Endoscopic Ultrasound - Guided Gastrojejunostomy Stent Placement - A Novel Technique to Manage Afferent Loop Syndrome

Abstract

1. Abstract 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). 2. Introduction Afferent loop is the duodenojejunal loop proximal to gastrojejunal anastomosis that carries biliopancreatic contents. Afferent Loop Syndrome (ALS) occurs when an intrinsic or extrinsic obstruction causes partial or complete blockage of the afferent loop. Increased intraluminal pressure in ALS causes severe abdominal pain, nausea, vomiting, and occasionally, bowel ischemia [1]. Surgical reconstruction is the preferred treatment, but in high-risk surgical patients, endoscopic placement of an enteral stent is an alternative [2, 3]. Endoscopic ultrasound-guided gastrojejunostomy stent placement (EUS-GJ) is a novel technique that allows endosonographic localization of the jejunum from inside the stomach and placement of a lumen-opposing stent across the newly created fistulous tract [3,4]. 3. Case Presentation A 60-year-old man initially presented with a resectable duodenal adenocarcinoma with pancreatic invasion. He underwent a Whipple procedure complicated by a pancreatic anastomotic leak that improved with non-surgical management. The patient later developed pulmonary embolism and was started on oral anticoagulation with IVC filter placement. Adjuvant chemotherapy with FOLFOX was started after, but discontinued due to severe abdominal pain, persistent nausea, anorexia and upper gastrointestinal bleeding. Computerized Tomography (CT) Abdomen revealed multiple hypodense hepatic lesions concerning for metastasis, a solid mass in the pancreatic bed suspicious for local recurrence and evidence of a distended afferent loop proximal to the area of local recurrence, with decompressed bowel distally (Figure 1A). Subsequent CT-guided biopsy of the liver lesions revealed metastatic adenocarcinoma of duodenal origin. After a multidisciplinary discussion, we decided to first try decompression by endoscopic or percutaneous approaches to avoid surgical morbidity due to his advanced malignancy. Our goal was to palliate his symptoms and allow him to restart systemic chemotherapy. The first attempt to place an intraluminal stent endoscopically 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. Although this technique has not been well-studied in these situations, it seemed viable as our patient’s afferent loop was dilated and fluid-filled. Moreover, the distance between the stomach and loop seemed appropriate on CT imaging (Figure 1B).