2183 Endoscopic Management of Efferent Loop Syndrome Using Axios Lumen-Apposing Metal Stent

Abstract

INTRODUCTION: Efferent loop syndrome (ELS) is a rare post gastrectomy syndrome that can occur following Billroth-II or Roux-en-Y reconstruction. The most common loop syndrome after gastric surgery is afferent loop syndrome (ALS), however efferent loop syndrome has been reported. ELS may occur due to a mechanical obstruction of the efferent limb due to an anastomotic stricture, malignancy, volvulus, intussusception, internal hernia or abdominal adhesion after surgery. Presentations include abdominal distension and vomiting and rarely pancreatitis or cholangitis. We present a case of efferent loop syndrome managed with an Axios lumen apposing metal stent (LAMS). CASE DESCRIPTION/METHODS: 79 year-old male with a history of gastric adenocarcinoma status post distal gastrectomy with Billroth-II reconstruction one month prior to admission presented with abdominal pain and nausea. Computed tomography of the abdomen revealed distended stomach with contrast, dilated biliary limb with collapsed distal jejunum and no passage of contrast distal to the anastomosis (Image 1). Upper endoscopy (EGD) revealed a friable gastrojejunostomy anastomosis with a patent afferent limb and a nearly obstructed stenosis at the efferent limb suture line. A 20 × 10 mm A-LAMS was deployed across the stenosed efferent limb under direct visualization and fluoroscopic guidance (Images 2 and 3). Follow up upper gastrointestinal series confirmed brisk passage of contrast into the efferent limb. The patient clinically improved and a repeat EGD revealed a patent efferent limb and a dislodged Axios LAMS which was endoscopically removed. DISCUSSION: ELS and ALS can be managed surgically or endoscopically. Endoscopic options include dilation and enteral stenting. Dilation may require multiple sessions and stenting utilizing self-expanding metallic stents (SEMS) may be limited by tumor in-growth in the setting of malignant obstruction. LAMS creates a de-novo fistulous tract to bypass an obstruction while its saddle shape provides anti-migratory properties and allows apposition of two gastrointestinal lumens. While LAMS has been reported in ALS, there are only rare reports in the management of ELS. Our case highlights a case of successful management of ELS with Axio LAMS.