Current status of, and challenges posed by, endoscopic ultrasound‐guided anastomosis of the digestive tract in patients with afferent loop syndrome

Abstract

Afferent loop syndrome (ALS) is a mechanical complication of a variety of upper gastrointestinal tract surgeries. Billroth II and Roux-en-Y gastrojejunostomy (GJ), Roux-en-Y esophagojejunostomy, and the Whipple procedure are associated with ALS. The loop transfers bile, pancreatic, and proximal intestinal secretions distally toward the efferent loop via the anastomosis. Thus, if the loop is blocked, the fluids may stagnate, triggering ALS symptoms including intestinal dilation, obstructive jaundice/cholangitis, and pancreatitis. The causes of ALS are roughly divided into benign and malignant obstructions. Benign causes include intestinal adhesions, internal hernias, scars from ulcers that developed after GJ, foreign bodies, stones, and radiation enteritis. Malignant obstructions are often caused by the recurrence of cancers previously operated on or intestinal dragging attributable to peritoneal dissemination. The incidence of ALS is 0.2-20% after gastrectomy and 13% after pancreatoduodenectomy to treat pancreatic adenocarcinomas; malignant causes account for 33% of all ALS. 1 The most common clinical presentations are obstructive jaundice or acute cholangitis (50%) and abdominal pain (29%). 1 Regardless of the cause, ALS is a semi-emergency requiring prompt drainage; if treatment is delayed, the patient may be at risk of death from perforation of the dilated intestine (septic shock that causes multiorgan failure). Malignant ALS can be treated via surgical or percutaneous drainage, stenting of the stricture, or endoscopic ultrasound (EUS)-guided drainage, but the optimal approach is unclear.A lumen-apposing metal stent (LAMS) is a device that forms a fistula by creating a hole of appropriate diameter and then connecting two lumina. The LAMS is completely covered to prevent leakage from the fistula, and is used primarily to form fistulas connecting pancreatic pseudocysts and gallbladders. EUS-guided gastrojejunostomy (EUS-GJ) is a useful palliative treatment for gastric output obstruction (GOO) caused by malignant gastroduodenal stenosis. In a systematic review of 12 studies and 285 cases, the technical success rate was 92% (95% confidence interval [CI] 88-95),

Endoscopic ultrasound-guided antegrade treatment with uncovered self-expanding metal stent for malignant afferent loop syndrome-complicated cholangitis after biliary reconstruction

“…Malignant afferent loop syndrome often causes cholangitis and jaundice 1 2 , necessitating treatment. Endoscopic treatment is minimally invasive and utilizes a natural orifice, proving advantageous surgical or percutaneous management.…”

Endoscopic Ultrasound-Guided Gastrojejunostomy for Malignant Afferent Loop Syndrome Using a Fully Covered Metal Stent: A Multicenter Experience

“…Malignant afferent loop syndrome (MALS) is a rare late complication after surgery for upper abdominal malignancies caused by mechanical obstruction of the afferent loop after Billroth II or Roux-en-Y reconstruction due to local recurrence or peritoneal dissemination [1]. The dilated blind loop is filled with intestinal, bile, and pancreatic fluid, which can cause severe symptoms such as abdominal pain, nausea/vomiting, cholangitis, sepsis, and perforation, requiring rapid decompression [2,3]. In the past, surgery was applied but was too invasive for patients with advanced malignancies, and percutaneous drainage was problematic because of the risk of peritonitis and the loss of quality of life resulting from an external drainage [4].…”