CT Diagnosis of Afferent Loop Syndrome

Afferent loop syndrome 7-years post Roux-en-Y gastrojejunostomy: An often-forgotten pancreatitis cause. A case report

Afferent loop syndrome is a rare post-operative complication following upper gastrointestinal bypass surgeries, usually occurring within the first two weeks post-operation. This case report, however, outlines afferent loop syndrome almost a decade post-surgery, which was managed conservatively. A 54-year-old woman presented with a few days' history of epigastric pain, vomiting, and constipation. She had undergone a sleeve gastrectomy and was converted to a Roux-en-Y gastrojejunostomy for weight loss 9 and 7 years ago, respectively. Serum lipase was elevated at 1410 IU/L. Computed tomography showed high-grade proximal small bowel obstruction, involving the efferent and afferent loops of the Roux-en-Y gastric bypass. The patient was given intravenous rehydration, electrolyte replacement and had a nasogastric tube inserted. She was discharged on day 5 of admission without significant sequelae. Afferent limb syndrome should be considered in patients with altered upper gastrointestinal anatomy who present with pancreatitis, regardless of the time period post-operatively. Future guidelines should further more outline the factors indicated for surgical versus conservative management.

Endoscopic Ultrasound-Guided Enteroenterostomy for Afferent Limb Syndrome

Afferent limb syndrome (ALS) is a rare complication of duodenopancreatectomy, resulting from the mechanical obstruction of the afferent limb usually after local malignancy recurrence. Management of ALS (ie, surgery and palliative therapy) is often unsatisfactory. We present 5 cases of endoscopic ultrasound-guided internal drainage of the afferent limb using lumen-apposing metal stents. All procedures were successful, with no related complications; 2 patients had a complete regression of their symptoms, one experienced cholangitis recurrence, and 2 patients died after some weeks because of their malignancies. Endoscopic ultrasound-guided enteroenterostomy offers a convenient and safe palliative solution for patients presenting ALS.

Afferent Loop Syndrome with Intestinal Ischemia due to Internal Hernia after Whipple Operation for T2N1M0 Pancreatic Cancer

Afferent loop syndrome is an uncommon complication of Whipple procedure. The often vague and non-specific presentation results in difficulty and/or delay in diagnosis, which may lead to bowel ischemia or perforation. CT can demonstrate characteristic features, yield the diagnosis of afferent loop syndrome, and predict the cause before surgical intervention. We present a rare etiology of acute afferent loop syndrome in a patient 6 weeks after Whipple procedure who was reportedly recovering well, which resulted in prompt surgical intervention.

Afferent Loop Syndrome Due to Volvulus of the Afferent Limb

A 78-year-old woman with a history of stage IIB gastric adenocarcinoma with previous Billroth II subtotal gastrectomy was admitted with pancreatitis, with subsequent development of fevers and acute jaundice. Transabdominal ultrasound demonstrated bile duct obstruction. An endoscopic retrograde cholangiopancreatography was attempted, but the lumen of the afferent limb appeared distorted without an obstructing lesion. A computed tomography scan demonstrated volvulus of the afferent limb near the gastrojejunal anastomosis, with afferent limb dilation and significant biliary dilation.

Retrospective cohort study of 925 OAGB procedures. The UK MGB/OAGB collaborative group

BACKGROUND

Mini-One Anastomosis Gastric Bypass is a new operation that provides comparable outcomes to the common bariatric procedures. Revisional surgery is still needed after a number of MGB-OAGB procedures. The aim of this study is to report the causes and management of these revisions.

METHODS

From 2010 to 2018, 925 MGB-OAGB operations were performed at 7 bariatric units across the United Kingdom and included in this retrospective cohort study. The data was retrospectively collected and analysed. The primary end point was the identification of the causes and management of revisions. Follow up ranged from 6 months to 3 years.

RESULTS

Twenty-two patients [2.3%] required revisional surgery after MGB-OAGB. Five patients [0.5%] developed severe diarrhoea managed by shortening the bilio-pancreatic limb to 150 cm. Four patients [0.4%] developed afferent loop syndrome and bile reflux was reported in another 3 [0.3%] cases; all were managed by either conversion to Roux en Y Gastric Bypass or a Braun anastomosis. Postoperative bleeding was controlled laparoscopically in 3 patients [0.3%]. Liver decompensation that was reported in 2 patients [0.2%] was treated by shortening the BPL in one patient and a reversal to normal anatomy in another. The liver failure resolved in both patients. Other indications for revision included two gastro-jejunal stenosis [0.2%], one perforated ulcer [0.1%], one patient [0.1%] with excessive weight loss and one case [0.1%] of protein malnutrition. None of the 22 patients undergoing revisional surgery after MGB-OAGB died. Lost to follow up rate was 0.2%.

