Staged percutaneous transhepatic cholangial drainage-assisted endoscopic ultrasound-guided gastrojejunostomy for afferent loop syndrome after pancreaticoduodenectomy: Two case reports

Abstract

BACKGROUND

Afferent loop syndrome (ALS) following pancreaticoduodenectomy (PD) is a rare but serious complication. Traditional management options carry significant limitations. This report describes a novel staged approach combining percutaneous transhepatic cholangial drainage (PTCD) with endoscopic ultrasound-guided gastrojejunostomy (EUS-GE) for the management of ALS.

CASE SUMMARY

We present two cases of ALS following PD. Case 1 involved a 57-year-old male with bile duct cancer who developed ALS 18 months post-PD. Case 2 involved a 50-year-old female with pancreatic duct adenocarcinoma who developed ALS 10 months post-PD. Both were managed with a novel staged approach: Initial PTCD for biliary decompression, followed by PTCD-assisted EUS-GE, where the existing tract was used to opacify and distend the collapsed afferent limb for precise targeting. Technical and clinical success was achieved in both cases. Symptoms associated with bile duct obstruction resolved in both patients following PTCD. Subsequently, PTCD-assisted EUS-GE was performed. Both patients resumed oral intake, had their PTCD catheters removed, and were discharged without complications. During 3 months’ follow-up, both patients-maintained patent stents without requirement for reintervention.

CONCLUSION

Staged PTCD/EUS-GE is a feasible and promising minimally invasive option for managing ALS following PD.

Key Words: Afferent loop syndrome; Pancreaticoduodenectomy; Percutaneous transhepatic cholangial drainage; Endoscopic ultrasound-guided gastrojejunostomy; Minimally invasive; Case report

Core Tip: These case reports describe staged percutaneous transhepatic cholangial drainage-assisted endoscopic ultrasound-guided gastrojejunostomy for afferent loop syndrome after pancreaticoduodenectomy. By using the percutaneous transhepatic cholangial drainage access to distend and visualize the collapsed afferent limb, this technique overcomes the key technical limitation of conventional endoscopic ultrasound-guided gastrojejunostomy; difficulty in identifying the target loop. The approach achieved technical and clinical success in two cases, suggesting it is a feasible minimally invasive option warranting further evaluation.

INTRODUCTION

Pancreaticoduodenectomy (PD) remains the standard curative procedure for malignant tumors of the pancreatic head and periampullary region. While surgical techniques and perioperative care have substantially improved, postoperative complications continue to present significant clinical challenges. Afferent loop syndrome (ALS) is an uncommon but potentially fatal late complication, with reported incidence ranging from 0.3% to 2%[1,2]. ALS occurs when the afferent limb, which carries biliary and pancreatic secretions, becomes obstructed due to various mechanisms including adhesion formation, internal herniation, anastomotic stricture, or tumor recurrence[1,2].

The clinical presentation of ALS typically includes abdominal pain, distension, nausea, and vomiting of bilious material[3]. When complicated by obstructive jaundice due to concomitant biliary obstruction, patients face risks of cholangitis, liver failure, and sepsis. Traditional management strategies for ALS with obstructive jaundice have limitations. Surgical revision, while definitive, has high morbidity and mortality rates in the setting of post-PD anatomy with dense adhesions and altered anatomy. Isolated biliary drainage procedures, including percutaneous transhepatic cholangial drainage (PTCD), can leave patients with persistent enteric obstruction that often requires permanent external drainage with consequent reduced quality of life[4,5].

Endoscopic ultrasound-guided gastrojejunostomy (EUS-GE) has emerged as a promising minimally invasive alternative for the management of gastric outlet obstruction[6], and has been reported for treatment of ALS[7,8]. However, in the specific context of post-PD ALS, EUS-GE faces unique technical challenges, primarily related to difficulty in identifying and accessing the often-collapsed afferent limb. We describe a novel staged approach that combined PTCD with EUS-GE, utilizing the PTCD access to facilitate afferent limb identification and subsequent EUS-GE. This report describes the technical aspects and outcomes of this approach in two consecutive patients.

CASE PRESENTATION

Chief complaints

Case 1: A 57-year-old male who had undergone PD with Child reconstruction for bible duct adenocarcinoma 18 months previously presented with fever.

Case 2: A 50-year-old female who had undergone PD with Whipple procedure for duodenal adenocarcinoma 10 months previously presented with fever and abdominal pain.

History of present illness

The patients’ symptoms began 5 days before visiting the hospital.

History of past illness

No history of alcohol misuse or smoking was reported.

Personal and family history

No personal or family medical history was reported.

Physical examination

The physical examinations showed no positive signs except for jaundice.

Laboratory examinations

Case 1: Laboratory investigations revealed total bilirubin of 11 μmol/L, direct bilirubin of 9 μmol/L, alkaline phosphatase of 725 U/L, and gamma-glutamyl transferase of 552 U/L. Blood culture was positive for Enterococcus gallinarum.

