• Afferent loop syndrome
• Case report
• Digestive tract radiography
• Endoscopic
• Recurrent fever

Afferent loop syndrome is reported to be one of the very rare complications after gastrojejunostomy. The usual presentation in patients is with abdominal pain, distension and vomiting. It may present acutely because of complete obstruction, usually occurs early after surgery and is lethal in its course unless treated promptly with surgical management. In chronic cases obstruction is intermittent. There may be a reflux of bowel material into the biliary system and because of bacterial overgrowth patient may present with ascending cholangitis and obstructive jaundice. Here we report a case of 43-year-old gentleman presenting with jaundice, diffuse abdominal pain and distension. Later on, he was found to have a recurrence of gastric carcinoma associated with peritoneal carcinomatosis after subtotal gastrectomy and gastrojejunostomy for gastric carcinoma one year ago. He was diagnosed to be a case of afferent loop syndrome presenting as obstructive jaundice. The patient was managed conservatively by endoscopic decompression after confirmation of the diagnosis of afferent loop syndrome. 

• Endoscopic retrograde cholangiopancreatography
• Endoscopic ultrasonography
• Gastric outlet obstruction
• Malignant biliary obstruction
• Pancreatic cancer
• Stents

• Cholangiopancreatography, Endoscopic Retrograde
• Cholestasis
• Endosonography
• Gastric Outlet Obstruction/diagnosis
• Gastric Outlet Obstruction/etiology
• Gastric Outlet Obstruction/surgery
• Humans
• Palliative Care
• Pancreatic Neoplasms/complications
• Pancreatic Neoplasms/diagnosis
• Stents
• Treatment Outcome

Afferent loop syndrome is an uncommon postoperative complication. Currently, we lack a therapeutic option for treatment of malignant afferent loop obstruction following procedures like Whipple's. Here we present a case of afferent loop obstruction in a known case of pancreatic carcinoma, status after Whipple’s procedure, in which we used a percutaneous transhepatic approach to relieve the afferent loop obstruction using a self-expanding bare metal stent.

• aesthetically acceptable
• afferent loop syndrome
• non-surgical possibilities
• percutaneous transhepatic metallic stent insertion
• whipple’s

Afferent loop obstruction (ALO) is defined as duodenal or jejunal mechanical obstruction at the proximal anastomosis site of a gastrojejunostomy. With advances in chemotherapy, the incidence of malignant ALO is increasing. Malignant ALO can be complicated by ischemia, gangrenous bowel, pancreatitis, and ascending cholangitis. Moreover, the general condition of patients with recurrent cancer is often poor. Therefore, accurate and rapid diagnosis and minimally invasive treatments are required. However, no review articles on the diagnosis and treatment of malignant ALO have been published. Through literature searching, we reviewed related articles published between 1959 and 2020 in the PubMed database. Herein, we present recent advances in the diagnosis and treatment of malignant ALO and describe future perspectives. Endoscopic transluminal self-expandable metal stent (SEMS) placement is considered the standard treatment for malignant ALO, as this procedure is well established and less invasive. However, with the development of interventional endoscopic ultrasound (EUS) in recent years, the usefulness of EUS-guided gastrojejunostomy has been reported. Moreover, through indirect comparison, this approach has been reported to be superior to transluminal SEMS placement. It is expected that a safer and less invasive treatment method will be established through the continued advancement and innovation of interventional endoscopy techniques.

