Endoscopic nasogastric tube insertion for treatment of benign afferent loop obstruction after radical gastrectomy for gastric cancer

Abstract

Afferent loop obstruction is an uncommon complication associated with Billroth-II distal gastrectomy. Inappropriate treatment may result in life-threatening events as perforation and peritonitis. For the benign afferent loop obstruction, Braun or Roux-en-Y reconstruction has been reported as the choice. However, the edematous afferent loop may result in anastomotic fistula. In this study, a less invasive technique was described for treatment of benign afferent loop obstruction. The aim of this study was to investigate the effectiveness and safety of endoscopic nasogastric tube insertion for treatment of benign afferent loop obstruction. We conducted a retrospective review of the data of 2548 gastric cancer patients who underwent distal gastrectomy from January 2002 to January 2018. Patients who developed benign afferent loop obstruction were treated by this procedure. Outcomes were recorded. Follow-up was scheduled at 3, 6, and 12 months after the treatment. Twenty-six patients (1.0%) developed afferent loop obstruction. The median age, consisting of 19 men and 7 women, was 60 years (range 36–69 years). Of these 26 patients, 23 underwent the endoscopic treatment. The obstructive symptoms had a rapid relief in all the 23 patients. No one died due to this procedure. However, 2 patients underwent surgical treatment due to intestinal obstruction because of adhesion at >4 and 7 months after the endoscopic drainage, respectively. Endoscopic nasogastric tube insertion is an effective and safe procedure for treatment of benign afferent loop obstruction. In addition, it could be considered as the first step in treatment, especially in high-surgical-risk patients.

Percutaneous transhepatic afferent loop balloon dilatation and indwelling catheter placement for benign afferent loop obstruction

“…According to Blouhos et al, 2 the causes of benign ALO are as follows: 1) post-operative adhesion, 2) internal herniation or intussusception of afferent loop, and 3) scarring due to repeated inflammation and ulceration. In addition, according to the endoscopic findings of Cao et al, 5 mucosal inflammatory edema was observed in benign ALO, which may be responsible for the occurrence of stenosis and intussusception. The author explained that postoperative anatomical changes may have been caused by erosion due to the gastric and duodenal juice, which led to mucosal injury and inflammation of the afferent loop.…”

“…Endoscopic nasogastric tube insertion is an example of an endoscopic approach. 5 Among the treatments mentioned, metallic stent placement is only one to directly treat the obstruction point; however, patency typically lasts less than a year according to one report, about 9 months. 6 It can be used for only malignant ALO cases with a short life expectancy, On the other hand, it should not be used for benign ALO cases with a long life expectancy.…”

“…The author explained that postoperative anatomical changes may have been caused by erosion due to the gastric and duodenal juice, which led to mucosal injury and inflammation of the afferent loop. 5 In the two cases above, after balloon dilatation, a 12-Fr catheter or larger was passed through the obstruction point and placed front and back, which helped with the kinking and herniation, release of intussusception, and improved edema during the indwelling period, which may have helped in treating benign ALO (Fig. 3).…”

Treatment of afferent loop syndrome using fluoroscopic-guided nasointestinal tube placement: Two case reports

“…However, surgery is not suitable for every patient with ALS[ 11 , 12 ]. A considerable proportion of patients could not undergo an operation because of poor physical condition, extensive peritoneal adhesions, or disseminated tumor[ 13 ]. On the other hand, for patients with acute ALS soon after operation, a secondary operation could increase the risk of anastomotic fistula, stenosis, stomatitis, and other postoperative complications.…”

“…With the progress of endoscopic treatment and interventional radiology, treating ALS with endoscopic interventions has been reported recently[ 24 , 25 ]. A single-center study evaluated the effectiveness and safety of endoscopic nasogastric tube insertion and found that this technique was a conservative treatment for patients with benign ALS[ 13 ]. However, we attempted this procedure first with our patients, but the afferent loop was so twisted that the endoscope failed to pass, which is a common occurrence.…”