Efficacy of endoscopic ultrasound-guided gastroenterostomy using self-expandable metallic stent for afferent loop syndrome: A single-center retrospective study.

BACKGROUND AND AIM: Endoscopic ultrasound-guided gastroenterostomy is a procedure used to connect the stomach and dilated afferent loop using a stent under endoscopic ultrasound for afferent loop syndrome. However, the actual efficacy and safety of this procedure remain unclear. Therefore, this retrospective study aimed to evaluate the efficacy and safety of endoscopic ultrasound-guided gastroenterostomy using a laser-cut-type fully covered self-expandable metallic stent and an anchoring plastic stent for afferent loop syndrome. METHODS: Technical and clinical success rates, adverse events, recurrent intestinal obstruction rates, time to recurrent intestinal obstruction, and technical and clinical success rates of re-intervention were evaluated in intended patients who underwent endoscopic ultrasound-guided gastroenterostomy for afferent loop syndrome from October 2018 to August 2022. RESULTS: In 25 intended patients with afferent loop syndrome who intended endoscopic ultrasound-guided gastroenterostomy, the technical success rate was 100% (25/25), whereas the clinical success rate was 96% (24/25). Two patients experienced grade ≥ 3 early adverse events, including one with intra-abdominal abscess and one with hypotension. Both events were attributed to intestinal fluid leakage. No late adverse events were observed. The recurrent intestinal obstruction rate was 32% (8/25), and the median time to recurrent intestinal obstruction was 6.5 months (95% confidence interval: 2.8-not available). The technical and clinical success rates of re-intervention were both 100% (8/8). CONCLUSIONS: Endoscopic ultrasound-guided gastroenterostomy using a fully covered self-expandable metallic stent and an anchoring plastic stent is effective and safe as a treatment procedure for afferent loop syndrome.

Endoscopic ultrasound-guided gastrointestinal anastomosis: Current status and future perspectives.

OBJECTIVES: Both clinical experience and supporting data have improved drastically in the context of endoscopic ultrasound-guided gastrointestinal anastomosis (EUS-GIA). Where outcomes used to be questioned, focus has now moved towards performing comparative studies, optimizing technical approaches, improving patient selection, and developing well-defined treatment algorithms. METHODS: The purpose of this review is to provide an overview of technical developments within EUS-GIA and to discuss the current status of EUS-GIA and future directions. RESULTS: EUS-GIA techniques such as EUS-guided gastroenterostomy (EUS-GE), EUS-directed transgastric endoscopic retrograde cholangiopancreatography (ERCP) (EDGE) and EUS-guided treatment afferent loop syndrome have undergone further development, refining technical approaches, improving patient selection and subsequent outcomes. Retrospective evaluations of EUS-GE have shown similar safety when compared to enteral stenting, whilst attaining surgical range efficacy. Whereas, in patients with gastric bypass anatomy, EDGE seems less cumbersome and time consuming than enteroscopy-assisted ERCP, while preventing surgical morbidity associated with laparoscopy-assisted ERCP. Although less evidence is available on EUS-guided treatment of afferent loop syndrome, this technique has been associated with higher clinical success and fewer reinterventions and adverse events when compared to enteral stenting and percutaneous drainage, respectively. Several randomized studies are currently underway evaluating EUS-GE in malignant gastric outlet obstruction (GOO), whereas more prospective data are still required on EDGE and long-term fistula management. CONCLUSION: EUS-GIA has become a crucial alternative to established techniques, overcoming technical limitations and subsequently improving patient outcomes. Although we should focus on prospective confirmation of these results in the context of GOO and EDGE, the current evidence already allows for a prominent role for EUS-GIA in our everyday practice.

EUS-guided hepaticogastrostomy for patients with afferent loop syndrome: a comparison with EUS-guided gastroenterostomy or percutaneous drainage.

