2625 Intussusception After Classic Pancreaticoduodenectomy With a Roux-en-Y Pancreatico-hepaticojejunostomy

Abstract

INTRODUCTION: Intussusception in adults is uncommon, accounting for 1%–5% of all intussusception cases. It usually occurs because of a lead point, frequently malignancy or adhesions from previous surgery. Here we report an exceedingly rare case of jejunal intussusception into the gastric lumen in a patient after classic pancreaticoduodenectomy with a Roux-en-Y pancreatico-hepaticojejunostomy. CASE DESCRIPTION/METHODS: A 49 year-old male with Down syndrome, celiac disease and surgical history significant for classic pancreaticoduodenectomy (Whipple procedure) with a Roux-en-Y pancreatico-hepaticojejunostomy for pancreatic mass with distal bile duct stricture and duodenal stricture presented with one-day history of abdominal pain. He was minimally verbal due to Down's syndrome however pointed to his upper and lower abdomen. Associated symptoms included mild nausea but no emesis, melena or hematochezia. Abdominal examination was negative for any mass or peritoneal signs. Initial labs were remarkable for only mild anemia; while blood cell count and lactic acid were normal. A CT scan demonstrated an approximately 7-cm length of jejunum protruding into the lumen of the stomach at the gastrojejunostomy site concerning for intussusception, but no high-grade mechanical obstruction observed. EGD showed intussusception of the blind jejunal limb with healthy appearing mucosa and jejunum biopsies were obtained to rule out ischemia; examination of gastrojejunal anastomotic site and the jejunum (efferent limb) was otherwise normal. Endoscopic reduction of intussusception was attempted but was unsuccessful. Remaining hospital course was uneventful. He was tolerating diet, having proper bowel movements and his abdominal pain resolved. No surgical intervention for repair was planned as he continued to improve clinically and he was safely discharged home. He was seen in surgery clinic a few months later and remained asymptomatic. DISCUSSION: Intussusception is a rare entity in adults and only a few cases have been reported after Whipple procedure. Diagnosis of intussusception in adults, regardless of previous surgeries, is primarily through imaging because presenting symptoms are often vague and nonspecific. Surgical management is often required. However, in our patient, due to the absence of bowel obstruction or ischemia, surgical intervention was not needed. This case highlights that intussusception should be considered as a potential diagnosis in patients with history of Whipple presenting with vague abdominal symptoms.