Case 2: Laboratory tests showed total bilirubin of 42.9 μmol/L, direct bilirubin of 26.1 μmol/L, alanine aminotransferase of 816 U/L, aspartate aminotransferase of 579 U/L, alkaline phosphatase of 191 U/L, and gamma-glutamyl transferase of 172 U/L.

Imaging examinations

Case 1: Contrast-enhanced abdominal computed tomography demonstrated dilated intra- and extrahepatic bile ducts with a markedly dilated afferent loop (Figure 1A and B), suggesting mechanical obstruction distal to the bilioenteric anastomosis, likely due to tumor recurrence.

Figure 1 Radiographic images of afferent loop obstruction in case 1. A and B: Computed tomography; C: Percutaneous transhepatic cholangial drainage; D: After completion of percutaneous transhepatic cholangial drainage-assisted endoscopic ultrasound-guided gastrojejunostomy. Yellow arrow indicates the obstructed loop; blue arrow indicates the jejunum near the stomach; green arrow indicates the stomach; black arrow indicates the lumen-apposing metal stent.

Case 2: Magnetic resonance imaging revealed dilated biliary radicals and a significantly dilated afferent loop (diameter 3.2 cm), suggesting adhesive ALS with secondary biliary obstruction.

FINAL DIAGNOSIS

Both patients were diagnosed with ALS. Diagnosis of ALS was based on combination of clinical presentation and imaging findings. Diagnostic criteria included: (1) Clinical symptoms of abdominal pain, distension, nausea, and/or vomiting; (2) Imaging evidence of a dilated afferent loop (defined as jejunal limb diameter ≥ 3.0 cm on computed tomography or magnetic resonance cholangiopancreatography, in contrast to the normal postoperative diameter of < 2.0 cm); and (3) Demonstration of obstruction at or below the level of the bilioenteric or pancreaticoenteric anastomosis, with no contrast transit into the efferent limb on delayed-phase imaging. In both cases, the suspected etiology was tumor recurrence vs benign adhesive obstruction. The differential diagnosis was assessed by: (1) Temporal relationship to the initial surgery (18 months and 10 months post-PD, respectively); (2) Serial imaging showing progressive loop dilation; and (3) Absence of high-grade anastomotic stricture on PTCD. However, histopathological confirmation was not obtained in either case.

TREATMENT

Both patients were deemed poor surgical candidates and proceeded directly to the staged interventional approach. A staged PTCD/EUS-GE approach was used. In the first stage, under local anesthesia, PTCD was performed with placement of an 8-Fr drainage catheter. Postprocedural bile output averaged 800-1000 mL daily. After 7 days, there was no fever or jaundice, with clinical improvement in the patient’s general condition. Percutaneous cholangiography indicated obstruction of the intestinal loop (Figure 1C).

The second stage involved EUS-GE performed under general anesthesia. After routine scanning with a gastroscope, linear echoendoscopy was performed. The afferent limb was poorly visualized initially. Through the PTCD catheter, 350 mL contrast-mixed saline was instilled, resulting in progressive dilation and clear sonographic visualization of the afferent limb. The criteria for adequate afferent-limb distension included the following: (1) Sonographic visualization of the afferent loop as a clearly demarcated anechoic/hypoechoic tubular structure immediately apposed to the gastric wall, with a measurable luminal diameter of ≥ 2.5 cm; (2) Fluoroscopic confirmation of contrast opacification throughout the target segment without extravasation; (3) Sufficient bowel wall apposition against the stomach to allow deployment of a 15-mm lumen-apposing metal stent (LAMS; Hot AXIOS; Boston Scientific, MA, United States), without interposed intervening structures. The contrast agent-saline mixture was prepared at a 1:3 ratio (1 mL contrast agent: 150 mL saline per 200-mL aliquot), instilled manually through the PTCD catheter using a 50-mL syringe with gentle hand pressure. No pressure monitoring device was used; instead, instillation was continued until the afferent limb was adequately distended as judged by real-time ultrasound visualization. The total volume was 300-350 mL per case.

A puncture site was selected at the gastric body where the stomach wall and distended afferent limb were apposed, with Doppler confirmation of the avascular pathway. A 15-mm LAMS was deployed under endoscopic ultrasound and fluoroscopic guidance. Immediate efflux of bile through the stent confirmed successful anastomosis (Figure 1D). The procedural steps are illustrated in Figure 2. The PTCD catheter was removed only after the patient had resumed full oral diet for ≥ 48 hours without symptoms.

Figure 2 Procedural steps of percutaneous transhepatic cholangial drainage-assisted endoscopic ultrasound-guided gastrojejunostomy. PTCD: Percutaneous transhepatic cholangial drainage; EUS-GE: Endoscopic ultrasound-guided gastrojejunostomy; LAMS: Lumen-apposing metal stent.

OUTCOME AND FOLLOW-UP

Technical success: PTCD and PTCD/EUS-GE were successfully performed in both patients (Figure 2). Clinical success: After PTCD, both patients showed rapid resolution of symptoms associated with bile duct obstruction and cholangitis, and a significant decrease in bilirubin levels. After EUS-GE, both patients resumed diet on day 2, the PTCD was removed, they were discharged after uneventful recovery. Key procedural and outcome parameters are summarized in Table 1. Complications: There were no cases of bleeding or perforation.

