Combined endoscopic drainage for afferent loop obstruction and bilioenteric anastomosis stricture in a patient after pancreatoduodenectomy

Tumor recurrence is a common cause of bilioenteric anastomosis stricture or afferent loop obstruction (ALO) in patients who have undergone pancreaticoduodenectomy. Endoscopic management in ALO included enteroscopy-assisted luminal stenting with a self-expanding metal stent or plastic stents and endoscopic ultrasound (EUS)-guided enteroenterostomy with a lumen-apposing metal stent [1] [2]. In addition, the bridge technique for drainage of the right liver across the left liver through hepaticogastrostomy (HGS) is feasible [3] [4]. We describe a case of concurrent ALO and bilioenteric anastomosis stricture in a patient who received the above two endoscopic treatments.

A 55-year-old man was admitted to our hospital with abdominal pain and progressive jaundice. He had undergone a pancreaticoduodenectomy 10 years prior because of distal cholangiocarcinoma. Abdominal computed tomography showed dilated intrahepatic bile ducts and locally dilated intestinal ducts near the bilioenteric anastomosis ([Fig. 1] a–b). We diagnosed ALO, which indirectly caused obstructive jaundice. The patient underwent a gastroscopy; however, due to severe intestinal twisting, the gastroscopy could not reach the site of the afferent loop obstruction. Under fluoroscopy, we attempted to apply a sphincterotome with a guidewire into the obstructed bowel successfully ([Fig. 1] c–d). A 7-Fr plastic stent 73 cm in length (modified nasobiliary tube) was placed to ensure passage through the sharp bends and stricture of the afferent loop ([Fig. 1] e–f, [Video 1]). The patient's abdominal pain resolved but jaundice continued to worsen (direct bilirubin up to 357.4 umol/L) after the operation. Subsequently the patient received endoscopic ultrasound-guided hepaticogastrostomy (EUS-HGS) for biliary drainage. We found that the bilioenteric anastomosis was narrow and the guidewire could not pass through. We then bridged a 7-Fr double-pigtail plastic stent 15 cm in length (Zimmon; Wilson-Cook Medical Inc., Limerick, Ireland) to the right intrahepatic bile duct to achieve simultaneous drainage of the right and left intrahepatic bile duct ([Fig. 2] , [Video 1]). The patient was discharged as his bilirubin decreased to 284.7 umol/L 10 days later.

Fig. 1 a Abdominal computed tomography (CT) showing liver neoplasms (asterisks) and dilated intrahepatic bile ducts. b CT showing afferent loop dilatation near the bilioenteric anastomosis. c Fluoroscopic image showing the guidewire attempting to enter the obstructed afferent loop with the assistance of the sphincterotome. d The guidewire passed through sharp bends (triangles) and the stricture (arrow) of the afferent loop. e A self-made 7-Fr plastic stent 70 cm in length was inserted into the dilated afferent loop. f Endoscopy showing the properly placed plastic stent.

Fig. 2 a Endoscopic ultrasound (EUS) image shows the left intrahepatic bile duct (segment 2) was punctured using a 19G fine-needle aspiration needle. b Fluoroscopic image showing a guidewire entered from the left intrahepatic bile duct to the right intrahepatic bile duct, and a plastic stent was placed in the dilated afferent loop (black triangle). c A 7-Fr double-pigtail plastic stent 15 cm in length was inserted into the left and right hepatic ducts (yellow triangles). d Side holes were added on the plastic stent. e Endoscopy shows the plastic stent placed to drain bile. f CT showing improved intrahepatic bile duct obstruction and afferent loop dilatation.

Download Video

Combined gastroscopy-assisted luminal stenting and endoscopic ultrasound-guided hepaticogastrostomy with bridge technique for afferent loop obstruction and bilioenteric anastomosis stricture in a patient after pancreatoduodenectomy.Video 1

Endoscopy_UCTN_Code_TTT_1AS_2AH

Conflict of Interest

The authors declare that they have no conflict of interest.

• References

• 1 Wu CCH, Brindise E, Abiad RE. et al. The role of endoscopic management in afferent loop syndrome. Gut Liver 2023; 17: 351-359
• 2 Soga K, Mukai H, Kitae H. Management of afferent loop obstruction using multiple single-pigtail plastic stents in a patient with recurrent metastatic pancreatic cancer. Endoscopy 2022; 54: E1041-E1042
• 3 Caillol F, Rouy M, Pesenti C. et al. Drainage of the right liver using EUS guidance. Endosc Ultrasound 2019; 8: 199-203
• 4 Ogura T, Masuda D, Imoto A. et al. EUS-guided hepaticogastrostomy for hepatic hilar obstruction. Endoscopy 2014; 46: E32-E33

Publication History

Article published online:
07 August 2024