• Malignant afferent loop obstruction
• Endoscopic self-expandable metal stent placement
• Endoscopic ultrasound guided gastrojejunostomy
• Lumen-apposing metal stent

• Afferent loop syndrome
• Comparative study
• Laparoscopy
• Pancreaticoduodenectomy
• Postoperative complications

• Afferent Loop Syndrome/surgery
• Aged
• Digestive System Neoplasms/surgery
• Female
• Humans
• Laparoscopy
• Male
• Middle Aged
• Pancreaticoduodenectomy/methods
• Postoperative Complications/surgery
• Reoperation/statistics & numerical data
• Retrospective Studies
• Risk Factors
• Suture Techniques

• Endoscopic Ultrasound
• Intestinal Obstruction
• Stents

• Adolescent
• Adult
• Afferent Loop Syndrome/etiology
• Afferent Loop Syndrome/surgery
• Aged
• Female
• Humans
• Jejunostomy/methods
• Male
• Middle Aged
• Pancreatectomy/adverse effects
• Pancreatic Neoplasms/surgery
• Postoperative Complications/etiology
• Postoperative Complications/prevention & control
• Prospective Studies
• Young Adult

• Afferent loop syndrome
• Braun anastomosis
• Pancreaticoduodenectomy
• Pancreaticojejunostomy
• Postoperative complications
• Roux-en-Y anastomosis

• Biliary stasis
• Double-balloon enteroscopy
• Hepaticojejunostomy
• Hepatobiliary scintigraphy
• Nonobstructive afferent loop syndrome

One of the most difficult biliary drainages is the recurrence and stenosis on afferent loop after surgery. We report an original case of hepaticogastrostomy (HGE) in a patient who had malignant stenosis of afferent loop after cephalic duodenopancreatectomy (CDP). After failure of the gastrointestinal stent, two metal self-expandable stents were placed by endoscopic ultrasound (EUS) after puncture of the dilated left hepatic duct. On clinical improvement and disappearance of jaundice, palliative chemotherapy was started.

• afferent loop syndrome
• endoscopic treatment
• metal enteral stent
• pancreaticoduodenectomy

Progress in double-balloon endoscopy (DBE) has allowed for the diagnosis and treatment of disease in the postoperative bowel. For example, a short DBE, which has a 2.8 mm working channel and 152 cm working length, is useful for endoscopic retrograde cholangiopancreatography in bowel disease patients. However, afferent loop and Roux-limb obstruction, though rare, is caused by postoperative recurrence of biliary tract cancer with intractable complications. Most of the clinical findings involving these complications are relatively nonspecific and include abdominal pain, nausea, vomiting, fever, and obstructive jaundice. Treatments by surgery, percutaneous transhepatic biliary drainage, percutaneous enteral stent insertion, and endoscopic therapy have been reported. The general conditions of patients with these complications are poor due to cancer progression; therefore, a less invasive treatment is better. We report on the usefulness of metallic stent insertion using an overtube for afferent loop and Roux-limb obstruction caused by postoperative recurrence of biliary tract cancer under short DBE in two patients with complexly reconstructed intestines.

• Afferent loop obstruction
• Double balloon endoscopy
• Overtube
• Metallic stent
• Biliary tract cancer

• gastrectomy - PTBD - duodenal stump leakage - afferent loop syndrome

• Adenocarcinoma/complications
• Adenocarcinoma/surgery
• Aged
• Endoscopy
• Humans
• Intestinal Obstruction/etiology
• Intestinal Obstruction/surgery
• Jejunal Diseases/etiology
• Jejunal Diseases/surgery
• Male
• Neoplasm Recurrence, Local/complications
• Pancreatic Neoplasms/complications
• Pancreatic Neoplasms/surgery
• Pancreaticoduodenectomy
• Quality of Life
• Self Expandable Metallic Stents
• Pancreatic Neoplasms

