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Yamamoto K, Itoi T, Matsunami Y, Sofuni A, Tsuchiya T, Mukai S, Kojima H, Minami H, Nakatsubo R, Tonozuka R. Early and late effects of endoscopic interventions in patients with malignant afferent loop syndrome: A single-center experience and literature review. JOURNAL OF HEPATO-BILIARY-PANCREATIC SCIENCES 2024; 31:120-132. [PMID: 37907717 DOI: 10.1002/jhbp.1380] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/18/2023] [Revised: 08/09/2023] [Accepted: 09/07/2023] [Indexed: 11/02/2023]
Abstract
BACKGROUND/PURPOSE Afferent loop syndrome (ALS) is a rare adverse event after gastrointestinal surgery requiring appropriate early decompression treatment. Several endoscopic interventions have been attempted for treatment, including endoscopic enteral metal stent placement (EMSP), endoscopic ultrasound (EUS)-guided entero-enterostomy (EUS-EE), and EUS-guided hepaticogastrostomy (EUS-HGS). However, there are limited data on outcomes, including duration of stent patency. In this study, we evaluated the usefulness of each endoscopic intervention for malignant ALS. METHODS We retrospectively investigated nine patients with malignant ALS who underwent EMSP, EUS-EE, or EUS-HGS. Information on technical success, clinical efficacy, adverse events, stent dysfunction, and overall survival was collected and analyzed. RESULTS The most common symptoms were abdominal pain and cholangitis. ALS was treated by EMSP in three patients, EUS-EE in three patients, and EUS-HGS in three patients. Stent placement was successful and clinically effective in all patients with no adverse events. During follow-up, stent dysfunction occurred in two patients treated by EUS-HGS. Eight patients died of primary disease during a median follow-up of 157 days. CONCLUSIONS Each of the available endoscopic interventions for malignant ALS can be expected to produce similar outcomes, including duration of stent patency. The choice of endoscopic intervention should be made based on the characteristics of each treatment.
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Affiliation(s)
- Kenjiro Yamamoto
- Department of Gastroenterology and Hepatology, Tokyo Medical University, Tokyo, Japan
| | - Takao Itoi
- Department of Gastroenterology and Hepatology, Tokyo Medical University, Tokyo, Japan
| | - Yukitoshi Matsunami
- Department of Gastroenterology and Hepatology, Tokyo Medical University, Tokyo, Japan
| | - Atsushi Sofuni
- Department of Gastroenterology and Hepatology, Tokyo Medical University, Tokyo, Japan
| | - Takayoshi Tsuchiya
- Department of Gastroenterology and Hepatology, Tokyo Medical University, Tokyo, Japan
| | - Shuntaro Mukai
- Department of Gastroenterology and Hepatology, Tokyo Medical University, Tokyo, Japan
| | - Hiroyuki Kojima
- Department of Gastroenterology and Hepatology, Tokyo Medical University, Tokyo, Japan
| | - Hirohito Minami
- Department of Gastroenterology and Hepatology, Tokyo Medical University, Tokyo, Japan
| | - Ryosuke Nakatsubo
- Department of Gastroenterology and Hepatology, Tokyo Medical University, Tokyo, Japan
| | - Ryosuke Tonozuka
- Department of Gastroenterology and Hepatology, Tokyo Medical University, Tokyo, Japan
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Wu CCH, Brindise E, Abiad RE, Khashab MA. The Role of Endoscopic Management in Afferent Loop Syndrome. Gut Liver 2023; 17:351-359. [PMID: 36578193 PMCID: PMC10191797 DOI: 10.5009/gnl220205] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/18/2022] [Revised: 09/11/2022] [Accepted: 10/07/2022] [Indexed: 12/30/2022] Open
Abstract
Afferent loop syndrome (ALS) is a morbid complication that may occur after gastrectomy and gastrojejunostomy reconstruction. The aim of this article is to review the different endoscopic treatment options of ALS. We describe the evolution of the endoscopic treatment of ALS and its limitations despite the overall propitious profile. We analyze the advantages of endoscopic ultrasound-guided entero-enterostomy (EUS EE) over enteroscopy-guided intervention, and the clinical outcomes of EUS EE. We expound on pre-procedural considerations, intra-procedural techniques and post-procedural care following EUS EE. We conclude that given the simplification of the technique and the ability to place a stent away from the tumor, EUS EE is a promising technique that will likely be established as the treatment of choice for ALS.
