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Patients with resection of stomach and especially with Billroth II reconstruction (gastro jejunal anastomosis), are more likely to develop afferent loop syndrome which is a rare complication. When the afferent part is obstructed, biliary and pancreatic secretions accumulate and cause the distention of this part. In the case of a complete obstructio...
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Citations
... Likewise, with acute obstruction, the cumulating and constrained secretions cause increased intraluminal pressure that precipitate a variety of complications such as pancreatitis, ascending cholangitis, and peritonitis secondary to afferent loop perforation. [1][2][3] In chronic ALS, there is partial or open loop obstruction where the impounded fluid is able to drain through a "pressure relief valve" mechanism. The sequelae of chronic ALS are generally more indolent and less catastrophic than with complete obstruction and include bacterial overgrowth, vitamin B 12 deficiency, steat-orrhea and malnutrition. ...
Afferent loop syndrome (ALS) is a morbid complication that may occur after gastrectomy and gastrojejunostomy reconstruction. The aim of this article is to review the different endoscopic treatment options of ALS. We describe the evolution of the endoscopic treatment of ALS and its limitations despite the overall propitious profile. We analyze the advantages of endoscopic ultrasound-guided entero-enterostomy (EUS EE) over enteroscopy-guided intervention, and the clinical outcomes of EUS EE. We expound on pre-procedural considerations, intra-procedural techniques and post-procedural care following EUS EE. We conclude that given the simplification of the technique and the ability to place a stent away from the tumor, EUS EE is a promising technique that will likely be established as the treatment of choice for ALS.
... CT scan done to look for the cause of obstruction revealed Afferent Loop Syndrome. Obstructive jaundice in such cases occurs when the pressure in the afferent loop is more than 18 cmH 2 O, leading to obstruction to biliary drainage and dilatation of biliary channels [7]. Cases of ascending cholangitis have been reported after pancreaticoduodenectomy [8]. ...
... The management includes surgical and non-surgical options [4,6]. The patients who are not stable enough for surgery, especially, those who are suffering from disease recurrence, non-surgical options include endoscopic decompression and percutaneous trans-hepatic catheter drainage [4,7]. In 75% of patients with afferent loop syndrome, surgical treatment is not successful because of the bad health condition of the patient and the spread of the disease [10,11]. ...
Afferent loop syndrome is reported to be one of the very rare complications after gastrojejunostomy. The usual presentation in patients is with abdominal pain, distension and vomiting. It may present acutely because of complete obstruction, usually occurs early after surgery and is lethal in its course unless treated promptly with surgical management. In chronic cases obstruction is intermittent. There may be a reflux of bowel material into the biliary system and because of bacterial overgrowth patient may present with ascending cholangitis and obstructive jaundice. Here we report a case of 43-year-old gentleman presenting with jaundice, diffuse abdominal pain and distension. Later on, he was found to have a recurrence of gastric carcinoma associated with peritoneal carcinomatosis after subtotal gastrectomy and gastrojejunostomy for gastric carcinoma one year ago. He was diagnosed to be a case of afferent loop syndrome presenting as obstructive jaundice. The patient was managed conservatively by endoscopic decompression after confirmation of the diagnosis of afferent loop syndrome.
... Unrecognized ALS can cause repeated episodes of acute pancreatitis after pancreaticoduodenectomy or gastrectomy [11]. Also, enterobiliary reflux from the obstructed bowel loop can cause biliary dilatation and acute ascending cholangitis complicated by sepsis and bacteremia due to translocation of overgrowing bacteria into the systemic circulation [12,13]. ...
Afferent loop syndrome (ALS) is a mechanical complication that arises after gastric surgery with gastrojejunostomy reconstruction. This condition was first described in 1950 by Roux, Pedoussaut, and Marchal to post-gastrectomy patients with bilious vomiting. Acute ALS is associated with complete obstruction and considered a surgical emergency, whereas chronic ALS is mostly related to partial obstruction of the afferent loop. The delay in diagnosis may lead to intestinal ischemia, perforation and can be associated with a high mortality rate up to 60%. Surgery is usually the mainstay treatment of ALS, but endoscopic therapy, including stent placement in malignancy-related, anastomotic stricture dilation, has been evolving over the past recent years.
... Afferent loop obstruction is usually caused by mechanical obstruction from kinking of the afferent limb, tumor recurrence, adhesions, radiation-induced stenosis, or internal hernias. [4] Obstruction of the afferent loop with progressive accumulation of biliary, pancreatic, and intestinal secretions results in afferent loop dilatation, subsequent dilatation of the biliary tract, cholangitis, and pancreatitis. ...