OBJECTIVES: Where palliative surgery or percutaneous drainage used to be the only option in patients with afferent loop syndrome, endoscopic management by EUS-guided gastroenterostomy has been gaining ground. However, EUS-guided hepaticogastrostomy might also provide sufficient biliary drainage. Our aim was to evaluate the feasibility of EUS-guided hepaticogastrostomy for the management of afferent loop syndrome and provide comparative data on the different approaches. METHODS: The institutional databases were queried for all consecutive minimally invasive procedures for afferent loop syndrome. A retrospective, dual-centre analysis was performed, separately analysing EUS-guided hepaticogastrostomy, EUS-guided gastroenterostomy and percutaneous drainage. Efficacy, safety, need for re-intervention, hospital stay and overall survival were compared. RESULTS: In total, 17 patients were included (mean age 59 years (± SD 10.5), 23.5% female). Six patients, which were ineligible for EUS-guided gastroenterostomy, were treated with EUS-guided hepaticogastrostomy. EUS-guided gastroenterostomy and percutaneous drainage were performed in 6 and 5 patients respectively. Clinical success was achieved in all EUS-treated patients, versus 80% in the percutaneous drainage group (p = 0.455). Furthermore, higher rates of bilirubin decrease were seen among patients undergoing EUS: > 25% bilirubin decrease in 10 vs. 1 patient(s) in the percutaneously drained group (p = 0.028), with > 50% and > 75% decrease identified only in the EUS group. Using the ASGE lexicon for adverse event grading, adverse events occurred only in patients treated with percutaneous drainage (60%, p = 0.015). And last, the median number of re-interventions was significantly lower in patients undergoing EUS (0 (IQR 0.0-1.0) vs. 1 (0.5-2.5), p = 0.045) when compared to percutaneous drainage. CONCLUSIONS: In the management of afferent loop syndrome, EUS seems to outperform percutaneous drainage. Moreover, in our cohort, EUS-guided gastroenterostomy and hepaticogastrostomy provided similar outcomes, suggesting EUS-guided hepaticogastrostomy as the salvage procedure in situations where EUS-guided gastroenterostomy is not feasible or has failed.

Endoscopic ultrasound-guided entero-enterostomy for the treatment of afferent loop syndrome: a multicenter experience.

BACKGROUND: Afferent loop syndrome (ALS) is traditionally managed surgically and, more recently, endoscopically. The role of endoscopic ultrasound-guided entero-enterostomy (EUS-EE) has not been well described. The aim of this study was to assess the technical and clinical success and safety of EUS-EE. METHODS: This was a multicenter, retrospective series at six centers in patients with ALS treated by EUS-EE. Data on patients treated with enteroscopy-assisted luminal stenting (EALS) at a single center were also collected. RESULTS: 18 patients (mean age 64.2 years, 72 % post-pancreaticoduodenectomy, 10 female) underwent EUS-EE. The most common symptoms were vomiting (27.8 %) and jaundice (33.3 %). Clinical success included resolution of symptoms in 88.9 % and improvement to allow hospital discharge in 11.1 %. Technical success was achieved in 100 % of cases, with a mean procedure time of 29.7 minutes. The most common procedure was a gastro-jejunostomy (72.2 %). Three adverse events (16.7 %) occurred (two mild, one moderate). When compared with data on EALS, patients treated with EUS-EE needed fewer re-interventions (16.6 % vs. 76.5 %; P < 0.001). CONCLUSION: EUS-EE seems to be safe and effective in the treatment of ALS. Indirect comparison with EALS suggested that EUS-EE is associated with a reduced need for re-intervention.

[A Case of Roux-en-Y Loop Reconstruction Using a Modified Aboral Pouch Technique for Y-Limb Obstruction Following Distal Gastrectomy].

A 53-year-old man underwentdistal gastrectomy with Roux-en-Y(R-Y)reconstruction for gastric cancer. An R-Y anastomosis was performed usinga 21mm circular stapler. Five years postoperatively, he visited our hospital with anorexia. An abdominal computed tomography scan showed dilatation of the afferent loop. He was diagnosed with afferent loop syndrome due to R-Y anastomotic stenosis that resulted in poor oral intake and malnutrition. A U-shaped bend created by an adhesion caused a bowel obstruction of the Y-anastomotic site for which the patient underwent R-Y loop reconstruction with an aboral pouch usinga 60mm linear stapler. He has been well without postoperative complaints. Here, we report a case of R-Y loop reconstruction with an aboral pouch for afferent loop obstruction complicated by stenosis of the Y-anastomotic site after distal gastrectomy.

