|Year : 2018 | Volume
| Issue : 3 | Page : 122-124
Jejunostomy tube-induced intussusception
Department of Surgical Oncology, Cancer Institute (WIA), Chennai, Tamil Nadu, India
|Date of Submission||01-Aug-2017|
|Date of Decision||22-Aug-2017|
|Date of Acceptance||17-Sep-2017|
|Date of Web Publication||21-Jun-2018|
Prof. Arvind Krishnamurthy
Department of Surgical Oncology, Cancer Institute (WIA), 38, Sardar Patel Road, Adyar, Chennai - 600 036, Tamil Nadu
Source of Support: None, Conflict of Interest: None
Intussusception involves the telescoping of a segment of bowel into an adjacent segment. It is the leading cause of intestinal obstruction in the pediatric age group; however, it is relatively rare and accounts for just about 1% of the cases of small bowel obstruction in adults. Jejunostomy tube-induced intussusception is an extraordinarily rare complication of feeding jejunostomy tube placement, the exact mechanism of which is not definitively known. The diagnosis of jejunostomy tube-induced intussusception is not easy as it generally does not interfere with the enteral feeding. Computed tomography (CT) scan is widely considered to be the imaging modality of choice in the diagnostic evaluation of adult intussusception. The finding of a heterogeneous sausage-shaped soft-tissue mass consisting of an outer intussuscipiens and central intussusceptum is virtually pathognomonic of intussusception. Surgery is the mainstay of management in an adult with intussusception. Nonoperative treatment strategies including radiologic reductions aided by hydrostatic/contrast/air enemas, which have mainly been attempted in the pediatric age group, have shown unpredictable results and are not recommended in adults. We present an unusual cause of jejunostomy tube-induced intussusception following a salvage laryngopharyngoesophagectomy and gastric pull-up in a patient with a postchemoradiation residue of a locally advanced carcinoma of the postcricoid region. A high degree of suspicion among clinicians and timely imaging with a CT scan are prerequisites for diagnosing intussusception in patients who complain of persistent gastrointestinal symptoms, especially with a jejunostomy tube in situ.
Keywords: Complications, feeding jejunostomy, intussusception, jejunojejunal intussusception
|How to cite this article:|
Krishnamurthy A. Jejunostomy tube-induced intussusception. Formos J Surg 2018;51:122-4
| Introduction|| |
Intussusception in adults is an uncommon entity and accounts for just about 1% of the cases of small bowel obstruction and up to 5% of all the cases of intussusception. Jejunostomy tube-induced intussusception is an extremely rare complication of feeding jejunostomy tube placement. The actual incidence of this problem is not clearly known with paucity of data and only isolated case reports in literature., We present an unusual cause of intussusception following a salvage laryngopharyngoesophagectomy and gastric pull-up in a patient with a postchemoradiation residue of a locally advanced carcinoma of the postcricoid region.
| Case Report|| |
A 43-year-old woman underwent a salvage laryngopharyngoesophagectomy and gastric pull-up for a postchemoradiation residue of a locally advanced carcinoma of the postcricoid region (cT3N0M0). A feeding jejunostomy tube (Stamm technique) was placed intraoperatively and enteral feeds were gradually started from day 1 and escalated to full enteral feeds over the subsequent 48 h. Her hospital stay was prolonged in view of a minor anastomotic leak; the jejunostomy tube hence had to be left in situ to maintain supplemental enteral nutrition. On day 25 of her surgery, the patient complained of intractable pain abdomen. The patient was able to partially tolerate oral feeds by then. Clinical examination revealed a soft abdomen and a prominent bowel loop in her umbilical region. She was passing flatus and motion and was even able to tolerate jejunostomy feeds.
