Simultaneous stent placement for biliary and afferent loop obstruction due to tumor recurrence after pancreatoduodenectomy

After pancreaticoduodenectomy, patients experiencing tumor recurrence involving the Roux limb can suffer from afferent loop syndrome, cholangitis, and jaundice [1]. Placement of expandable metal stents at the site of enteral obstruction is considered a reasonable treatment option [2] [3] [4]. However, when the tumor recurs near the choledochojejunostomy, biliary and enteral stent placements would be required to decompress the dilated bile duct and afferent loop. Herein we report the first case of afferent loop syndrome with cholangitis and liver abscess treated by simultaneous metal stent placement using the stent-in-stent technique.

A 55-year-old woman with a 2-year history of pancreaticoduodenectomy with modified Child reconstruction for pancreatic cancer was admitted to our hospital for the treatment of cholangitis. Contrast-enhanced computed tomography showed the dilatation of the afferent loop and the bile duct due to a recurrent tumor near the choledochojejunostomy and a liver abscess in the right hepatic lobe. A lower gastrointestinal endoscope (PCF-Q260JI; Olympus, Tokyo, Japan) was inserted into the afferent loop ([Video 1]). A guidewire was advanced across the stricture and inserted into the bile duct; contrast injection revealed the stenotic regions of the afferent loop. Another guidewire was placed in the dilated afferent loop ([Fig. 1]). Subsequently, we proceeded with the placement of two uncovered stents (A: enteral, 22 mm in diameter, 100 mm long, Niti-S duodenal; and B: metallic, 10 mm in diameter, 100 mm long, Niti-S large cell; Taewoong Medical, Seoul, Korea). Stent A was placed in the afferent loop ([Fig. 2]); then, a guidewire was advanced toward the bile duct through the stent mesh of the enteral stent and stent B was placed successfully using the stent-in-stent technique ([Fig. 3]). No complications were observed; the patient’s liver abscess and cholangitis improved.

Video 1 We performed simultaneous endoscopic metallic stent placements using the stent-in-stent technique for afferent loop obstruction with cholangitis and liver abscess due to a recurrent tumor after a pancreatoduodenectomy.

Fig. 1 Fluoroscopic image reveals the afferent loop stenosis (arrow) and the dilated bile duct (arrowhead).

Fig. 2 An uncovered enteral stent is placed in the afferent loop.

Fig. 3 An uncovered metallic stent is placed in the bile duct using the stent-in-stent technique.

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Publication History

Article published online:
25 October 2021

• References

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