[Afferent Loop Syndrome after Hepatobiliary and Pancreatic Surgery Successfully Treated with Percutaneous Drainage].

We report 2 cases where afferent loop syndrome after hepatobiliary and pancreatic surgery was successfully treated with percutaneous drainage. Case 1: A 74-year-old man who had undergone pancreaticoduodenectomy for pancreatic cancer presented with cholangitis, obstructive jaundice, and dilatation of the elevated jejunum. These conditions were attributed to obstruction of the elevated jejunum on the anal side due to peritoneal dissemination. Subsequently, percutaneous transhepatic biliary drainage was performed, and the dilated jejunum was drained through the approach route. Case 2: A 71-year-old woman who had undergone left hepatectomy for hilar bile duct cancer presented with peritoneal dissemination. Owing to the dissemination, the elevated jejunum was obstructed, resulting in its dilatation on the oral side. Percutaneous drainage of the dilated jejunum was directly performed. Percutaneous drainage was effective in both the abovementioned cases, and no symptoms related to the obstruction were observed until the death of the patients because of primary cancer. This suggested that percutaneous drainage may be an effective treatment option for afferent loop syndrome after hepatobiliary and pancreatic surgery.

Percutaneous drainage for afferent limb syndrome and pancreatic fistula via the blind end of the jejunal limb after pancreatoduodenectomy or bile duct resection.

PURPOSE: To investigate the feasibility of percutaneous drainage via the blind end of the jejunal limb (BEJL) for afferent limb syndrome and pancreatic fistula. MATERIALS AND METHODS: Percutaneous drainage via the BEJL was performed in eight patients (seven men and one woman; mean age, 63 y; range, 42-71 y) presenting with afferent limb syndrome (n = 6) or pancreatic fistula (n = 2) following pancreatoduodenectomy or bile duct resection with reconstruction at our institute from March 2005 to June 2013. Reconstruction was performed by using a modified Child method or the Roux-en-Y method, and the BEJL was surgically fixed to the abdominal wall. Afferent limb syndrome was caused by tumor recurrence or postoperative complications. Technical success, clinical success, and complications were evaluated retrospectively. RESULTS: Technical success of drainage via BEJL was achieved in all patients. Drainage catheters (5-10 F) were inserted into the afferent limbs of six patients, into the pancreatic duct of one patient, and into the pancreatic fistula of one patient. Metallic stents were subsequently placed to address malignant afferent limb obstruction in two patients. Clinical success was achieved in seven patients (87.5%), and no patients developed major complications. Drainage catheters were removed from four patients. The mean catheter indwelling period in all patients was 143 days (range, 21-292 d). CONCLUSIONS: Percutaneous drainage via BEJL after pancreatoduodenectomy or bile duct resection may be a feasible treatment for afferent limb syndrome and pancreatic fistula.

Effects of adding Braun jejunojejunostomy to standard Whipple procedure on reduction of afferent loop syndrome - a randomized clinical trial.

BACKGROUND: Whipple surgery (pancreaticodeudenectomy) has a high complication rate. We aimed to evaluate whether adding Braun jejunojejunostomy (side-to-side anastomosis of afferent and efferent loops distal to the gastrojejunostomy site) to a standard Whipple procedure would reduce postoperative complications. METHODS: We conducted a randomized clinical trial comparing patients who underwent standard Whipple surgery (standard group) and patients who underwent standard Whipple surgery with Braun jejunojejunostomy (Braun group). Patients were followed for 1 month after the procedure and postoperative complications were recorded. RESULTS: Our study included 30 patients: 15 in the Braun and 15 in the standard group. In the Braun group, 4 (26.7%) patients experienced 6 complications, whereas in the standard group, 7 (46.7%) patients experienced 11 complications (p = 0.14). Complications in the Braun group were gastrointestinal bleeding and wound infection (n = 1 each) and delayed gastric emptying and pulmonary infection (n = 2 each). Complications in the standard group were death, pancreatic anastomosis leak and biliary anastomosis leak (n = 1 each); gastrointestinal bleeding (n = 2); and afferent loop syndrome and delayed gastric emptying (n = 3 each). There was no significant difference between groups in the subtypes of complications. CONCLUSION: Our results showed that adding Braun jejunojejunostomy to standard Whipple procedure was associated with lower rates of afferent loop syndrome and delayed gastric emptying. However, more studies are needed to define the role of Braun jejunojejunostomy in this regard. TRIAL REGISTRATION: IRCT2014020316473N1 (www.irct.ir).

