Endoscopic Management of Afferent Loop Syndrome: Case of Recurrent Gastric Cancer Leading to Pancreatitis and Gastric Outlet Obstruction

Abstract

Introduction: Afferent loop syndrome (ALS) is a rare complication of Bilroth ll gastrojejunostomy. ALS occurs due to a mechanical obstruction of the afferent limb secondary to anastomotic site stricture, cancer recurrence, peritoneal metastasis, volvulus, intussusceptions, internal hernia, or abdominal adhesion after surgery. Case presentation: 82 years old woman with the history of stage lllc gastric adenocarcinoma underwent Billroth ll gastrectomy. One year later, the patient was admitted with pancreatitis and ALS that was managed conservatively. At that time, some overgrowth of tissue was noted at the gastrojejunostomy (GJ) anastomosis on EGD. However, the endoscope was easily passed to the afferent loop which was found to be distended and filled with food debris, suggestive of partial obstruction. 3 months later, while continuing her chemotherapy, patient presented with nausea, vomiting, and abdominal distension. CT scan also showed obstruction of the afferent limb which was markedly dilated. EGD confirmed recurrence of tumor at GJ anastomosis and significant narrowing at the entrance of the afferent loop. A 22mm, 9cm uncovered self-expandable metal stent (SEMS) was placed in the afferent loop. The proximal tip of the stent placed in the gastric pouch. Then a 22 mm, 12 cm uncovered SEMS was placed in the efferent loop, bridging the partial obstruction of GJ anastomosis. Proximal end of the stent was positioned just above gastroesophageal junction to reduce chance of migration. This method of stenting was performed to facilitate passage of food directly to the efferent loop. The afferent loop stent ending in the gastric pouch would decompress the afferent loop without causing obstruction of the efferent side. After the procedure, abdominal distension resolved, and the patient was able to eat without nausea or vomiting. Discussion: ALS can be managed surgically, endoscopically or percutaneously. However, surgical management is usually avoided if recurrence of malignancy is the etiology of ALS. Percutaneous placement of drainage catheter into the afferent loop, for decompression purposes, has the risk of leakage of enteric contents to the peritoneum and infection. Endoscopic management with placement of uncovered SEMS in the afferent loop, or in both loops, such as in this case with efferent and afferent loop obstruction, appears to be of less risk and excellent palliative choice in patients with recurrence of malignancy.2150_A Figure 1. Endoscopic image of Stent Placement in Afferent and Efferent Loops2150_B Figure 2. Fluoroscopic image of Stent Placement in Afferent and Efferent Loops2150_C Figure 3. Efferent loop stent tip at GE junction