We present a case of afferent loop syndrome (ALS) occurring after pancreaticoduodenectomy (PD) in a patient who had previously undergone total gastrectomy (TG), and review the English-language literature concerning reconstruction procedures following PD in patients who had undergone TG. The patient was a 69-year-old man who had undergone TG reconstruction by a Roux-en-Y method at age 58 years. The patient underwent PD for pancreas head adenocarcinoma. A jejunal limb previously made at the prior TG was used for pancreaticojejunostomy and hepaticojejunostomy. Despite normal patency of the hepaticojejunostomy, he suffered from repeated postoperative cholangitis which was brought on by ALS due to shortness of the jejunal limb (15 cm in length). We therefore performed receliotomy in which the hepaticojejunostomy was disconnected and reconstructed using a new Y limb 40-cm in length constructed in a double Roux-en-Y fashion. The refractory cholangitis resolved immediately after the receliotomy and did not recur. Review of the literature revealed the lack of any current consensus for a standard procedure for reconstruction following PD in patients who had previously undergone TG. This issue warrants further attention, particularly given the expected future increase in the number of PDs in patients with a history of gastric cancer.

• Pancreaticoduodenectomy following total gastrectomy
• Afferent loop syndrome after pancreaticoduodenectomy

• Adenocarcinoma/pathology
• Adenocarcinoma/surgery
• Afferent Loop Syndrome/diagnosis
• Afferent Loop Syndrome/etiology
• Afferent Loop Syndrome/surgery
• Aged
• Anastomosis, Roux-en-Y
• Cholangitis/etiology
• Gastrectomy/adverse effects
• Humans
• Male
• Pancreatic Neoplasms/pathology
• Pancreatic Neoplasms/surgery
• Pancreaticoduodenectomy/adverse effects
• Plastic Surgery Procedures/adverse effects
• Reoperation
• Stomach Neoplasms/pathology
• Stomach Neoplasms/surgery
• Treatment Outcome

• Afferent loop syndrome
• Endoscopic treatment
• Obstructive jaundice
• Pylorus preserving pancreaticoduodenectomy

• Adenocarcinoma/therapy
• Adult
• Afferent Loop Syndrome/etiology
• Afferent Loop Syndrome/therapy
• Aged
• Aged, 80 and over
• Anastomosis, Surgical/adverse effects
• Catheterization
• Chemoradiotherapy, Adjuvant/adverse effects
• Constriction, Pathologic/etiology
• Drainage
• Female
• Humans
• Intestines/pathology
• Intestines/radiation effects
• Logistic Models
• Male
• Middle Aged
• Neoplasm Recurrence, Local/complications
• Pancreatic Neoplasms/therapy
• Pancreaticoduodenectomy/adverse effects
• Radiation Injuries/complications
• Retrospective Studies
• Stents
• Time Factors
• Ulcer/etiology
• Ulcer/pathology

• Afferent loop necrosis
• Cholangiojejunostomy
• Roux-en-Y reconstruction

Patients with resection of stomach and especially with Billroth II reconstruction (gastro jejunal anastomosis), are more likely to develop afferent loop syndrome which is a rare complication. When the afferent part is obstructed, biliary and pancreatic secretions accumulate and cause the distention of this part. In the case of a complete obstruction (rare), there is a high risk developing necrosis and perforation. This complication has been reported once in the literature.

A 54-year-old Greek male had undergone a pancreato-duodenectomy (Whipple procedure) one year earlier due to a pancreatic adenocarcinoma. Approximately 10 months after the initial operation, the patient started having episodes of cholangitis (fever, jaundice) and abdominal pain. This condition progressively worsened and the suspicion of local recurrence or stenosis of the biliary-jejunal anastomosis was discussed. A few days before his admission the patient developed signs of septic cholangitis.

Our case demonstrates a rare complication with serious clinical manifestation of the afferent loop syndrome. This advanced form of afferent loop syndrome led to the development of huge enterobiliary reflux, which had a serious clinical manifestation as cholangitis and systemic sepsis, due to bacterial overgrowth, which usually present in the afferent loop. The diagnosis is difficult and the interventional radiology gives all the details to support the therapeutic decision making. A variety of factors can contribute to its development including adhesions, kinking and angulation of the loop, stenosis of gastro-jejunal anastomosis and internal herniation. In order to decompress the afferent loop dilatation due to adhesions, a lateral-lateral jejunal anastomosis was performed between the afferent loop and a small bowel loop.