CONTEXTE: La chirurgie de Whipple (pancréatoduodénectomie) s'accompagne de taux de complications élevés. Nous avons voulu vérifier si l'ajout d'une jéjunojéjunostomie de Braun (anastomose latérolatérale des anses afférente et efférente à la partie distale de la gastrojéjunostomie) à une chirurgie de Whipple standard permet de réduire les complications postopératoires. MÉTHODES: Nous avons procédé à un essai clinique randomisé pour comparer des patients soumis à une chirurgie de Whipple standard (groupe standard) à des patients soumis à une chirugie de Whipple standard avec jéjunojéjunostomie de Braun (groupe Braun). Les patients ont été suivis pendant 1 mois après l'intervention et les complications postopératoires ont été notées. RÉSULTATS: Notre étude a regroupé 30 patients : 15 dans le groupe Braun et 15 dans le groupe standard. Dans le groupe Braun, 4 patients (26,7 %) ont présenté 6 complications, tandis que dans le groupe standard, 7 patients (46,7 %) ont présenté 11 complications (p = 0,14). Les complications dans le groupe Braun ont été saignements gastro- intestinaux et infection de plaie (n = 1 chacun) et retard de la vidange gastrique et infection pulmonaire (n = 2 chacun). Les complications dans le groupe standard ont été décès, fuite de l'anastomose pancréatique et fuite de l'anastomose biliaire (n = 1 chacun); saignement gastro- intestinal (n = 2); et syndrome de l'anse afférente et retard de la vidange gastrique (n = 3 chacun). On n'a noté aucune différence significative entre les groupes pour ce qui est des sous-types de complications. CONCLUSION: Nos résultats ont montré que l'ajout de la jéjunojéjunostomie de Braun à une chirurgie de Whipple standard a été associé à des taux moindres de syndrome de l'anse afférente et de retard de la vidange gastrique. Il faudra toutefois procéder à d'autres études pour définir le rôle de la jéjunojéjunostomie de Braun à cet égard. ENREGISTREMENT DE L'ESSAI: IRCT2014020316473N1 (www.irct.ir).

[A Case of Acute Afferent Loop Obstruction after Total Gastrectomy, Successfully Managed by Endoscopic Treatment].

The patient was a 76-year-old man who had 3 times previously undergone laparotomies, including distal gastrectomy with a Billroth Ⅰ operation. In the current case, a total gastrectomy, end-to-side esophagojejunostomy, and a Roux-en-Y anastomosis for adenocarcinoma of the remnant stomach were performed. On postoperative day (POD) 7, he complained of epigastralgia. Abdominal CT revealed a markedly dilated duodenum, and a diagnosis of acute afferent loop obstruction was made. Emergency endoscopy revealed edematous stenosis of the Y-anastomotic site. A nasal endoscope could not pass the stricture, but an endoscopic nasobiliary drainage (ENBD) catheter was successfully inserted into the duodenum. Epigastralgia decreased after drainage. Stenosis of the Y-anastomotic site was still observed 18 days after onset; therefore, we inserted 1 endoscopic retrograde biliary drainage (ERBD) tube, in addition to the ENBD catheter. Twenty-five days after onset, slight improvement of the stenosis was observed. By inserting 2 more ERBD tubes, the ENBD catheter could be removed. On day 28, abdominal CT revealed reduced dilatation of the duodenum. On day 29, oral intake was initiated, and the patient was discharged from the hospital on POD 66. During the early post-operative phase, the use of nasal endoscope drainage is an effective, minimally invasive, and safe procedure for decompression of the duodenum in afferent loop obstruction.