Rationale:
Self-expanding metal stent placement is a useful procedure for intestinal obstruction. Afferent loop syndrome after gastrectomy is an uncommon complication of gastroenterostomy reconstruction. Ascending cholangitis caused by afferent loop syndrome is a potential, but rare, complication.
Patient concerns:
A 73-year-old man with abdominal pain and vomiting was admitted to the emergency room. His medical history was significant for subtotal gastrectomy with Billroth II anastomosis for benign gastric ulcer perforation 40 years prior. He had notable tenderness to palpation, particularly on the epigastric area, and a temperature of 39.0°C.
Diagnosis:
Abdominal computed tomography revealed afferent loop syndrome with ascending cholangitis caused by remnant gastric cancer.
Interventions:
Percutaneous catheter drainage for management of ascending cholangitis was performed on the day of admission. He was subsequently treated with self-expandable metal stent insertion into the stenotic lesion.
Outcomes:
After treatment with percutaneous transhepatic insertion of a self-expanding stent, the patient achieved complete resolution of symptoms. The patient died of disease progression 2 months later, without further recurrence of afferent loop syndrome.
Lessons:
Our case shows that insertion of a metal stent via percutaneous transhepatic biliary drainage (PTBD) can effectively treat ascending cholangitis and resolve afferent loop syndrome in inoperable patients.
... The afferent loop syndrome is a recognized complication following Whipple surgery. The main etiologies of late-stage afferent loop syndromes are tumor recurrences, adhesions, radiation-induced stenosis or internal hernias [5]. The average appearance time of the latter is 1.2 years, whereas -according to a few current reports -the most frequent cause is a radiation-induced enteropathy (37.5%) followed by tumor recurrences (33%) and adhesion syndromes (17%) [6,7]. ...
... The etiology of this syndrome can be quite varied. The main cause of this complication among post-surgery patients following a Whipple procedure is tumor recurrence, more so if patients were subjected to intensive chemotherapy protocols [4,5], similar to our case. According to clinical and radiographic characteristics, the afferent loop syndrome can be sub-classified into acute and chronic. ...
... A bowel obstruction should be treated appropriately; if not, further complications can develop such as bowel strangulation, perforation, and panperitoni- tis. 18,19 Although the incidence of ALS was 0.3% in another study, 20 in the present study ALS had an incidence of 1.9% in B-II anastomosis after radical subtotal gastrectomy for gastric cancer with longterm follow-up. This is the first report of a large series of patients who underwent radical subtotal gastrectomy and B-II reconstruction with laparoscopic surgery; however, it was a single-center study. ...
The aim of this study was to evaluate the clinical characteristics, treatment, and prognosis of afferent loop syndrome (ALS) following radical subtotal gastrectomy with B-II reconstruction in gastric cancer patients. ALS is an infrequent mechanical complication, which occurs after reconstruction of Billroth-II (B-II) gastrojejunostomy or Roux-en-Y esophagojejunosotomy. From 2002 through 2010, 672 patients who had undergone subtotal gastrectomy with B-II reconstruction for gastric cancer were enrolled. Clinical data, symptom interval, cause, and treatment of 13 ALS patients were reviewed. The body mass index (BMI) of patients who suffered ALS was significantly less than that of patients who did not (P = 0.0244). And, there were significant differences in rates of recurrence (P = 0.0032) and follow-up duration (P = 0.0119) between the two groups. Acute ALS within 1 month occurred in 5 patients (38.5%). Obstructive jaundice or acute pancreatitis occurred in 4 patients (30.1%). The most frequent cause was ana...
... Manual reduction or enterectomy and conversion to Roux-en-Y [4] Manual reduction or enterectomy and revision of Roux-en-Y reconstruction Anastomotic ulceration Balloon dilation [34] , stricturoplasty or conversion to Roux-en-Y Balloon dilation, stricturoplasty or revision of the Roux-en-Y reconstruction Adhesiolysis, excision of redundant loop and revision of the jejunojejunostomy Adhesions Adhesiolysis, Braun anastomosis or excision of redundant loop and conversion to Roux-en-Y [35] Volvulus ...
