Intussusceptions leading to small bowel obstruction after bariatric surgery are rare. A retrospective single institution study of Zak et al. [
7] showed a higher incidence of repeated operations after Roux-en-Y gastric bypass compared to sleeve gastrectomy. After six years of follow up, 6,9% of 934 patients undergoing RYGB required reoperations for other reasons than cholecystectomy. Non-healing ulcers and intussusception were responsible for 3,7% of these. In their review including 9527 patients, Koppmann et al. [
3] described an overall incidence of small bowel obstruction after RYGB of 3,6%. Those complications include internal hernias (due to a Petersen’s space hernia, the mesomesenteric defect at the jejunojejunostomy and in the case of a retro colic technique, the mesocolonic defect) in ≤1% in most RYGB studies, an obstruction a the jejunojejunostomy (due to luminal narrowing or acute angulation) in 0.5% and incisional hernias in 0.3% of the cases. In only 10 reported cases included in their review, an intussusception was the cause of the small bowel obstruction. An intussusception can be retrograde or antegrade, but the retrograde intussusception of the common channel is the most common one (86%). Female gender and weight loss are risk factors for intussusception [
6]. The most common symptoms are abdominal pain and/or nausea and vomiting. A peritonitis is very uncommon and only 10% of the patients have a palpable mass [
8]. Compared to laboratory parameters and physical examination, imaging is much more effective method for diagnostics, with the CT being the technique of choice, with a sensitivity ranging between 64 and 81% [
3,
9], but also with its limitations due to a weight limits or the radius of the gantry. An endoscopy might show a stenosis or an ulceration of the upper gastrointestinal tract, but also has its limitations, even with the double-balloon-technique, when trying to reach the remaining stomach. The exploratory laparoscopy is the most valuable diagnostic tool in patients with suspected intussusception, due to the high rate of non-specific symptoms and misinterpreted radiographic investigations. In summary, when presented with a small bowel obstruction after bariatric surgery, the surgeon has to compare the risk of an increase of the patient’s mortality in case of a bowel necrosis due to a delay in diagnostics with a relatively minimal morbidity of a negative exploratory laparoscopy.
In conclusion, agreeing with the personal guidelines presented by Bag et al. [
6] and Koppmann et al. [
3], we strongly emphasis the importance of early imaging diagnostics, preferably the CT and exploratory laparoscopy or even laparotomy in more complex cases.