Afferent loop syndrome (ALS) is a rare mechanical complication that occurs after reconstruction of the stomach or esophagus to the jejunum, such as Billroth II gastrojejunostomy, Roux-en-Y gastrojejunostomy, or Roux-en-Y esophagoje-junostomy. Traditionally, an operation is the first choice for benign causes. However, for patients in poor physical condition who experience ALS soon after R0 resection, the type of treatment remains controversial. Here, we present an efficient conservative method to treat ALS.

Case 1 was a 69-year-old male patient who underwent total gastrectomy with Roux-en-Y jejunojejunostomy. On postoperative day (POD) 10 he developed symptoms of ALS that persisted and increased over 1 wk. Case 2 was a 59-year-old male patient who underwent distal gastrectomy with Billroth II gastrojejunostomy. On postoperative day POD 9 he developed symptoms of ALS that persisted for 2 wk. Both patients underwent fluoroscopic-guided nasointestinal tube placement with maintenance of continuous negative pressure suction. Approximately 20 d after the procedure, both patients had recovered well and were discharged from hospital after removal of the tube. At 3-mo follow-up, there were no signs of ALS in these two patients.

This is the first report of treating postoperative ALS by fluoroscopic-guided nasointestinal tube placement. Our cases demonstrate that this procedure is an effective and safe method to treat ALS that relieves patients' symptoms and avoids complications caused by other invasive procedures.

Self-expanding metal stent placement is a useful procedure for intestinal obstruction. Afferent loop syndrome after gastrectomy is an uncommon complication of gastroenterostomy reconstruction. Ascending cholangitis caused by afferent loop syndrome is a potential, but rare, complication.

A 73-year-old man with abdominal pain and vomiting was admitted to the emergency room. His medical history was significant for subtotal gastrectomy with Billroth II anastomosis for benign gastric ulcer perforation 40 years prior. He had notable tenderness to palpation, particularly on the epigastric area, and a temperature of 39.0°C.

Abdominal computed tomography revealed afferent loop syndrome with ascending cholangitis caused by remnant gastric cancer.

Percutaneous catheter drainage for management of ascending cholangitis was performed on the day of admission. He was subsequently treated with self-expandable metal stent insertion into the stenotic lesion.

After treatment with percutaneous transhepatic insertion of a self-expanding stent, the patient achieved complete resolution of symptoms. The patient died of disease progression 2 months later, without further recurrence of afferent loop syndrome.

Our case shows that insertion of a metal stent via percutaneous transhepatic biliary drainage (PTBD) can effectively treat ascending cholangitis and resolve afferent loop syndrome in inoperable patients.

Afferent loop syndrome (ALS) is a rare and dreaded complication after pancreaticoduodenectomy (PD). Malignant ALS after PD is usually difficult to manage due to patients' poor condition. Effective and safe therapeutic strategies for these patients are reported scarcely at present.

To analyze and evaluate the clinical characteristics and treatment of these patients.

We analyzed 3 patients with malignant ALS after PD. They were treated by endoscopic enteral metal stent placement in our hospital. Meanwhile we retrospectively reviewed 49 cases with ALS after PD through available English literature. All these patients' clinical features, laboratory study, treatment and outcome were evaluated.

A total of 52 cases were analyzed in the study. The most common presenting symptoms of ALS after PD were jaundice (56.5%), upper abdominal pain (45.7%), fever (26.1%), and vomiting (23.9%). Sixty percent of ALS cases were caused by tumor recurrence. The mean time from prior surgery to diagnosis of ALS was 13.3 months. The rates of treatment with the endoscopic approach, percutaneous stenting or drainage, surgery, and the conservative method were 40.4%, 32.7%, 11.5%, and 15.4%, respectively. Endoscopic enteral metal stent placement proved more effective and less invasive in the treatment of malignant ALS after PD.

Cholangitis and cholangiectasis are the major manifestations of malignant ALS after PD. Invasive interventions are enjoying more and more acceptance for treatment. Endoscopic enteral metal stent placement appears to be a promising technique with effective palliation in these patients.

To investigate the feasibility of percutaneous drainage via the blind end of the jejunal limb (BEJL) for afferent limb syndrome and pancreatic fistula.

Percutaneous drainage via the BEJL was performed in eight patients (seven men and one woman; mean age, 63 y; range, 42-71 y) presenting with afferent limb syndrome (n = 6) or pancreatic fistula (n = 2) following pancreatoduodenectomy or bile duct resection with reconstruction at our institute from March 2005 to June 2013. Reconstruction was performed by using a modified Child method or the Roux-en-Y method, and the BEJL was surgically fixed to the abdominal wall. Afferent limb syndrome was caused by tumor recurrence or postoperative complications. Technical success, clinical success, and complications were evaluated retrospectively.

Technical success of drainage via BEJL was achieved in all patients. Drainage catheters (5-10 F) were inserted into the afferent limbs of six patients, into the pancreatic duct of one patient, and into the pancreatic fistula of one patient. Metallic stents were subsequently placed to address malignant afferent limb obstruction in two patients. Clinical success was achieved in seven patients (87.5%), and no patients developed major complications. Drainage catheters were removed from four patients. The mean catheter indwelling period in all patients was 143 days (range, 21-292 d).

