Endoscopic nasogastric tube insertion for treatment of benign afferent loop obstruction after radical gastrectomy for gastric cancer: A 16-year retrospective single-center study.

Afferent loop obstruction is an uncommon complication associated with Billroth-II distal gastrectomy. Inappropriate treatment may result in life-threatening events as perforation and peritonitis. For the benign afferent loop obstruction, Braun or Roux-en-Y reconstruction has been reported as the choice. However, the edematous afferent loop may result in anastomotic fistula. In this study, a less invasive technique was described for treatment of benign afferent loop obstruction. The aim of this study was to investigate the effectiveness and safety of endoscopic nasogastric tube insertion for treatment of benign afferent loop obstruction.We conducted a retrospective review of the data of 2548 gastric cancer patients who underwent distal gastrectomy from January 2002 to January 2018. Patients who developed benign afferent loop obstruction were treated by this procedure. Outcomes were recorded. Follow-up was scheduled at 3, 6, and 12 months after the treatment.Twenty-six patients (1.0%) developed afferent loop obstruction. The median age, consisting of 19 men and 7 women, was 60 years (range 36-69 years). Of these 26 patients, 23 underwent the endoscopic treatment. The obstructive symptoms had a rapid relief in all the 23 patients. No one died due to this procedure. However, 2 patients underwent surgical treatment due to intestinal obstruction because of adhesion at >4 and 7 months after the endoscopic drainage, respectively.Endoscopic nasogastric tube insertion is an effective and safe procedure for treatment of benign afferent loop obstruction. In addition, it could be considered as the first step in treatment, especially in high-surgical-risk patients.

[Two Cases of Afferent Loop Obstruction Treated with Percutaneous Bowel Drainage(PBD)].

Here, we report our experiences with 2 cases of afferent loop obstruction with percutaneous bowel drainage(PBD)and present a review of the literature. Case 1 involved a 60-year-old woman. She underwent pancreaticoduodenectomy for pancreatic cancer. Eighteen months postoperatively, a recurrence marked by a jejunal elevation and expansion on the cecal side near the porta hepatic lymph nodes appeared. We performed PBD because intestinal depression via the endoscopic approach was difficult. She was discharged from the hospital 7 days after PBD. Case 2 involved a 51-year-old woman. She underwent total gastrectomy and Roux-en-Y reconstruction for progressive stomach cancer. We detected a local recurrence in the Y anastomosis following a chief complaint of vomiting 10 months postoperatively. Fifteen months postoperatively, she developed acute pancreatitis with afferent loop syndrome. We performed PBD via a trans-liver route. The patient was discharged from the hospital 11 days after PBD. By devising a puncture route, we could safely perform PBD for an afferent loop obstruction.

[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 Transhepatic Cholangiodrainage to Alleviate Symptoms of Afferent Loop Obstruction--A Case Report].

The patient, a 78-year-old man, had undergone distal gastrectomy for a gastric ulcer 35 years previously. As melena was observed, he was referred to our department, and was subsequently diagnosed with residual gastric cancer and ascending colon cancer. Peritoneal metastasis of gastric cancer was found, and palliative surgeries, including right hemicolectomy, total gastrectomy, and Roux-en-Y reconstruction were performed. Although postoperative chemotherapy was commenced, side effects led to a decreased performance status (PS), which resulted in the patient shifting to the best supportive care (BSC). Five months after surgery, the patient was urgently transferred to the hospital with upper abdominal pain, and underwent computed tomography (CT) scan. The patient was diagnosed with acute afferent loop obstruction due to peritoneal metastases. It was not possible to perform endoscopic drainage because of the stenosis; therefore, percutaneous transhepatic cholangiodrainage (PTCD) was performed to reduce the pressure in the duodenal afferent loop. Herein, we report on a case of afferent loop obstruction, for which we performed decompression of the afferent loop with PTCD, allowing the patient to continue BSC for approximately 3 months.

[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.

[Acute pancreatitis and afferent loop syndrome. Case report]. / Pancreatitis aguda y síndrome de asa aferente. Reporte de caso.