Afferent loop obstruction is a purely mechanical complication that infrequently occurs following construction of a gastrojejunostomy. The operations most commonly associated with this complication are gastrectomy with Billroth II or Roux-en-Y reconstruction, and pancreaticoduodenectomy with conventional loop or Roux-en-Y reconstruction. Etiology of afferent loop obstruction includes: (1) entrapment, compression and kinking by postoperative adhesions; (2) internal herniation, volvulus and intussusception; (3) stenosis due to ulceration at the gastrojejunostomy site and radiation enteritis of the afferent loop; (4) cancer recurrence; and (5) enteroliths, bezoars and foreign bodies. Acute afferent loop obstruction is associated with complete obstruction of the afferent loop and represents a surgical emergency, whereas chronic afferent loop obstruction is associated with partial obstruction. Abdominal multiple detector computed tomography is the diagnostic study of choice. CT appearance of the obstructed afferent loop consists of a C-shaped, fluid-filled tubular mass located in the midline between the abdominal aorta and the superior mesenteric artery with valvulae conniventes projecting into the lumen. The cornerstone of treatment is surgery. Surgery includes: (1) adhesiolysis and reconstruction for benign causes; and (2) by-pass or excision and reconstruction for malignant causes. However, endoscopic enteral stenting, transhepatic percutaneous enteral stenting and direct percutaneous tube enterostomy have the principal role in management of malignant and radiation-induced obstruction. Nevertheless, considerable limitations exist as a former Roux-en-Y reconstruction limits endoscopic access to the afferent loop and percutaneous approaches for enteral stenting and tube enterostomy have only been reported in the literature as isolated cases.
... A few case reports describe single episodes of ascending cholangitis, post-Whipple procedure, in the presence of an obstructed afferent loop (afferent loop syndrome). 13 However, to the best of our knowledge, ours is the only case reporting recurrent ascending cholangitis causing sepsis in the absence of mechanical obstruction of the afferent loop. Given this as the aetiology, rather than bacterial translocation, the question as to why recurrent sepsis occurred only after the patient was established on parenteral nutrition remains unanswered. ...
We report a complex case involving an extremely rare cause of gastrointestinal dysmotility and an afferent loop, which together predisposed to the development of small intestinal bacterial overgrowth. The bacteria subsequently became multi-resistant. As a further consequence of the dysmotility, repeated bile duct reflux occurred despite the afferent loop being unobstructed. This bile duct reflux produced recurrent sepsis through repeated episodes of ascending cholangitis. Ultimately, the patient was referred to a National Small Intestinal Transplant Centre for consideration for enterectomy and subsequent transplantation. We describe the difficulties encountered in managing this unique case and discuss the underlying aetiology.
... Although rare, the afferent loop syndrome has been reported after the Whipple procedure (20), similar to its occurrence after Billroth II reconstruction for gastric surgeries (21). Intravenous administration of biliary contrast material has been shown to be effective for better evaluation of the afferent loop (biliopancreatic limb) (22). ...
Several pancreatic diseases may require surgical treatment, with most of these procedures classified as resection or drainage. Resection procedures, which are usually performed to remove pancreatic tumors, include pancreatoduodenectomy, central pancreatectomy, distal pancreatectomy, and total pancreatectomy. Drainage procedures are usually performed to treat chronic pancreatitis after the failure of medical therapy and include the Puestow and Frey procedures. The type of surgery depends not only on the patient's symptoms and the location of the disease, but also on the expertise of the surgeon. Radiologists should become familiar with these surgical procedures to better understand postoperative changes in anatomic findings. Multidetector computed tomography is the modality of choice for identifying normal findings after surgery, postoperative complications, and tumor recurrence in patients who have undergone pancreatic surgery.
... This mechanism is attribut- able to the surgical characteristics of pancreaticoduodenecto- my ancreaticanastomsis between bile duct stump and affer- ent loop of small bowel facilitates regurgitation more than normal bilio-enteric structure. 6 We also need to point out that pancreatitis occurred less than cholangitis, although both bile duct and pancreas may be affected by the increased af- ferent loop pressure, suggesting that, although pancreatitis may occur ultimately, sphincter of Boyden (submucosal mu- scle layer enclosing pancreatic duct distinct from sphincter of Oddi) protects pancreas for a long time, causing cholangi- tis to appear first than pancreatitis. 4 Afferent loop syndrome does not show a specific finding on laboratory tests or simple X-ray in the absence of cholan- gitis or pancreatitis. ...
Afferent loop syndrome is a rare complication of gastrojejunostomy. Patients usually present with abdominal distention and bilious vomiting. Afferent loop syndrome in patients who have undergone a pylorus preserving pancreaticoduodenectomy can present with ascending cholangitis. This condition is related to a large volume of reflux through the biliary-enteric anastomosis and static materials with bacterial overgrowth in the afferent loop. Patients with afferent loop syndrome after pylorus preserving pancreaticoduodenectomy frequently cannot be confirmed as surgical candidates due to poor medical condition. In that situation, a non-surgical palliation should be considered. Herein, we report two patients with afferent loop syndrome presenting with obstructive jaundice and ascending cholangitis. The patients suffered from the recurrence of pancreatic cancer after pylorus preserving pancreaticoduodenectomy. The diagnosis of afferent loop syndrome was confirmed, and the patients were successfully treated by inserting an endoscopic metal stent using a colonoscopic endoscope.
