EUS-guided drainage in Afferent loop syndrome in a patient with Billroth II anastomosis Gitips.org

EUS-guided drainage in Afferent loop syndrome in a patient with Billroth II anastomosis

Background

Afferent loop syndrome develops due to the obstruction of the duodeno-jejunal loop, mostly due to the recuurence of the malignancy (e.g. gastric carcinoma or pancreatic carcinoma.
It presents with abdominal pain due to the distension and congestion of bowel loop as well as associated biliary tree. Patients may present with jaundice and cholangitis as well.
Cross-sectional imaging is diagnostic.
Previousley surgical techniqes or interventional radiology were used for management. However EUS guided gastro-jejunostomy or jejuno-jejunostomty between afferent and efferent loops is the the technique of choice, especially for patients surgery is not considered.

Technique

Procedure is performed, preferably, under x-ray. However it is not an absolute necessity.
Stomach remnant is intubated with a therapeutic linear EUS scope. The distended afferent loop is easily identified. It may either be punctured form stomach or efferent loop. The advantage of puncturing from efferent loop is that even if the tumour obstructs the anastomosis of efferent loop in the future, the stent will maintain its efficacy. However jejuno-jejunostomy, techniqally, is more challanging than gastro-jejunostomy.
After puncture, the content is aspirated, it is bile-stained. Contrast may be administered to make sure the place in x-ray.
Afterwards an 0.035 guide-wire is inserted and 19 G FNA needle is exchanged with 6 F sistotom to dilate the tract with electrocautery (either pure-cut or endocut I (Erbe) or gastro-cut ( ?) is used and a metal apposing stent or 10 or 8 mm fully covered metalic stent is inserted. In case there is resistance on the Wall, graded bougie 5-10 (Cook) is used and stent is tried again. If available hot-axios may be used and in this case, 6 F cystotom is not necessary. If metalic stent is not available 10 F 5 cm double-pigtail plastic stent can be used.

CASE

Sixty-seven ys-old lady was admitted with abdominal fullness, pain, jaundice, nausea, vomiting, and weight loss of two weeks duration.
She had partial gastrectomy with BII anastomosis 20 years ago for peptic ulcer disease.
Upper GI endoscopy revealed polipoid masses, obstructing, especially, orifice of the afferent loop.
Biopsy revealed adenocarcinoma.
The patient was not a candidate for surgery

Before and After drainage