Introduction: Afferent limb syndrome (ALS) is a known complication after gastrojejunostomies from mechanical obstruction of the afferent limb (AL). Recently endoscopic ultrasound (EUS) guided gastroenterostomy placement has provided an alternate to surgical correction. However this approach is not always technically possible. We describe a case successfully treated with endoluminal non-cautery enhanced lumen apposing metal stent (LAMS) placement.
Case Description/Methods: A 63 year old woman with a history of ileocolonic Crohns disease (diagnosed at age 25), status post multiple surgeries including ileocolic resections and Billroth II gastrectomy, was referred with persistent abdominal pain. She was recently diagnosed with acute pancreatitis with CT concerning for dilated afferent jejunal limb, a luminal stricture near the biliary anastomosis and dilated intra and extra hepatic bile ducts (fig 1a). She underwent two deep enteroscopies revealing a stricture in the AL from intra-abdominal adhesion. This was dilated with minimal improvement in symptoms and imaging.
After multi-disciplinary discussion it was decided to attempt EUS guided drainage of the AL to promote drainage of pancreatico- biliary secretions. During the procedure a significant amount of food residue was identified in the gastric remnant. The dilated afferent limb was visualized endosonographically adjacent to the posterior stomach at an acute angle. Considering large amount of food in the stomach, difficult angulation to deploy the AXIOS stent and concern for food entering the already obstructed limb after stent deployment it was decided to reconsider this approach. The AL was then explored with a therapeutic upper endoscope with stenosis at 10 cm from the anastomosis. A wire was passed through the stenosis under fluoroscopy. It was decided to place a stent using the 15 x 10 mm LAMS stent system considering short (< 1 cm) stricture. Using non cautery technique both flanges were deployed successfully across the stricture under fluoroscopic and endoscopic guidance with decompression of the AL (fig 1b,c). 1 month follow up imaging demonstrated continued decompression of the AL.
Discussion: EUS guided gastrojejunostomy has been increasingly used for ALS. However it can be challenging in situations where a good window cannot be identified. In such settings using a traditional luminal route to reach the stenosis and placing a non-cautery enhanced LAMS can provide a viable alternative.