BACKGROUND: The afferent syndrome loop is a mechanic obstruction of the afferent limb before a Billroth II or Roux-Y reconstruction, secondary in most of case to distal or subtotal gastrectomy. Clinical case: Male 76 years old, with antecedent of cholecystectomy, gastric adenocarcinoma six years ago, with subtotal gastrectomy and Roux-Y reconstruction. Beginning a several abdominal pain, nausea and vomiting, abdominal distension, without peritoneal irritation sings. Amylase 1246 U/L, lipase 3381 U/L. Computed Tomography with thickness wall and dilatation of afferent loop, pancreas with diffuse enlargement diagnostic of acute pancreatitis secondary an afferent loop syndrome. CONCLUSION: The afferent loop syndrome is presented in 0.3%-1% in all cases with Billroth II reconstruction, with a mortality of up to 57%, the obstruction lead accumulation of bile, pancreatic and intestinal secretions, increasing the pressure and resulting in afferent limb, bile conduct and Wirsung conduct dilatation, triggering an inflammatory response that culminates in pancreatic inflammation. The severity of the presentation is related to the degree and duration of the blockage.

Antecedentes: el síndrome de asa aferente se caracteriza por la obstrucción mecánica del asa aferente luego de la reconstrucción tipo Billroth II o en Y de Roux, en la mayoría de los casos secundaria a gastrectomía distal o subtotal. Caso clínico: paciente masculino de 76 años de edad, con antecedentes de: colecistectomía, adenocarcinoma gástrico seis años previos, gastrectomía subtotal y reconstrucción en Y de Roux. Inició con dolor abdominal, náusea y vómito; abdomen distendido, sin datos de irritación peritoneal. Amilasa 1246 U/L, lipasa 3381 U/L. La tomografía computada abdominal mostró dilatación y engrosamiento de la pared del asa aferente y el páncreas con incremento de tamaño. Se le diagnosticó pancreatitis aguda, originada por síndrome de asa aferente. Conclusiones: el síndrome de asa aferente aparece en 0.3 a 1% de los casos de pacientes con reconstrucción Billroth II, a consecuencia de la obstrucción mecánica del asa aferente, con mortalidad incluso de 57%. La obstrucción del intestino aferente por acumulación de secreción biliar, pancreática e intestinal incrementa la presión, que resulta en dilatación del asa aferente de la vía biliar y del conducto de Wirsung, lo que desencadena una respuesta inflamatoria que finaliza en un cuadro de pancreatitis. Su manifestación severa se relaciona con el grado y duración de la obstrucción.

Afferent limb syndrome and delayed GI problems after pancreaticoduodenectomy for pancreatic cancer: single-center, 14-year experience.

BACKGROUND: There are limited data on the incidence of afferent limb syndrome and other delayed GI problems in pancreatic cancer (PaC) patients, especially among long-term survivors (>2 years). OBJECTIVE: To evaluate the incidence of afferent limb syndrome (chronic afferent limb obstruction resulting in pancreatobiliary obstruction) and delayed GI problems in PaC patients after pancreaticoduodenectomy (PD). DESIGN: Retrospective case series. SETTING: Tertiary referral center. PATIENTS: PaC patients treated with PD (N = 186) over a 14-year period (January 1995-October 2009). INTERVENTIONS: Endoscopic balloon dilation and stent placement, percutaneous biliary drainage. MAIN OUTCOME MEASUREMENTS: Incidence of afferent limb syndrome and delayed GI complications (marginal ulcers, radiation enteropathy, anastomotic strictures). RESULTS: Mean age was 63 ± 10 years; 55% of patients were male. Afferent limb syndrome was noted in 24 patients (13%). Median time to diagnosis was 1.2 years (range 0.03-12.3 years); obstruction was primarily caused by recurrent PaC (8 patients, 33%) and radiation enteropathy (9 patients, 38%). Afferent limb syndrome was more likely to develop in patients with 2 years or longer of follow-up (n = 71, [38%]) compared with patients with 2 years or less of follow-up, after controlling for age, sex, surgery type, and adjuvant treatment (adjusted odds ratio, 4.5; 95% CI, 1.8-11.7). Other delayed GI problems included radiation enteropathy (6%), marginal ulcers (5%), anastomotic strictures (4%), cholangitis/liver abscesses (5%), and GI bleeding (6%). LIMITATIONS: Retrospective, single-center study. CONCLUSIONS: GI problems, including afferent limb syndrome, are relatively common in PaC patients after surgery and adjuvant therapy. Clinicians should recognize and effectively treat these delayed GI problems, especially in long-term survivors.

