception: case report and review of the literature.  Digestive Endoscopy. 2004;  16 88-90
  CrossrefPubMedSearch in Google Scholar
• 18 Shiffman M, Rappaport I. Intussusception following gastric surgery.  Am Surg. 1966;  32 715-724
  PubMedSearch in Google Scholar
• 19 Gasparri M G, Pipinos I I, Kralovich K A, Margolin D A. Retrograde jejunogastric intussusception.  South Med J. 2000;  93 499-500
  PubMedSearch in Google Scholar
• 20 Alvarez W C, Hinshaw H C. The length of interval between the eating of a food and the appearance of distress caused thereby.  Proc Staff Meet Mayo Clin. 1935;  10 103-105
  PubMedSearch in Google Scholar
• 21 Mathias J R, Fernandez A, Sninsky C A. et al . Nausea, vomiting and abdominal pain after Roux-en-Y anastomosis: motility of the jejunal limb.  Gastroenterology. 1985;  88 101-107
  PubMedSearch in Google Scholar
• 22 Vogel S B, Hocking M P, Woodward E R. Radionuclide evaluation of gastric emptying in patients undergoing Roux-en-Y biliary diversion for alkaline reflux gastritis and postgastrectomy dumping.  Surg Forum. 1983;  34 173-175
  PubMedSearch in Google Scholar
• 23 Herrington J L Jr, Scott H W Jr, Sawyers J L. Experience with vagotomy, antrectomy, and Roux-en-Y gastrojejunostomy in surgical treatment of duodenal, gastric and stomal ulcers.  Ann Surg. 1984;  199 590-597
  PubMedSearch in Google Scholar
• 24 Czerniak A, Bass A, Bat L. et al . Jejunogastric intussusception: a new diagnostic test.  Arch Surg. 1987;  122 1190-1192
  PubMedSearch in Google Scholar
• 25 Littlewood Teele  R, Vogel S A. Intussusception: the paediatric radiologist’s perspective.  Pediatr Surg Int. 1998;  14 158-162
  CrossrefPubMedSearch in Google Scholar
• 26 Lee D WH, Lau J YW, Chan A CW. et al . Endoscopic diagnosis of retrograde jejunojejunal intussusception.  Endoscopy. 1996;  28 325
  PubMedSearch in Google Scholar
• 27 Brynitz S, Rubinstein E. Hematemesis caused by jejunogastric intussusception.  Endoscopy. 1986;  18 162-164
  PubMedSearch in Google Scholar
• 28 Mele C D, Porayko M K. Jejunogastric intussusception, an indication for emergent endoscopy: case report.  Gastrointest Endosc. 2003;  57 593-595
  PubMedSearch in Google Scholar
• 29 Takeuchi K, Tsuzuki Y, Ando T. et al . The diagnosis and treatment of adult intussusception.  J Clin Gastroenterol. 2003;  36 18-21
  CrossrefPubMedSearch in Google Scholar
• 30 Merine D, Fishman E K, Jones B, Siegelman S S. Enteroenteric intussusception: CT findings in nine patients.  AJR Am J Roentgenol. 1987;  148 1129-1132
  PubMedSearch in Google Scholar
• 31 Saxena R, Kochhar R, Nagi B. et al . Non-surgical treatment of jejunogastric intussusception.  Surg Endosc. 1988;  2 88-91
  CrossrefPubMedSearch in Google Scholar
• 32 Kochhar R, Saxena R, Nagi B. et al . Endoscopic management of retrograde jejunogastric intussusception.  Gastrointest Endosc. 1988;  34 56-57
  CrossrefPubMedSearch in Google Scholar
• 33 Guadagni S, Pistoia M, Catarci M. et al . Surgical treatment of retrograde jejunogastric intussusception after temporary endoscopic management.  Endoscopy. 1991;  23 243-244
  PubMedSearch in Google Scholar