CONCLUSION

Complications requiring revisional surgery after MGB-OAGB are uncommon [2.3%] and the majority can be managed by bilio-pancreatic limb shortening, the addition of a Braun side-to-side anastomosis or conversion to RYGB. Bilio-pancreatic limb length of 200 cm or more resulted in serious complications of liver failure, protein malnutrition, excessive weight loss and diarrhoea.

Endoscopic nasogastric tube insertion for treatment of benign afferent loop obstruction after radical gastrectomy for gastric cancer: A 16-year retrospective single-center study

Afferent loop obstruction is an uncommon complication associated with Billroth-II distal gastrectomy. Inappropriate treatment may result in life-threatening events as perforation and peritonitis. For the benign afferent loop obstruction, Braun or Roux-en-Y reconstruction has been reported as the choice. However, the edematous afferent loop may result in anastomotic fistula. In this study, a less invasive technique was described for treatment of benign afferent loop obstruction. The aim of this study was to investigate the effectiveness and safety of endoscopic nasogastric tube insertion for treatment of benign afferent loop obstruction.We conducted a retrospective review of the data of 2548 gastric cancer patients who underwent distal gastrectomy from January 2002 to January 2018. Patients who developed benign afferent loop obstruction were treated by this procedure. Outcomes were recorded. Follow-up was scheduled at 3, 6, and 12 months after the treatment.Twenty-six patients (1.0%) developed afferent loop obstruction. The median age, consisting of 19 men and 7 women, was 60 years (range 36-69 years). Of these 26 patients, 23 underwent the endoscopic treatment. The obstructive symptoms had a rapid relief in all the 23 patients. No one died due to this procedure. However, 2 patients underwent surgical treatment due to intestinal obstruction because of adhesion at >4 and 7 months after the endoscopic drainage, respectively.Endoscopic nasogastric tube insertion is an effective and safe procedure for treatment of benign afferent loop obstruction. In addition, it could be considered as the first step in treatment, especially in high-surgical-risk patients.

Incarcerated Hiatal Hernia with Perforation after Laparoscopic Total Gastrectomy with Roux-en-Y Reconstruction: a Case Report

The occurrence of hiatal hernia after total gastrectomy with Roux-en-Y reconstruction is rare. We report the case of a 76-year-old man who presented with dyspnea, vomiting, and fever around 8 days after total gastrectomy with Roux-en-Y reconstruction. Abdominal computed tomography revealed a hiatal hernia containing part of the small intestine in the left thoracic cavity. Emergent reduction and repair of the hiatal hernia were performed later. Operative findings revealed that the Roux limb was incarcerated in the left pleural cavity. Esophagojejunostomy leakage, perforation of the small intestine with transient ischemic change, and pyothorax were also found. Thus, feeding jejunostomy, thoracoscopic decortication, and diversion T-tube esophagostomy were performed. Considering that the main cause of hiatal hernia is blunt dissection with division of the phrenoesophageal membrane, approximating the crus with 1 or 2 figure-8 sutures, according to the size of the defect, to prevent the incidence of hiatal hernia after total gastrectomy may be performed.

Stomach Intestinal Pylorus Sparing (SIPS) Surgery for Morbid Obesity: Retrospective Analyses of Our Preliminary Experience

BACKGROUND

Although the duodenal switch (DS) has been the most effective weight loss surgical procedure, it is a small minority of the total bariatric surgical cases performed. Modifications that can make the operation technically simpler and reduce a long-term risk of short bowel syndrome would be of benefit. The aim of this study was to detail our initial experience with a modified DS called stomach intestinal pylorus sparing (SIPS) procedure.

METHODS

Data from patients who underwent a primary SIPS procedure performed by two surgeons at two centers from January 2013 to August 2014 were retrospectively analyzed. All revisions of prior bariatric procedures were excluded. Regression analyses were performed for all follow-up weight loss data.

RESULTS

One hundred twenty-three patients were available. One hundred two patients were beyond 1 year postoperative, with data available for 64 (62 % followed up). The mean body mass index (BMI) was 49.4 kg/m(2). Two patients had diarrhea (1.6 %), four had abdominal hematoma (3.2 %), and one had a stricture (0.8 %) in the gastric sleeve. Two patients (1.6 %) were readmitted within 30 days. One patient (0.8 %) was reoperated due to an early postoperative ulcer. At 1 year, patients had an average change in BMI of 19 units (kg/m(2)), which was compared to an average of 38 % of total weight loss or 72 % of excess weight loss.