Diagnosis and management of afferent limb syndrome in patients with ileal pouch-anal anastomosis.

BACKGROUND: Distal small bowel obstruction following ileal pouch-anal anastomosis (IPAA) can occur secondary to acute angulation or prolapse of the afferent limb at the pouch inlet, namely, afferent limb syndrome (ALS). The aim of this study is to report our experience in diagnosis and management of ALS in patients with IPAA. METHODS: All patients with ALS after IPAA were identified from prospectively maintained databases. Demographic, clinical, endoscopic, and radiographic features together with its management and outcome were studied. RESULTS: Eighteen patients (12 female) were included. The mean age was 35.6 ± 14.3 years. Most patients presented with intermittent obstructive symptoms. Fifteen patients were diagnosed by pouch endoscopy with features of angulation of the pouch inlet and difficulty in intubating the afferent limb; 12 patients had kinking or narrowing of the pouch inlet identified with abdominal imaging. The median follow-up was 1.3 (range, 0.14-16.1) years. Nine patients underwent empiric balloon dilatation of the afferent limb/pouch inlet. Of nine, four needed repeat dilatations. One patient with repeat dilatation ultimately had pouch excision; another has been scheduled for surgery after failed repeat dilatations. Eight patients underwent surgery, resection of angulated bowel (n = 3), pouchopexy (n = 2), pouch mobilization with small bowel fixation (n = 1), and pouch excision (n = 2). One patient without symptoms did not receive any therapy despite the finding of ALS on pouchoscopy. CONCLUSIONS: ALS was characterized by clinical presentation of partial small bowel obstruction, which can be diagnosed by careful pouchoscopy and/or abdominal imaging. Endoscopic or surgical intervention is often needed and surgical therapy appears to be more definitive.

Endoscopic removal of an enterolith causing afferent loop syndrome using electrohydraulic lithotripsy.

Electrohydraulic lithotripsy is a very useful method for fragmenting biliary stones and it can be used for endoscopic removal of difficult biliary stones. Acute afferent loop syndrome induced by enterolith is very rare, and surgical treatment is the usual choice for this condition. We describe a patient with acute afferent loop syndrome, which was induced by an enterolith after a Billroth II gastrectomy. We used electrohydraulic lithotripsy to endoscopically remove the enterolith.

Afferent loop obstruction treated by percutaneous transhepatic insertion of an expandable metallic stent.

The use of expandable metallic stents (EMSs) for the management of gastrointestinal obstruction is increasing. Traditionally, EMSs have been used for the treatment of malignant esophageal and biliary strictures; however, several groups are examining their use in different organs, including the stomach, duodenum, and colon. We describe a new method for the transhepatic insertion of an EMS together with a double-pigtail catheter, placed from the bile duct to the EMS to prevent migration, in a patient with afferent loop obstruction caused by recurrent gastric carcinoma.

Percutaneous transhepatic placement of covered, self-expandable nitinol stent for the relief of afferent loop syndrome: report of two cases.

The author reports successful outcomes after percutaneous transhepatic placement of covered, self-expandable nitinol stents in two patients who had afferent loop syndrome caused by recurrent gastric carcinoma. A 46-year-old woman and a 60-year-old man who had undergone subtotal gastrectomy and gastrojejunostomy (Billroth II) were both admitted with symptoms of afferent loop syndrome. In each patient, enhanced abdominal computed tomography showed marked dilation of the jejunal limb and intrahepatic bile ducts incident to recurrent gastric carcinoma. Percutaneous transhepatic biliary drainage was successfully performed, and a multi-sidehole drainage catheter was placed beyond the papilla of Vater. Successful palliation of the afferent loop obstruction was achieved by placing a covered, self-expandable nitinol stent through the transhepatic biliary drainage route. There were no procedure-related complications, and both patients showed clinical improvement.

