Single-step EUS-guided jejunojejunostomy with a lumen-apposing metal stent as treatment for malignant afferent limb syndrome (original) (raw)
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Acute afferent loop syndrome in the early postoperative period following pancreaticoduodenectomy
Annals of the Royal College of Surgeons of England, 2015
Introduction Afferent loop syndrome (ALS) is a recognised complication of foregut surgery caused by mechanical obstruction at the gastrojejunostomy anastomosis itself or at a point nearby. Acute ALS has only been reported following pancreaticoduodenectomy (PD) after several years due to recurrence of malignancy at the anastomotic site. We report five cases of acute ALS in the first postoperative week. Methods The presentation, clinical findings and successful management of the 5 patients with ALS were obtained from a prospectively collected database of 300 PDs. All five patients with early acute ALS presented with signs and symptoms of a bile leak. Since the fifth patient, the surgical technique has been modified with the creation of a larger window in the transverse mesocolon and a Braun enteroenterostomy. Results There have been no further incidents of ALS since the adoption of these modifications to the standard technique of PD and there has also been a reduction in postoperative...
Internal Medicine
A 63-year-old man with advanced pancreatic cancer and pyloric obstruction underwent surgical gastrojejunostomy. Malignant biliary obstruction appeared eight months after surgery and was managed with endoscopic ultrasound (EUS)-guided hepaticogastrostomy (HGS). Subsequently, afferent limb obstruction caused by cancer invasion occurred. Although an intestinal metal stent could not be placed, a biliary metal stent was deployed via the HGS route, which successfully decompressed the afferent limb; the abdominal symptoms subsequently disappeared. In future similar cases, decompression of the dilated intestine through the HGS and biliary stent might be a viable treatment option.
Pancreatology, 2021
kyo, Japan) with a transparent cap attached at its tip. After identification of the Roux-en-Y anastomosis, the afferent limb was intubated, followed by progression to the hepaticojejunal anastomosis. A severe stricture of the anastomosis was identified (Fig. 1). A 0.035-inch guidewire (METII-35-600E, Tracer Metro ® Direct TM Wire Guide, Cook ® , Bloomington, IN, USA) was passed through the stricture followed by a sphincterotome (CCPT-25ME, Classic Cotton ® CannulaTome ® , Cook ®). Upon contrast injection, dilation of the intrahepatic ducts was evident. Dilation with a 6-to 8-mm through-the-scope balloon (34106PRO, Endo-Flex ® , Düsseldorf, Germany) was then performed (Fig. 2, 3) with immediate spontaneous drainage of multiple small calculi. The intrahepatic bile ducts were explored with a balloon catheter, but no more calculi were identified. The patient was discharged on the second day after the procedure and did not present additional episodes of acute cholangitis after a 6-month follow-up. ERCP is an essential therapeutic technique for a wide range of pancreatobiliary conditions and presents a 90-95% success rate in patients with native gastric and pancreaticoduodenal anatomy [1]. In Roux-en-Y surgical reconstruction (hepaticojejunostomy and choledochojejunostomy, gastric bypass surgery, or post-Whipple surgery), ERCP is often unsuccessful because of the in
Annals of Surgery, 1994
This study was set up to identify patient-related factors favoring the application of either surgery or endoprostheses in the palliation of obstructive jaundice in subsets of patients with cancer of the head of the pancreas or periampullary region. Summary Background Data In the palliation of obstructive jaundice, surgical biliodigestive anastomosis has traditionally been performed. Surgical biliary bypass is associated with high mortality (15% to 30%) and morbidity rates (20% to 60%) but little recurrent obstructive jaundice (0% to 15%). Biliary drainage with endoscopically placed endoprostheses has a lower complication rate, but recurrent obstructive jaundice is seen in up to 20% to 50% of patients. Methods Patients with advanced cancer of the head of the pancreas or periampullary region treated at the
Endoscopic Ultrasound-Guided Enteroenterostomy for Afferent Limb Syndrome
ACG Case Reports Journal, 2020
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 ultrasoundguided enteroenterostomy offers a convenient and safe palliative solution for patients presenting ALS. Patient 1: A 72-year-old woman presented in a degraded condition with biliary sepsis. She had a history of hepatectomy and common bile duct resection with Roux-en-y anastomosis for a Bismuth III cholangiocarcinoma. CT showed ascitis, peritoneal carcinomatosis, several liver abscesses, and a dilation of the afferent limb measured up to 70 mm in diameter. We performed an
Annals of Surgery, 2004
The objective of this study was to assess the feasibility and safety of inserting a double-lumen gastrojejunostomy tube (GJT) after pancreaticoduodenectomy (PD) and to evaluate associated outcomes. Background: Gastroparesis is a frequent postoperative event following PD. This often necessitates prolonged gastric decompression and nutritional support. A double-lumen GJT may be particularly useful in this situation: gastric decompression may be achieved through the gastric port without a nasogastric tube; enteral feeding may be administered through the jejunal port. Methods: Thirty-six patients with periampullary tumors were randomized at the time of PD to insertion of GJT or to the routine care of the operating surgeon. Outcomes, including length of stay, complications, and costs, were followed prospectively. Results: The 2 groups had similar characteristics. Prolonged gastroparesis occurred in 4 controls (25%) and in none of the patients who had a GJT (P ϭ 0.03). Complication rates were similar in each group. Mean postoperative length of stay was significantly longer in controls compared with patients who had a GJT (15.8 Ϯ 7.8 days versus 11.5 Ϯ 2.9 days, respectively; P ϭ 0.01).
Supportive Care in Cancer, 2005
Malignant chronic bowel obstruction (MCBO) is a syndrome caused by abdomen-pelvic diffusion of neoplastic diseases of any origin. It generally occurs in an advanced disease, affecting 3-15% of patients recently operated, untreated, or submitted to radiotherapy. Patients complain of chronic pain and vomitus. The approach to this problem is multidisciplinary, involving the surgeon, the endoscopist, the oncologist, and the pain-therapy expert. Direct percutaneous jejunostomy (DPEJ) using a percutaneous endoscopic gastrostomy (PEG) tube is a jejunal percutaneous access procedure indicated for nutrition in those patients whose stomach cannot be used, as in cases of partially or totally gastrectomized ones. A venting PEG or percutaneous endoscopic jejunostomy (PEJ) is a solution to drain the gastrointestinal tract for MCBO even in difficult cases represented by patients with previous abdominal surgery, those with partial or total gastrectomies, ascites, or peritoneal carcinosis. We report our five-case experience of draining an MCBO in patients previously operated on for gastric cancer, using a DPEJ technique that we believe is the best technique for this purpose.