CONCLUSIONS

Modification of the classic DS to one with a single anastomosis and a longer common channel had effective weight loss results. Morbidity seems comparable to other stapling reconstructive procedures. Future analyses are needed to determine whether a SIPS procedure reduces the risk of future small bowel obstructions and micronutrient deficiencies.

Gastroduodenal and pancreatic surgeries: indications, surgical techniques, and imaging features

This review article focuses on gastroduodenal and pancreatic surgeries with the goal of identifying radiologic findings that translate to important surgical considerations. The topics covered include partial gastrectomy with reconstruction techniques, total gastrectomy, pancreaticoduodenectomy, and pancreaticojejunostomy. Indications, contraindications, surgical techniques, and postoperative imaging are described within each of these topics. Knowledge of these surgical techniques is extremely helpful for the interpreting radiologists to identify expected postoperative anatomy and related complications that would remain clinically relevant to our surgical colleagues and direct timely patient management.

Afferent Loop Syndrome After Subtotal Gastrectomy With Billroth-II Reconstruction: Etiology and Treatment

The aim of this study was to evaluate the clinical characteristics, treatment, and prognosis of afferent loop syndrome (ALS) following radical subtotal gastrectomy with B-II reconstruction in gastric cancer patients. ALS is an infrequent mechanical complication, which occurs after reconstruction of Billroth-II (B-II) gastrojejunostomy or Roux-en-Y esophagojejunosotomy. From 2002 through 2010, 672 patients who had undergone subtotal gastrectomy with B-II reconstruction for gastric cancer were enrolled. Clinical data, symptom interval, cause, and treatment of 13 ALS patients were reviewed. The body mass index (BMI) of patients who suffered ALS was significantly less than that of patients who did not (P = 0.0244). And, there were significant differences in rates of recurrence (P = 0.0032) and follow-up duration (P = 0.0119) between the two groups. Acute ALS within 1 month occurred in 5 patients (38.5%). Obstructive jaundice or acute pancreatitis occurred in 4 patients (30.1%). The most frequent cause was anastomosis inflammation (6 patients). Only 2 patients required surgery. Most patients with ALS were treated conservatively with or without percutaneous transhepatic biliary drainage (PTBD). Clinical suspicion is of significant importance because ALS is not common and the symptoms are nonspecific. ALS occurs more frequently in low BMI patients than high. PTBD can be considered as a primary treatment option for ALS if rupture of the afferent loop is not present.

Role of percutaneous transhepatic biliary drainage in patients with complications after gastrectomy

OBJECTIVE

The aim of this study was to elucidate the role of PTBD in patients with DSL and ALS post-gastrectomy for malignancy or benign ulcer perforation.

SUMMARY OF BACKGROUND DATA

Percutaneous transhepatic biliary drainage (PTBD) is an interventional radiologic procedure used to promote bile drainage. Duodenal stump leakage (DSL) and afferent loop syndrome (ALS) can be serious complications after gastrectomy.

METHODS

From January 2002 through December 2014, we retrospectively reviewed 19 patients who underwent PTBD secondary to DSL and ALS post-gastrectomy. In this study, a PTBD tube was placed in the proximal duodenum near the stump or distal duodenum in order to decompress and drain bile and pancreatic fluids.

RESULTS

Nine patients with DSL and 10 patients with ALS underwent PTBD. The mean hospital stay was 34.3 days (range, 12-71) in DSL group and 16.4 days (range, 6-48) in ALS group after PTBD. A liquid or soft diet was started within 2.6 days (range, 1-7) in the ALS group and within 3.4 days (range, 0-15) in the DSL group after PTBD. One patient with DSL had PTBD changed, and 2 patients with ALS underwent additional surgical interventions after PTBD.

CONCLUSIONS

The PTBD procedure, during which the tube was inserted into the duodenum, was well-suited for decompression of the duodenum as well as for drainage of bile and pancreatic fluids. This procedure can be an alternative treatment for cases of DSL and ALS post-gastrectomy.

CT of Acute Biliopancreatic Limb Obstruction

OBJECTIVE

Our objective was to report the CT features of biliopancreatic limb (afferent loop) obstruction.

CONCLUSION

Acute biliopancreatic limb obstruction has typical CT features. Given its high morbidity and rate of reoperation, it is useful to make this specific diagnosis instead of reporting the findings as postoperative small bowel obstruction.