Enteroscopic direct drainage for submucosal intestinal juice leakage due to afferent loop syndrome in Roux-en-Y anatomy

We report a case of intestinal fluid accumulation secondary to afferent loop syndrome, successfully treated via enteroscopic submucosal drainage.

A 66-year-old man with a history of gastric resection and Roux-en-Y reconstruction for gastric cancer 6 years earlier presented with fever. Computed tomography (CT) revealed liver metastasis invading the bile duct near the duodenal end loop ([Fig. 1]). Enteroscopy confirmed tumor invasion near the end loop of the duodenum, with no additional intestinal abnormalities. Suspecting cholangitis, bilateral biliary plastic stent (PS) drainage was performed using an enteroscope (EI-580BT; Fujifilm, Tokyo, Japan), and the patient was discharged after clinical improvement.

Fig. 1 a Computed tomography reveals a liver metastasis (arrow) with invasion to the bile duct (arrowhead) in a patient with Roux-en-Y reconstruction. Enteroscopy shows tumor invasion near the duodenal end loop (green arrow) without other intestinal abnormalities. b Bilateral biliary plastic stent drainage (yellow arrow) was performed under enteroscopic guidance.

Three weeks later, he developed abdominal pain. CT revealed a distended end loop and submucosal expansion in the horizontal part of the duodenum ([Fig. 2]), suggesting leakage of accumulated intestinal fluid from the end-loop cavity into the duodenal submucosal space. Endoscopic ultrasound failed to access the site. Therefore, an enteroscope was used, and the tensed mucosa was punctured with a precut needle knife, with the elasticity of the mucosal surface assessed prior to entry. A 6-mm dilation balloon was used to expand the puncture tract, and both 7-Fr PS and 6-Fr drainage tubes were placed in the fluid collection cavity. One week later, fluoroscopy confirmed collapse of the fluid collection, and the 6-Fr tube was removed ([Video 1]).

Fig. 2 Computed tomography shows a tensed end loop (arrow) and expansion of the submucosal space in the horizontal part of the duodenum (arrowhead).

Massive submucosal fluid collection in the duodenum was drained using a precut needle knife under enteroscopy in a case of afferent loop syndrome with Roux-en-Y anatomy.Video 1

Although endoscopic ultrasound-guided gastroenterostomy is a safe option for afferent loop syndrome, as it allows the evaluation of blood vessels and needle access to the afferent limb [1] [2] [3], access was limited in this case due to Roux-en-Y anatomy. Direct enteroscopic puncture poses a perforation risk but was safely performed with mucosal elasticity assessment. Fluid accumulated after drainage tube removal, though the patient remained asymptomatic, with partial drainage via the remaining 7-Fr PS ([Fig. 3]).

Fig. 3 a PTGBD (arrow) is performed. No communication was observed between the gallbladder and the duodenal submucosal cavity. b Fluoroscopy and computed tomography demonstrate collapse of the fluid collection. After which, the 6-Fr drainage tube (yellow arrow) was removed. c Following drainage tube removal, fluid retention reappeared (arrowhead), although the patient remained asymptomatic. It was considered that intestinal juice continued to drain partially through the remaining 7-Fr plastic stent (green arrow). PTGBD: percutaneous transhepatic gallbladder drainage.

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Conflict of Interest

The authors declare that they have no conflict of interest.

• References

• 1 Tanikawa T, Urata N, Ishii K. et al. Afferent-Loop Syndrome Treated with Endoscopic Ultrasound-Guided Drainage of the Afferent Loop with a Plastic Stent. Case Rep Gastroenterol 2022; 16: 122-128
• 2 Shiomi H, Sakai A, Nakano R. et al. Endoscopic Ultrasound-Guided Gastroenterostomy for Afferent Loop Syndrome. Clin Endosc 2021; 54: 810-817
• 3 Matsubara S, Takahashi S, Takahara N. et al. Endoscopic Ultrasound-Guided Gastrojejunostomy for Malignant Afferent Loop Syndrome Using a Fully Covered Metal Stent: A Multicenter Experience. J Clin Med 2023; 12

Publication History

Article published online:
08 August 2025