Table 1 Key procedural and outcome parameters of percutaneous transhepatic cholangial drainage-assisted endoscopic ultrasound-guided gastrojejunostomy.

Parameter	Case 1	Case 2	Average
PTCD/EUS-GE interval (days)	7	7	7
Instillation volume (mL)	350	300	325
Procedure time (minutes)	25	30	27.5
Technical success	Yes	Yes	100%
Clinical success	Yes	Yes	100%
Complications	None	None	0%
Hospital stay (days)	12	11	11.5

PTCD: Percutaneous transhepatic cholangial drainage; EUS-GE: Endoscopic ultrasound-guided gastrojejunostomy.

DISCUSSION

The management of ALS following PD is a significant clinical challenge. The staged PTCD/EUS-GE approach described in these cases offers a novel solution that addresses both the biliary and enteric components of this complex condition.

The key innovation of this approach lies in the strategic utilization of PTCD beyond its conventional role as a biliary decompressive measure. By using the PTCD access to actively dilate and visualize the afferent limb, we overcame the primary technical obstacle in EUS-GE for ALS - the identification and targeting of an often collapsed and anatomically ambiguous intestinal segment. This PTCD-guided navigation significantly enhances the safety and precision of the subsequent EUS-GE procedure. Several other minimally invasive approaches have been described for ALS with obstructive jaundice. Isolated PTCD provides effective biliary decompression but leaves the patient with persistent enteric obstruction and an external drainage catheter, with associated risks of electrolyte depletion, nutritional compromise, and reduced quality of life. Enteral stenting via balloon-assisted enteroscopy has been reported for ALS[3], but requires precise endoscopic access through the altered post-PD anatomy, which may be technically challenging or impossible in cases of complete obstruction or long-segment strictures. Surgical revision, while definitive, carries the highest morbidity of all options, with reoperation rates associated with substantially increased morbidity and mortality in the post-PD setting. Broader recent experience with endoscopic ultrasound-guided gastrointestinal bypass for malignant gastric outlet obstruction has been encouraging, with technical success rates exceeding 90% in many series[9]. However, these data come from patients with intact anatomy or simpler Roux-en-Y configurations, and direct extrapolation to the post-PD setting with a collapsed afferent limb is not straightforward. Our staged approach addresses this specific limitation by using the PTCD access to actively distend and visualize the target loop, potentially expanding the applicability of EUS-GE to this challenging cohort.

This staged approach offers several advantages over existing management strategies. Compared to surgical revision, it provides a minimally invasive alternative with presumably reduced morbidity, shorter hospital stay, and faster recovery. Unlike isolated PTCD, it offers a definitive solution that addresses the underlying enteric obstruction, eliminating the need for permanent external drainage and its associated complications, including electrolyte imbalances, nutritional deficiencies, and diminished quality of life.

Based on our experience with these cases, several technical aspects deserve emphasis. First, the interval between PTCD and EUS-GE (approximately 7 days in both cases) allows for adequate biliary decompression and clinical stabilization, potentially reducing the risk of procedure-related complications. Second, the volume of instilled contrast agent-saline mixture (300-350 mL) appears sufficient for adequate loop distension without risking overdistension injury. Third, the use of LAMS provides immediate secure apposition between the gastric and jejunal walls, minimizing leakage risk.

Both procedures were completed without major complications. The absence of significant adverse events, particularly perforation or bleeding, in these complex cases underlines the safety of this approach when performed by experienced operators. The strategic distension of the afferent limb through the existing PTCD access likely contributes to this safety profile by providing a well-defined target for puncture and stent deployment. While no major complications occurred in our two cases, the staged PTCD/EUS-GE approach carries several procedure-specific risks that warrant consideration: (1) Afferent limb overdistension: Injection of 300-350 mL of contrast agent-saline mixture carries a theoretical risk of excessive luminal pressure leading to bowel wall ischemia or perforation. The distension was performed under real-time ultrasound guidance with careful monitoring for patient discomfort; however, a defined pressure limit is currently lacking; (2) Bile leakage and peritonitis: The PTCD tract provides an avenue for potential bile leakage, particularly during injection; no leakage was observed fluoroscopically in our cases; (3) Tumor seeding along the PTCD tract: Although uncommon, this is a recognized risk of PTCD in the setting of malignancy, especially in bile duct cancer[10]; (4) LAMS-related complications: Delayed complications including stent migration, bleeding, tissue overgrowth, or food impaction have been reported in 10%-15% of EUS-GE cases in some series[11]; and (5) Stent occlusion: Although both patients had patent stents at 3 months’ follow-up, longer-term patency requires further surveillance.

CONCLUSION

The staged PTCD/EUS-GE approach represents a promising minimally invasive alternative for the management of ALS following PD. This technique effectively addresses the dual pathology of biliary and enteric obstruction while leveraging the PTCD access to overcome the key technical challenges of conventional EUS-GE. While larger prospective studies are needed to validate these preliminary findings and establish long-term outcomes, this approach offers a new paradigm in the management of this complex condition.