Endoscopic Ultrasound-Guided Gastrojejunostomy With Use of Lumen-Apposing Covered Metal Stent (LACMS) for Treatment of Afferent Loop Syndrome

Abstract

Introduction: Afferent loop syndrome (ALS) is a complication that can occur after abdominal surgery causing obstruction to the afferent jejunal loop. ALS occurs when something traps the flow of bile up to and past the surgical anastomosis into the digestive system. The accumulation of bile acid and pancreatic juice causes pressure and occlusion in the afferent limb. Common causes of ALS may be twisting or kinking of the afferent loop, scar tissue, ulceration, or cancer. The incidence of patients developing ALS after a Whipple procedure may be as high as 13%. A patient with ALS is most likely to present with symptoms of cholangitis, abdominal pain, nausea, fullness after eating and sudden vomiting of bilious fluid (Pannala et al). ALS can be lethal if not treated promptly. The most common treatment for ALS is surgery. This is the first case reported using a cold AXIOS stent for the treatment of ALS.Figure 1Figure 2Case Description: The patient is a fifty-one year old male who has a history of pancreatic adenocarcinoma, chronic pancreatitis and post Whipple procedure in August 2013. The patient presents with severe abdominal pain and nausea. Afferent loop obstruction was confirmed on CT. A percutaneous internal-external drain was placed but unsuccessful in treatment. Endoscopic ultrasound revealed severe stenosis of the pancreatoduodectomy afferent limb anastomosis. A novel technique using EUS guided cold AXIOS under fluoroscopy guidance was performed. A 10 mm x 15 mm AXIOS (LACMS) was placed creating a gastro-jejunal anastomosis with decompression of the afferent jejunal limb. Thirty day follow up showed decompression of the afferent limb and proper stent placement. Discussion: Diagnosis of ALS is most often made by abdominal ultrasound, CT, or chlangiography (Yao, et al). Prior to endoscopic and percutaneous techniques, the most common treatment of ALS was surgery. The most commonly used non-surgical treatment of ALS is the percutaneous approach. This case presents the treatment of ALS using a novel endoscopic technique with placement of a cold AXIOS (LACMS) stent for the creation of a gastro-jejunal anastamosis for decompression of the afferent limb. Evidence has shown the endoscopic approach to be an effective treatment for ALS and have less procedure-related complications than other alternatives (Burdick, et al).