Urgent percutaneous transhepatic cholangiography was performed with the placement of an external biliary drain for decompression. An exploratory laparotomy for gastrojejunostomy revision with antecolic Roux-en-Y reconstruction was subsequently performed. She had a complicated postoperative course. She developed pneumonia associated with bacteremia, severe acute respiratory distress syndrome, with multiorgan failure. Despite aggressive medical therapy, she died 2 weeks after surgical revision.
Gastric cancer is the third most common cause of death worldwide.1 For localized cancers, gastrectomy is usually the preferred method of treatment. There has been an ongoing debate on the type of anastomosis (Billroth I, Billroth II, and Roux-en-Y) used to reduce the postoperative complications. One of the uncommon, late postoperative complications is the development of ALS.
A major study reported the incidence of ALS after distal gastrectomy with Billroth II or Roux-en-Y reconstruction as 0.3%–1.0%. Although the exact incidence is unknown, ALS is certainly not rare, especially in antecolic Billroth II gastrectomies.2 Comparatively, the Sanada study reported a relatively more common occurrence of ALS after pancreatoduodenectomy cases (13%) caused mainly by mechanical obstruction.3 Some cases of nonobstructive ALS were also seen mainly due to jejunal motility failure or due to the length of the blind loop.
The etiologies of afferent limb syndrome include recurrence of malignancy, entrapment, compression, and kinking of the afferent loop by postoperative adhesions; internal herniation, volvulus, and intussusception of the afferent loop; scarring due to marginal ulceration of the gastrojejunostomy; radiation enteritis of the afferent loop; and enteroliths, bezoars, and foreign bodies affected in the afferent loop.4 Radiation, peritoneal seeding, and adhesions are the common causes.4,5 Volvulus and intussusception are uncommon. A case involving afferent loop intussusception has been reported.6 CT scan has been identified as a useful tool for the diagnosis of ALS.5,7 Recognition of the characteristic CT findings will avoid both inappropriate procedures and delay in treatment.
Most cases of cholangitis originate due to biliary stasis, which is broadly caused by either anastomotic or nonanastomotic stenosis. The safest and simplest treatment for patients whose original operation was Billroth II gastrectomy is conversion to a Roux-en-Y procedure.2 Nonobstructive ALS may improve by conservative treatment alone in many cases; the cause is often not identified, thus resulting in many patients suffering repeated cholangitis.3
Our case demonstrates a rare etiology of afferent limb syndrome. In retrospect, her presumptive diagnosis of alcohol-related acute pancreatitis was incongruent with her reported history of postoperative alcohol intolerance.
In conclusion, afferent limb syndrome should be considered in patients with altered surgical anatomy who present with pancreatitis and/or obstructive jaundice. A low threshold to obtain cross-sectional imaging in these patients may prevent delays in diagnosis. Endoscopic intervention has been used successfully as the first choice, but in certain cases where it does not help relieve the ALS, surgical intervention becomes inevitable. However, reoperation itself poses an increased risk of morbidity and mortality.4
Author contributions: A. Desai and A. Manvar wrote the manuscript. S. Ho edited the manuscript and is the article guarantor.
Financial disclosures: None to report.
Informed consent was obtained for this case report.
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© 2019 by Lippincott Williams & Wilkins, Inc.
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