An X-ray of her abdomen only revealed dilated small bowel loops, an ultrasound of the abdomen revealed a target sign, with a feeding tube in a dilated jejunum. A CT scan of the abdomen and pelvis done subsequently confirmed the sonographic finding of jejunostomy tube-induced jejunojejunal intussusception; the patient was hence taken for an emergency laparotomy [Figure 1]. The intraoperative finding was that of a jejunojejunal intussusception starting at a distance of about 15 cm from the site of jejunostomy insertion proximally to a length of around 15 cm of involved segment of jejunum distally and normally placed jejunostomy tube. The site of fixation on the jejunostomy tube to the peritoneum was normal. Intra-operative reduction of the intussuscepted jejunal loop was attempted but in view of dense adhesions, there were serosal tears along with unhealthy patches in the reduced intussuscepted bowel segment. A decision was hence taken to perform a resection and anastomosis, which was done in single layer using 3-0 vicryl (polyglactin 910) after removing the jejunostomy tube. Postoperatively, the patient was restarted on oral feeds after 48 h and escalated the full normal diet over the next 48 h and discharged after a week.
|Figure 1: A computed tomography scan of the abdomen and pelvis showing dilated jejunal loops and a feeding jejunostomy tube in situ alongside the sausage-shaped mass comprising of the outer intussuscipiens and central intussusceptum suggesting the presence of jejunostomy tube-induced jejunojejunal intussusception|
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| Discussion|| |
Intussusception occurs when a portion of the bowel has invaginated into another bowel loop, most intussusceptions are known to occur in the pediatric age group, and intussusceptions among adults are considered rare. Further, in contrast to intussusceptions in children, which are mostly idiopathic, a vast majority of the adult intussusceptions are caused by a structural lesion. The exact mechanism of jejunostomy tube-induced intussusceptions is not definitively known. Many theories have been floated suggesting that it may be due to the tip of the tube acting as a lead point or a jejunostomy tube-induced inflammatory reaction causing hypertrophy of the mucosa, which then forms the lead point. Further theories suggesting a retrograde peristalsis of jejunum and following forceful feeding which also acts as a lead point have also been proposed. It has also been suggested that poorly built patients have reduced fatty tissue in the omentum and the mesentery, and this allows for free movement of intestine which also is an added risk factor.
The diagnosis of jejunostomy tube-induced intussusception is not easy as it generally does not interfere with the enteral feeding. The common presenting symptoms include bilious vomiting, pain, mass abdomen, or rarely may even be asymptomatic. Imaging with an X-ray abdomen, contrast radiography, sonography, and computed tomography (CT) scans are helpful in diagnosing postoperative intussusception in adults.,,,
Intussusception may not be apparent on plain abdominal X-rays; the presence of an apparently normal abdominal X-rays alone should not form the basis for excluding a diagnosis of intussusception. A careful search should be made for intraperitoneal free air as its presence is a sign of preexisting perforation, warranting an emergency surgery.
Ultrasound is a particularly useful tool for the diagnosis of intussusception in children; it can be useful in adults, especially when an abdominal mass can be palpated. Its use is, however, limited by body habitus and the presence of air-filled dilated bowel loops. On ultrasonography, intussusception has a characteristic appearance of the mass with a swirled pattern of alternating hyperechogenicity and hypoechogenicity, representing the alternating layers of mucosa, muscularis, and serosa in a transverse scan and a sandwich-like appearance with alternating loops of bowel and a loop-within-loop in a longitudinal scan. Further serial ultrasound examination has been used to monitor the reduction of the intussusception when the nonoperative radiographic reduction techniques are used.
A CT scan is not normally indicated in a child with intussusception; however, it plays a vital role and is widely believed to be the imaging modality of choice for the diagnosis of intussusception in adults. The finding of a heterogeneous sausage-shaped soft-tissue mass consisting of an outer intussuscipiens and central intussusceptum is virtually pathognomonic of intussusception.,,
Surgery is considered to be the mainstay of management of adult intussusception. Nonoperative treatment strategies including radiologic reductions aided by hydrostatic/contrast/air enemas, which have mainly been attempted in the pediatric age group, have shown unpredictable results and are not recommended in adults. The surgical procedure may be simple reduction or resection and an anastomosis if the affected bowel loops are unhealthy/nonviable.,
| Conclusion|| |
Our case emphasizes the need of high degree of suspicion among clinicians to diagnose intussusception in patients who complain of persistent gastrointestinal symptoms, especially with a jejunostomy tube in situ. CT scan is widely considered to be the imaging modality of choice in the diagnostic evaluation of an adult intussusception. The management of intussusception in adults is more often surgical, and delays in diagnosis can lead to potentially life-threatening complications such as bowel obstruction, ischemia, or perforation.
Declaration of patient consent
The authors certify that they have obtained all appropriate patient consent forms. In the form the patients have given their consent for their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.
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Conflicts of interest
There are no conflicts of interest.
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