LAUSR

We present a rare case of recurrent retrograde gastrojejunal intussusception post gastric bypass with a failure of non-revisional management. A 61-year-old man presented with severe epigastric pain and vomiting. A CT abdomen demonstrated recurrent gastrojejunal intussusception (Fig. 1). This presentation occurred 18 months following a laparoscopic loop gastrojejunostomy. This was undertaken for distal duodenal obstruction caused by post-operative adhesions from an aneurysmal sac after emergency open abdominal aortic aneurysm repair. Conservative management was trialled, although the patient had multiple admissions with recurrent obstruction over a 5-month period. The patient then underwent a laparoscopic division of adhesions which was unsuccessful in definitively relieving the obstruction. Due to the patient’s non-resolving obstruction, and after considering options such as a PEG/PEJ, an operative bypass was chosen as the most appropriate management. A loop gastrojejunostomy was created with a laparoscopic linear stapler and two layered sutured closure of the anterior wall of the anastomosis. Unfortunately, following this, he had three presentations with retrograde gastrojejunal intussusception. The first episode of gastro-jejunal intussusception occurred 9 months post-operatively and was managed with endoscopic decompression alone. Contrast was injected into the jejunum intraoperatively to confirm reduction of the intussusception. The second episode occurred 14 months post the bypass. CT imaging demonstrated gastrojejunal intussusception. A gastroscopy demonstrated no intussusception, but congested jejunal mucosa, and a moderate volume of blood in the stomach. A laparotomy confirmed no intussusception and viable small bowel. Some upper abdominal adhesions were divided, and the mesenteric defect was closed. Operative findings were consistent with a spontaneous reduction of the intussusception. The patient made a prompt recovery from both episodes. On the third presentation the patient proceeded promptly to theatre. Gastroscopy revealed ischaemic gastrointestinal mucosa and blood within the stomach. The duodenum, initially obstructed postabdominal aortic aneurysm repair, was widely patent through to the gastrojejunal anastomosis. Laparotomy confirmed efferent limb jejunal intussusception with 80 cm of ischaemic small bowel into the stomach (Figs. 2 and 3). In the setting of a patent duodenum, the gastrojejunal anastomosis was taken down, the gastrostomy was