Endoscopic ultrasound-guided entero-enterostomy for the treatment of afferent loop syndrome: a multicenter experience

Abstract

Background Afferent loop syndrome (ALS) is traditionally managed surgically and, more recently, endoscopically. The role of endoscopic ultrasound-guided entero-enterostomy (EUS-EE) has not been well described. The aim of this study was to assess the technical and clinical success and safety of EUS-EE.

Methods This was a multicenter, retrospective series at six centers in patients with ALS treated by EUS-EE. Data on patients treated with enteroscopy-assisted luminal stenting (EALS) at a single center were also collected.

Results 18 patients (mean age 64.2 years, 72 % post-pancreaticoduodenectomy, 10 female) underwent EUS-EE. The most common symptoms were vomiting (27.8 %) and jaundice (33.3 %). Clinical success included resolution of symptoms in 88.9 % and improvement to allow hospital discharge in 11.1 %. Technical success was achieved in 100 % of cases, with a mean procedure time of 29.7 minutes. The most common procedure was a gastro-jejunostomy (72.2 %). Three adverse events (16.7 %) occurred (two mild, one moderate). When compared with data on EALS, patients treated with EUS-EE needed fewer re-interventions (16.6 % vs. 76.5 %; P < 0.001).

Conclusion EUS-EE seems to be safe and effective in the treatment of ALS. Indirect comparison with EALS suggested that EUS-EE is associated with a reduced need for re-intervention.

• References

• 1 Blouhos K, Andreas K, Tsalis K. et al. Management of afferent loop syndrome: reoperation or endoscopic and percutaneous interventions?. World J Gastrointest Surg 2015; 7: 190-195
• 2 Pannala R, Brandabur JJ, Gan SI. et al. Afferent limb syndrome and delayed GI problems after pancreaticoduodenectomy for pancreatic cancer: single-center, 14-year experience. Gastrointest Endosc 2011; 74: 295-302
• 3 Katagiri H, Tahara K, Yoshikawa K. et al. Afferent loop syndrome after Roux-en-Y total gastrectomy caused by volvulus of the Roux-limb. Case Rep Surg 2016; 2016 DOI: 10.1155/2016/4930354.
• 4 Kim JK, Park HP, Huh JH. et al. Endoscopic management of afferent loop syndrome after pylorus preserving pancreatoduodenectomy presenting with obstructive jaundice and ascending cholangitis. Clin Endosc 2011; 44: 59-64
• 5 Yao NS, Wu CW, Tiu CM. et al. Percutaneous transhepatic duodenal drainage as an alternative approach in afferent loop obstruction with secondary obstructive jaundice in recurrent gastric cancer. Cardiovasc Intervent Radiol 1998; 21: 350-353
• 6 Ikeuchi N, Itoi T, Tsuchiya T. et al. One-step EUS-guided gastrojejunostomy with use of lumen-apposing metal stent for afferent loop syndrome treatment. Gastrointest Endosc 2015; 82: 166
• 7 Rodrigues-Pinto E, Grimm IS, Baron TH. Efficacy of endoscopically created bypass anastomosis in treatment of afferent limb syndrome: a single-center study. Clin Gastroenterol Hepatol 2016; 14: 633-637
• 8 Shah A, Khanna L, Sethi A. Afferent limb syndrome treated with EUS-guided creation of a gastrojejunostomy and placement of a lumen-apposing stent. Endoscopy 2015; 47: E309-E310
• 9 Taunk P, Cosgrove N, Loren DE. et al. Endoscopic ultrasound-guided gastroenterostomy using a lumen-apposing self-expanding metal stent for decompression of afferent loop obstruction. Endoscopy 2015; 47 (Suppl. 01) E395-396
• 10 Cotton PB, Eisen GM, Aabakken L. et al. A lexicon for endoscopic adverse events: report of an ASGE workshop. Gastrointest Endosc 2010; 71: 446-454
• 11 Itoi T, Baron TH, Khashab MA. et al. Technical review of endoscopic ultrasonography-guided gastroenterostomy in 2017. Dig Endosc 2017; 29: 495-502
• 12 Chauhan SS, Manfredi MA, Abu Dayyeh BK. et al. ASGE Technology Committee Enteroscopy. Gastrointest Endosc 2015; 82: 975-990