M. K. Jang, M. D.

Dept. of Internal Medicine · Kangdong Sacred Heart Hospital

445, Gildong, Kangdong-gu · Seoul 134-701 · Republic of Korea

Fax: +82-2-478-6925

Email: mkjang2@medimail.co.kr

References

• 1 Azar T, Berger D L. Adult intussusception.  Ann Surg. 1997;  226 134-138
  CrossrefPubMedSearch in Google Scholar
• 2 Waits J O, Beart R W, Charboneau J W. Jejunogastric intussusception.  Arch Surg. 1980;  115 1449-1452
  PubMedSearch in Google Scholar
• 3 Bozzi E. Annotation.  Bull Acad Med. 1914;  122 3-4
  PubMedSearch in Google Scholar
• 4 Shackman R. Jejunogastric intussusception.  Br J Surg. 1940;  27 475-480
  CrossrefPubMedSearch in Google Scholar
• 5 Irons H S Jr, Lipin R J. Jejunogastric intussusception following gastroenterostomy and vagotomy.  Ann Surg. 1955;  141 541-546
  PubMedSearch in Google Scholar
• 6 Foster D F. Retrograde jejunogastric intussusception: a rare cause of hematemesis.  Arch Surg. 1956;  73 1009-1017
  PubMedSearch in Google Scholar
• 7 Salem M H, Coffman S E, Postlethwait R W. Retrograde intussusception at the gastrojejunal stoma.  Ann Surg. 1959;  150 864-871
  PubMedSearch in Google Scholar
• 8 Reyelt W P Jr, Anderson A A. Retrograde jejunogastric intussusception.  Surg Gynecol Obstet. 1964;  119 1305-1311
  PubMedSearch in Google Scholar
• 9 Conklin E F, Markowitz A M. Intussusception, a complication of gastric surgery.  Surgery. 1965;  57 480-488
  PubMedSearch in Google Scholar
• 10 Gundersen S, Cogbill T. Acute jejunogastric intussusception.  Am Surg. 1985;  51 511-513
  PubMedSearch in Google Scholar
• 11 Wheatly M J. Jejunogastric intussusception diagnosis and management.  J Clin Gastroenterol. 1989;  11 452-454
  PubMedSearch in Google Scholar
• 12 Gerst P H, Iyer S, Murthy R M, Albu E. Retrograde intussusception as a complication of Roux-en-Y anastomosis.  Surgery. 1991;  110 717-719
  PubMedSearch in Google Scholar
• 13 O’Dell K B, Gordon R S, Victory C. Acute jejunogastric intussusception: a rare cause of abdominal pain.  Ann Emerg Med. 1992;  21 565-567
  PubMedSearch in Google Scholar
• 14 Loizou M C, Koundourakis S S, Kollias V D. et al . Jejunojejunal intussusception after Roux-en-Y gastrojejunostomy: a rare complication of postoperative bowel obstruction in an adult.  Eur J Surg. 1994;  160 451-452
  PubMedSearch in Google Scholar
• 15 Archimandritis A J, Hatzopoulos N, Hatzinikolaou P. et al . Jejunogastric intussusception presented with hematemesis: a case presentation and review of the literature.  BMC Gastroenterol. 2001;  1 1
  CrossrefPubMedSearch in Google Scholar
• 16 Ren P L, Huang J C, Shin J S. et al . Jejunojejunogastric intussusception: a rare intussusception in an adult patient after gastric surgery.  Gastrointest Endosc. 2002;  56 296-298
  CrossrefPubMedSearch in Google Scholar
• 17 Joshi M A, Jambhulkar M I, Balsarkar D. et al . Jejunogastric intussusception: case report and review of the literature.  Digestive Endoscopy. 2004;  16 88-90
  CrossrefPubMedSearch in Google Scholar
• 18 Shiffman M, Rappaport I. Intussusception following gastric surgery.  Am Surg. 1966;  32 715-724
