University of California Irvine Orange, CA, United States
Jennifer Kolb, MD, MS1, Sagar Shah, MD2, Anastasia Chahine, MD3, Jason Samarasena, MD4, John G. Lee, MD5 1University of California Irvine, Orange, CA; 2University of California Los Angeles, Los Angeles, CA; 3H. H. Chao Comprehensive Digestive Disease Center, University of California Irvine, Orange, CA; 4University of California - Irvine, Orange, CA; 5Digestive Health Institute, UC Irvine, Orange, CA
Introduction: Afferent limb syndrome occurs from obstruction of the pancreatobiliary limb causing pain, bloating and nausea. Jaundice develops in afferent limb syndrome either due to worsening small bowel obstruction which block even bile from draining into the stomach and/or direct biliary obstruction, for example by progressing cancer. ERCP and biliary therapy requires successful negotiation of the afferent limb obstruction first, in order to be able to advance the scope to the choledochojejunostomy. We describe a novel approach of ERCP performed through endoscopic gastrojejunostomy (GJ) in patients whom conventional approach through the afferent limb failed.
Case Description/Methods: A 66-year-old woman presented with cholangitis 2 years after Whipple resection for pancreatic adenocarcinoma. A percutaneous transhepatic biliary drain (PTBD) was placed at an outside facility. CT demonstrated dilated loops of bowel consistent with afferent limb syndrome and an ill-defined circumferential mass near surgical bed concerning for recurrent disease. Endoscopy showed a stricture (proven malignant on mucosal biopsy) about 10 cm from the PTBD. Attempts at passing a guidewire for stenting failed. EUS showed the dilated blind afferent limb next to the stomach and close to the biliary drain. A 19G needle was used to puncture and fill the limb with contrast and methylene blue dye. Next a 10x15mm electrocautery enhanced lumen-apposing metal stent (LAMS) was placed to create the GJ and antegrade ERCP was performed through it. Cholangioscopy showed tumor in the bile duct. PTBD was removed and replaced with an uncovered metal stent.
A 67 year old man presented with afferent limb syndrome and sepsis 1 year after Whipple resection for ampullary adenocarcinoma. ERCP failed as the hepaticojejunostomy could not be reached. Endoscopic GJ was performed but ERCP failed as the choledochojejunostomy could not be reached due to a stricture in the afferent limb around the expected site of the choledochojejunostomy. Sepsis resolved after GJ but jaundice persisted so ERCP was repeated 3 days later and bilateral biliary metal stents were placed using EUS rendezvous technique with resolution of the jaundice.
Discussion: ERCP performed through endoscopic GJ into the afferent limb is an effective alternative method for biliary therapy in patients with afferent limb syndrome where conventional retrograde approach through the pancreatobiliary limb fails.
Figure: A. EUS showed massively dilated loop of small bowel next to the stomach, corresponding to the afferent limb. B. EUS-guided placement of lumen apposing metal stent into afferent limb with deployment of distal flange. C. Gastrojejunostomy stent in place. D. EUS guided rendezvous performed and wire passed antegrade to the afferent limb. E. Gastroscope passed through the GJ into the afferent limb. E. Final fluoroscopy showed LAMS and metal biliary stents in the left and right hepatic ducts.
Disclosures: Jennifer Kolb indicated no relevant financial relationships. Sagar Shah indicated no relevant financial relationships. Anastasia Chahine indicated no relevant financial relationships. Jason Samarasena: Cook Medical – Grant/Research Support. Olympus – Consultant. John Lee indicated no relevant financial relationships.
Jennifer Kolb, MD, MS1, Sagar Shah, MD2, Anastasia Chahine, MD3, Jason Samarasena, MD4, John G. Lee, MD5. P1740 - ERCP Through Endoscopic Gastrojejunostomy in Patients With Complete Obstruction of the Afferent Limb After Whipple Resection, ACG 2021 Annual Scientific Meeting Abstracts. Las Vegas, Nevada: American College of Gastroenterology.
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