Percutaneous transhepatic insertion of metal stents with a double-pigtail catheter in afferent loop obstruction following distal gastrectomy.

We report successful outcome following transhepatic insertion of metal stents with a double-pigtail catheter in a patient with afferent loop syndrome caused by recurrent gastric carcinoma. A 77-year-old man was admitted with a 2-week history of fever, right upper quadrant pain, and jaundice. His past medical history included distal gastrectomy for treatment of gastric cancer two years previously. Abdominal computed tomography revealed marked dilation of the jejunal limb and intrahepatic bile duct. We diagnosed the patient with afferent loop syndrome resulting from recurrent cancer. Percutaneous transhepatic biliary drainage was performed, and a catheter was placed beyond the papilla of Vater. Approximately 1300 mL of turbid jejunal contents were removed. Symptoms resolved by one day after initiation of drainage. After 1 week, a sheath introducer was inserted beyond the point of stenosis, and two metal stents were placed. A double-pigtail catheter was inserted into the metal stents to prevent migration. Good stent placement was confirmed and the drainage catheter was removed.

Palliative percutaneous tube enterostomy in afferent-loop syndrome presenting as jaundice: clinical effectiveness.

The purpose of this study was to investigate the clinical effectiveness of percutaneous tube enterostomy in afferent loop syndrome presenting as jaundice. Tube enterostomy was successfully performed in seven patients without procedural complications. The serum bilirubin level normalized in five patients but remained elevated in the other two, presumably related to more proximal bile duct obstruction. Percutaneous tube enterostomy is an effective palliative treatment in afferent loop syndrome presenting as an obstructing jaundice. However, coexisting biliary obstruction might be problematic for relieving jaundice with tube enterostomy.

Non-surgical treatment for afferent loop syndrome in recurrent gastric cancer complicated by peritoneal carcinomatosis: percutaneous transhepatic duodenal drainage followed by 24-hour infusion of high-dose fluorouracil and leucovorin.

Afferent loop syndrome (ALS) is a debilitating complication of recurrent gastric cancer. Surgical intervention is usually not feasible in the face of poor general performance, presence of advanced peritoneal carcinomatosis and limited survival of the patients. Non-surgical approaches include internal drainage by stenting at the stenotic or anastomotic site and external drainage via the percutaneous routes. Percutaneous transhepatic duodenal drainage (PTDD) has been shown to provide effective palliation for ALS, but long-term catheterization is usually inevitable. We hereby present two cases of recurrent gastric cancer whose ALS was successfully treated with PTDD followed by weekly 24-h infusion of high-dose 5-fluorouracil and leucovorin (HDFL). PTDD rapidly ameliorated the incapacitating symptoms of ALS, and the effective, low-toxicity chemotherapy subsequently led to tumor regression, restoration of bowel patency and removal of the drainage tube. At present, both patients have remained ALS-free and drainage-free for 16 and 17 months, respectively. Our results indicate that this non-surgical approach with PTDD followed by weekly HDFL could serve as a safe and effective treatment for ALS in recurrent gastric cancer complicated by peritoneal carcinomatosis.

Transhepatic insertion of a metallic stent for the relief of malignant afferent loop obstruction.

A 65-year-old man with a polya gastrectomy presented with biliary obstruction. Percutaneous cholangiography indicated strictures of the distal common bile duct and afferent duodenal loop due to an inoperable carcinoma of the head of the pancreas. The patient was unfit for bypass surgery, and a previous gastrectomy precluded endoscopic intervention. Successful palliation of the biliary obstruction was achieved by placing metallic stents across the duodenal and biliary strictures via the transhepatic route. The use of stents for gastrointestinal stricture is reviewed.