Seetha Lakshmanan, MD1, Nabil Toubia, MD2, Vincent Armenio, MD2, Abdul S. Calvino, MD, MPH, FACS2 1Kent Hospital, Warwick, RI; 2Roger Williams Medical Center, Providence, RI
Introduction: Afferent loop syndrome (ALS) is a complication caused by obstruction of the biliopancreatic limb after gastrointestinal reconstruction. Re-operation is preferred in surgically fit patients, but higher-risk patients have limited surgical options. We present a case of ALS secondary to duodenal cancer recurrence after a Whipple procedure, treated successfully with the novel endoscopic ultrasound-guided gastrojejunostomy stent placement (EUS-GJ).
Case Description/Methods: A 60-year-old man with advanced duodenal adenocarcinoma post-Whipple procedure presented with worsening abdominal pain, nausea and anorexia. CT Abdomen revealed pancreatic mass suspicious for local recurrence, distended afferent loop proximal to the mass and multiple liver metastases. Decompression by endoscopic approach was planned to avoid surgical morbidity due to his advanced malignancy. The first attempt to place an intraluminal stent however failed because the afferent limb was significantly looped, preventing us from reaching the area of obstruction. The alternative was to use EUS-GJ from the stomach to the obstructed afferent loop. Using an echoendoscope, the measured distance between the stomach wall and bowel loop was 5.4mm, ideal for GJ stent placement. A fistula was created and a 20mmx1cm lumen-apposing Axios stent was deployed opposing the afferent loop to the distal gastric body wall. A large amount of bile was immediately seen gushing through the stent. The stent was cannulated using a 5.5cm CRE 15mm balloon, with dilation performed at 15mm and held for 1 minute. Within 24 hours post-procedure, the patient’s symptoms had improved significantly. Follow-up CT Abdomen demonstrated decompression of the obstructed loop with a stent in place without any intra-abdominal complications.
Discussion: ALS post-Whipple procedure has been reported in 13% of patients, especially those who survive >3 years following surgery. In these cases, palliative approaches remain the mainstay of treatment. Novel endoscopic procedures, like the one presented here, have encouraging success rates with lower complications compared to other reported procedures. In our patient, multidisciplinary collaboration helped us identify innovative potential endoscopic solutions that allowed us to avoid more morbid surgical interventions. A team experienced in this advanced technique in collaboration with a surgical team is crucial to identify patients who could potentially benefit from this procedure.
Figure: Image Above: Shows the area of recurrence and obstruction with distended proximal afferent loop Image Below: Shows the Axios stent in place between the gastric fundus and the decompressed afferent jejunal loop
Disclosures:
Seetha Lakshmanan indicated no relevant financial relationships.
Nabil Toubia indicated no relevant financial relationships.
Vincent Armenio indicated no relevant financial relationships.
Abdul Calvino indicated no relevant financial relationships.
Seetha Lakshmanan, MD1, Nabil Toubia, MD2, Vincent Armenio, MD2, Abdul S. Calvino, MD, MPH, FACS2. P1725 - Endoscopic Ultrasound-Guided Gastrojejunostomy Stent Placement: A Novel Technique to Manage Afferent Loop Syndrome, ACG 2021 Annual Scientific Meeting Abstracts. Las Vegas, Nevada: American College of Gastroenterology.