  PubMedSearch in Google Scholar
• 19 Gasparri M G, Pipinos I I, Kralovich K A, Margolin D A. Retrograde jejunogastric intussusception.  South Med J. 2000;  93 499-500
  PubMedSearch in Google Scholar
• 20 Alvarez W C, Hinshaw H C. The length of interval between the eating of a food and the appearance of distress caused thereby.  Proc Staff Meet Mayo Clin. 1935;  10 103-105
  PubMedSearch in Google Scholar
• 21 Mathias J R, Fernandez A, Sninsky C A. et al . Nausea, vomiting and abdominal pain after Roux-en-Y anastomosis: motility of the jejunal limb.  Gastroenterology. 1985;  88 101-107
  PubMedSearch in Google Scholar
• 22 Vogel S B, Hocking M P, Woodward E R. Radionuclide evaluation of gastric emptying in patients undergoing Roux-en-Y biliary diversion for alkaline reflux gastritis and postgastrectomy dumping.  Surg Forum. 1983;  34 173-175
  PubMedSearch in Google Scholar
• 23 Herrington J L Jr, Scott H W Jr, Sawyers J L. Experience with vagotomy, antrectomy, and Roux-en-Y gastrojejunostomy in surgical treatment of duodenal, gastric and stomal ulcers.  Ann Surg. 1984;  199 590-597
  PubMedSearch in Google Scholar
• 24 Czerniak A, Bass A, Bat L. et al . Jejunogastric intussusception: a new diagnostic test.  Arch Surg. 1987;  122 1190-1192
  PubMedSearch in Google Scholar
• 25 Littlewood Teele  R, Vogel S A. Intussusception: the paediatric radiologist’s perspective.  Pediatr Surg Int. 1998;  14 158-162
  CrossrefPubMedSearch in Google Scholar
• 26 Lee D WH, Lau J YW, Chan A CW. et al . Endoscopic diagnosis of retrograde jejunojejunal intussusception.  Endoscopy. 1996;  28 325
  PubMedSearch in Google Scholar
• 27 Brynitz S, Rubinstein E. Hematemesis caused by jejunogastric intussusception.  Endoscopy. 1986;  18 162-164
  PubMedSearch in Google Scholar
• 28 Mele C D, Porayko M K. Jejunogastric intussusception, an indication for emergent endoscopy: case report.  Gastrointest Endosc. 2003;  57 593-595
  PubMedSearch in Google Scholar
• 29 Takeuchi K, Tsuzuki Y, Ando T. et al . The diagnosis and treatment of adult intussusception.  J Clin Gastroenterol. 2003;  36 18-21
  CrossrefPubMedSearch in Google Scholar
• 30 Merine D, Fishman E K, Jones B, Siegelman S S. Enteroenteric intussusception: CT findings in nine patients.  AJR Am J Roentgenol. 1987;  148 1129-1132
  PubMedSearch in Google Scholar
• 31 Saxena R, Kochhar R, Nagi B. et al . Non-surgical treatment of jejunogastric intussusception.  Surg Endosc. 1988;  2 88-91
  CrossrefPubMedSearch in Google Scholar
• 32 Kochhar R, Saxena R, Nagi B. et al . Endoscopic management of retrograde jejunogastric intussusception.  Gastrointest Endosc. 1988;  34 56-57
  CrossrefPubMedSearch in Google Scholar
• 33 Guadagni S, Pistoia M, Catarci M. et al . Surgical treatment of retrograde jejunogastric intussusception after temporary endoscopic management.  Endoscopy. 1991;  23 243-244
  PubMedSearch in Google Scholar

M. K. Jang, M. D.

Dept. of Internal Medicine · Kangdong Sacred Heart Hospital

445, Gildong, Kangdong-gu · Seoul 134-701 · Republic of Korea

Fax: +82-2-478-6925

Email: mkjang2@medimail.co.kr