University of Minnesota Medical Center Minneapolis, MN, United States
David E. Jonason, MD, Guru Trikudanathan, MBBS University of Minnesota Medical Center, Minneapolis, MN
Introduction: Afferent loop obstruction (ALO) is an infrequent complication after creation of a gastrojejunostomy most commonly with gastrectomy with Billroth II or Roux-en-Y reconstruction surgery. Etiologies include entrapment or compression from adhesions, internal herniation, volvulus, stenosis at the gastrojejunostomy site, cancer recurrence, or foreign bodies. Management is surgical vs endoscopic or percutaneous with stenting depending on if benign or malignant in etiology respectively. However the complex and altered anatomy following a Billroth II or Roux-en-Y reconstruction makes endoscopic and percutaneous access to the afferent loop difficult and few cases have been reported in the literature. We present a case of ALO managed via EUS-guided jejunojejunostomy with LAMS.
Case Description/Methods: A 57 year old female with history of stage IV signet ring cell adenocarcinoma of the ampulla status post Whipple, Billroth II reconstruction and neoadjuvant chemotherapy in 2019 presented with abdominal pain, newly confirmed peritoneal metastasis, and CT evidence of ALO. Physical exam revealed a nondistended, firm abdomen with mild RUQ tenderness. Labs showed a lipase of 3000, ALP 694, ALT 38, AST 59, Tbili 1.9, WBC 5. Enteroscopy found a 3cm segment of extrinsic stenosis near the hepaticojejunostomy with upstream dilation. A 10 x 80mm uncovered self-expanding metal stent (SEMS) was deployed across the stenosis with immediate decompression. However within 72 hours she became cholangitic with repeat CT again showing a dilated afferent loop confirmed to be 2 cm distal to the GJ anastomosis with endoscopy. A jejunojejunostomy was created between the gastrojejunum anastomosis and afferent loop and a 15 x 15mm lumen-apposing metal stent (LAMS) deployed. Her LFTs, fever and pain subsequently improved.
Discussion: Studies have shown no difference in mortality in patients with malignant ALO who are treated with palliative versus curative intent. Historically, these patients have been managed endoscopically with balloon dilation, double-pigtail stenting, balloon dilation and double-pigtail stenting, or metal stent placement of the afferent loop stenosis. In this case, a SEMS of the afferent loop stenosis failed to improve symptoms and subsequent jejunojejunostomy tract stenting with EUS successfully resolved the ALO. Creation of a Jejunojejunostomy should be considered in ALO cases refractory to traditional endoscopic treatments.
Disclosures: David Jonason indicated no relevant financial relationships. Guru Trikudanathan indicated no relevant financial relationships.
David E. Jonason, MD, Guru Trikudanathan, MBBS. P0680 - EUS-Guided Jejunojejunostomy With LAMS for Malignant Afferent Loop Obstruction, ACG 2021 Annual Scientific Meeting Abstracts. Las Vegas, Nevada: American College of Gastroenterology.