A 65-year-old man presented with jaundice, intermittent fever, and abdominal pain
for 3 weeks. He had undergone distal gastrectomy with gastrojejunostomy for benign
gastric outlet obstruction 40 years previously. His laboratory parameters were as
follows: hemoglobin 10.8 g/dL, total leukocyte count 12 700 cells/mm3, bilirubin 5 mg/dL (direct 3.6 mg/dL), serum albumin 2.5 g/dL, alkaline phosphatase
568 IU/L (normal 120), and serum lipase 698 U/L (normal 50). A contrast-enhanced computed
tomography (CT) scan of the abdomen showed a grossly dilated afferent limb with dilated
common bile duct and pancreatic duct along with peripancreatic fat stranding ([Fig. 1]). He received antibiotics along with supportive care. Endoscopic retrograde cholangiopancreatography
was not technically feasible because of the surgically altered anatomy. Passage of
an endoscope and accessories deep into the afferent loop failed because of the twisted
bowel. He therefore underwent endoscopic ultrasound (EUS)-guided drainage of the afferent
limb using a lumen-apposing metal stent (LAMS) ([Video 1]).
Fig. 1 Computed tomography image showing the dilated afferent loop, along with dilated common
bile duct and pancreatic duct.
Video 1 Video showing endoscopic ultrasound-guided transjejunal drainage of an obstructed
afferent loop with a lumen-apposing metal stent.
The dilated afferent loop was best visualized with favorable alignment on EUS from
the proximal part of efferent loop, which was punctured with a conventional 19-gauge
needle. Injection of contrast and subsequent passage of a guidewire (0.035 inch, 450 cm,
Jagwire; Boston Scientific) through the needle confirmed the afferent jejunal loop
([Fig. 2 a]). A balloon (4 mm, Titan balloon; Cook Medical) was passed over the guidewire to
dilate the fistula track. Finally, the novel LAMS (16-mm diameter, 20-mm long, Spaxus
stent; Taewoong-Medical, Korea) was placed across the newly created fistulous track
between the afferent and efferent jejunal loops ([Fig. 2 b]). The Spaxus is a fully covered LAMS that is available in various diameters with
a silicone covering membrane that prevents leaks and tissue in-growth.
Fig. 2 Fluoroscopic images showing: a the afferent loop confirmed by contrast injection followed by subsequent coiling
of the guidewire; b transjejunal deployment of a lumen-apposing metal stent under fluoroscopy guidance.
There were no periprocedural complications. The patient’s symptoms gradually resolved,
with improvement in his liver function. A CT scan at 48 hours showed there had been
a reduction in the caliber of the afferent loop, the stent was in position, and there
was air in the biliary tract ([Fig. 3]). An upper gastrointestinal endoscopy was performed on day 2 and again 3 months
after the procedure; on both occasions, it showed the novel LAMS was correctly positioned
([Fig. 4]). So far, the patient has completed 5 months of follow-up and the intention is to
remove the LAMS 6 months after the index placement procedure to allow a stable and
permanent anastomosis to form between the afferent and efferent jejunal loops. EUS
guided trans-jejunal drainage of an obstructed afferent loop using a novel LAMS is
feasible and safe in benign conditions.
Fig. 3 Computed tomography image showing the lumen-apposing metal stent in position.
Fig. 4 Follow-up endoscopy at 3 months showing the metal stent in position, with complete
drainage of the afferent loop.
Afferent loop obstruction is an uncommon complication that occurs years after upper
gastrointestinal bypass surgery. A few case reports have demonstrated the feasibility
and safety of EUS-guided transgastric drainage with a LAMS in afferent loop syndrome
associated with upper gastrointestinal malignancy. Though technically challenging,
the EUS-guided transjejunal route of drainage of an obstructed afferent loop is safe
and feasible.
Endoscopy_UCTN_Code_TTT_1AS_2AD
Endoscopy E-Videos is a free access online section, reporting on interesting cases and new techniques
in gastroenterological endoscopy. All papers include a high quality video and all
contributions are freely accessible online.
This section has its own submission website at https://mc.manuscriptcentral.com/e-videos