Percutaneous drainage via BEJL after pancreatoduodenectomy or bile duct resection may be a feasible treatment for afferent limb syndrome and pancreatic fistula.

In the treatment of afferent loop syndrome, jejunostomy or Roux-en-Y gastrojejunostomy have tended to represent the preferred procedures. In patients who are not good candidates for surgery, palliative treatment-i.e., percutaneous transhepatic biliary drainage or percutaneous direct transperitoneal jejunostomy techniques-have been applied. Transhepatic biliary drainage confers a risk of ascending cholangitis. Direct percutaneous transperitoneal drainage may be impractical when overlying bowel loops prevent access to deeply located afferent loops. In the present case, percutaneous jejunostomy through the liver parenchyma was performed successfully for palliation of afferent loop syndrome.

Afferent loop syndrome caused by an impacted enterolith is very rare, and endoscopic removal of the enterolith may be difficult if a stricture is present or the normal anatomy has been altered. Electrohydraulic lithotripsy is commonly used for endoscopic fragmentation of biliary and pancreatic duct stones. A 64-year-old man who had undergone subtotal gastrectomy and gastrojejunostomy presented with acute, severe abdominal pain for a duration of 2 hours. Initially, he was diagnosed with acute pancreatitis because of an elevated amylase level and pain, but was finally diagnosed with acute afferent loop syndrome when an impacted enterolith was identified by computed tomography. We successfully removed the enterolith using direct electrohydraulic lithotripsy conducted using a transparent cap-fitted endoscope without complications. We found that this procedure was therapeutically beneficial.

The purpose of this article is to assess the technical feasibility and clinical effectiveness of the placement of partially covered self-expandable dual stents in patients with afferent loop syndrome.

Data from 13 consecutive patients who had undergone partially covered dual stent placement for afferent loop syndrome after various types of surgery were retrospectively analyzed. Nine patients underwent stent placement via the percutaneous transhepatic biliary drainage tract, and four patients underwent placement via the peroral route. A total of 16 stents were used in this study (i.e., 15 dual stents and one fully covered esophageal stent).

The route of stent insertion was determined on the basis of each patient's general condition, the site of obstruction, anatomic variations, and associated symptoms. Stent placement was technically successful in all patients. After stent placement, 12 of 13 patients experienced normalization of their abnormal biliary laboratory findings and decompression of the dilated bowel loop, whereas the remaining patient showed no change. This patient had to undergo the additional treatment of surgical jejunojejunostomy. No procedure-related complications occurred in any patients enrolled in this study.

Placement of partially covered dual stents appears to be a promising technique that may offer successful palliation for patients who develop afferent loop syndrome after various types of surgery.

The author reports successful outcomes after percutaneous transhepatic placement of covered, self-expandable nitinol stents in two patients who had afferent loop syndrome caused by recurrent gastric carcinoma. A 46-year-old woman and a 60-year-old man who had undergone subtotal gastrectomy and gastrojejunostomy (Billroth II) were both admitted with symptoms of afferent loop syndrome. In each patient, enhanced abdominal computed tomography showed marked dilation of the jejunal limb and intrahepatic bile ducts incident to recurrent gastric carcinoma. Percutaneous transhepatic biliary drainage was successfully performed, and a multi-sidehole drainage catheter was placed beyond the papilla of Vater. Successful palliation of the afferent loop obstruction was achieved by placing a covered, self-expandable nitinol stent through the transhepatic biliary drainage route. There were no procedure-related complications, and both patients showed clinical improvement.

The purpose of this study was to investigate the clinical effectiveness of percutaneous tube enterostomy in afferent loop syndrome presenting as jaundice. Tube enterostomy was successfully performed in seven patients without procedural complications. The serum bilirubin level normalized in five patients but remained elevated in the other two, presumably related to more proximal bile duct obstruction. Percutaneous tube enterostomy is an effective palliative treatment in afferent loop syndrome presenting as an obstructing jaundice. However, coexisting biliary obstruction might be problematic for relieving jaundice with tube enterostomy.

Afferent loop syndrome (ALS) is a debilitating complication of recurrent gastric cancer. Surgical intervention is usually not feasible in the face of poor general performance, presence of advanced peritoneal carcinomatosis and limited survival of the patients. Non-surgical approaches include internal drainage by stenting at the stenotic or anastomotic site and external drainage via the percutaneous routes. Percutaneous transhepatic duodenal drainage (PTDD) has been shown to provide effective palliation for ALS, but long-term catheterization is usually inevitable. We hereby present two cases of recurrent gastric cancer whose ALS was successfully treated with PTDD followed by weekly 24-h infusion of high-dose 5-fluorouracil and leucovorin (HDFL). PTDD rapidly ameliorated the incapacitating symptoms of ALS, and the effective, low-toxicity chemotherapy subsequently led to tumor regression, restoration of bowel patency and removal of the drainage tube. At present, both patients have remained ALS-free and drainage-free for 16 and 17 months, respectively. Our results indicate that this non-surgical approach with PTDD followed by weekly HDFL could serve as a safe and effective treatment for ALS in recurrent gastric cancer complicated by peritoneal carcinomatosis.