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Affiliation(s)
- Clement Chun Ho Wu
- Department of Gastroenterology and Hepatology, Singapore General Hospital, Singapore
- Duke-NUS Medical School, Singapore
| | - Elizabeth Brindise
- Division of Gastroenterology and Hepatology, Department of Medicine, University of Iowa, Iowa City, IA, USA
| | - Rami El Abiad
- Division of Gastroenterology and Hepatology, Department of Medicine, University of Iowa, Iowa City, IA, USA
| | - Mouen A. Khashab
- Division of Gastroenterology and Hepatology, The Johns Hopkins Hospital, Baltimore, MD, USA
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Satoh T, Ishiwatari H, Ishikawa K, Kimura H, Matsubayashi H, Ono H. Simultaneous stent placement for biliary and afferent loop obstruction due to tumor recurrence after pancreatoduodenectomy. Endoscopy 2022; 54:E524-E525. [PMID: 34695847 DOI: 10.1055/a-1662-4433] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/10/2022]
Affiliation(s)
- Tatsunori Satoh
- Division of Endoscopy, Shizuoka Cancer Center, Shizuoka, Japan
| | | | - Kazuma Ishikawa
- Division of Endoscopy, Shizuoka Cancer Center, Shizuoka, Japan
| | - Hidenori Kimura
- Division of Endoscopy, Shizuoka Cancer Center, Shizuoka, Japan
| | | | - Hiroyuki Ono
- Division of Endoscopy, Shizuoka Cancer Center, Shizuoka, Japan
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Lam S, Khan S, Hutchins R, Fotheringham T. Extra-anatomic percutaneous stenting of a malignant afferent loop obstruction following pancreaticoduodenectomy. INTERNATIONAL JOURNAL OF GASTROINTESTINAL INTERVENTION 2022. [DOI: 10.18528/ijgii210014] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Affiliation(s)
- Stefan Lam
- Department of Medicine, Barts and the London School of Medicine and Dentistry, Queen Mary University of London, London, United Kingdom
| | - Sarah Khan
- Department of Imaging, The Royal London Hospital, Barts Health NHS Trust, London, United Kingdom
| | - Robert Hutchins
- Department of Imaging, The Royal London Hospital, Barts Health NHS Trust, London, United Kingdom
| | - Tim Fotheringham
- Department of Imaging, The Royal London Hospital, Barts Health NHS Trust, London, United Kingdom
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Shiomi H, Sakai A, Nakano R, Ota S, Kobayashi T, Masuda A, Iijima H. Endoscopic Ultrasound-Guided Gastroenterostomy for Afferent Loop Syndrome. Clin Endosc 2021; 54:810-817. [PMID: 34775697 PMCID: PMC8652169 DOI: 10.5946/ce.2021.234] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/14/2021] [Accepted: 10/17/2021] [Indexed: 02/06/2023] Open
Abstract
Afferent loop syndrome (ALS) is a mechanical obstruction of the afferent limbs after gastrectomy with gastrojejunostomy reconstruction. Patients with cancer recurrence require immediate and less invasive treatment because of their poor condition. Percutaneous transhepatic/transluminal drainage (PTD) and endoscopic enteral stenting offer reasonable palliative treatment for malignant ALS but are not fully satisfactory in terms of patient quality of life (QoL) and stent patency. Endoscopic ultrasound-guided gastroenterostomy (EUS-GE) using a lumen-apposing metal stent may address these shortcomings. Clinical data from 11 reports showed that all patients who had undergone EUS-GE had positive technical and clinical outcomes. The adverse event rate was 11.4%, including only mild or moderate abdominal pain, with no severe adverse events. Indirect comparative studies indicated that patients who had undergone EUS-GE had a significantly superior QoL, a higher clinical success rate, and a lower reintervention rate than those who had undergone PTD or endoscopic enteral stenting. Although the evidence is limited, EUS-GE may be considered as a first-line treatment for malignant ALS because it has better clinical outcomes than other less invasive treatments, such as PTD or endoscopic enteral stenting. Further prospective randomized control trials are necessary to establish EUS-GE as a standard treatment for ALS.
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Affiliation(s)
- Hideyuki Shiomi
- Division of Gastroenterology and Hepatobiliary and Pancreatic Diseases, Department of Internal Medicine, Hyogo College of Medicine, Hyogo, Japan
| | - Arata Sakai
- Division of Gastroenterology, Department of Internal Medicine, Kobe University Graduate School of Medicine, Kobe, Japan
| | - Ryota Nakano
- Division of Gastroenterology and Hepatobiliary and Pancreatic Diseases, Department of Internal Medicine, Hyogo College of Medicine, Hyogo, Japan
| | - Shogo Ota
- Division of Gastroenterology and Hepatobiliary and Pancreatic Diseases, Department of Internal Medicine, Hyogo College of Medicine, Hyogo, Japan
| | - Takashi Kobayashi
- Division of Gastroenterology, Department of Internal Medicine, Kobe University Graduate School of Medicine, Kobe, Japan
| | - Atsuhiro Masuda
- Division of Gastroenterology, Department of Internal Medicine, Kobe University Graduate School of Medicine, Kobe, Japan
| | - Hiroko Iijima
- Division of Gastroenterology and Hepatobiliary and Pancreatic Diseases, Department of Internal Medicine, Hyogo College of Medicine, Hyogo, Japan
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Sakai A, Shiomi H, Masuda A, Kobayashi T, Yamada Y, Kodama Y. Clinical management for malignant afferent loop obstruction. World J Gastrointest Oncol 2021. [DOI: 10.4251/wjgo.v13.i7.509] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
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Sakai A, Shiomi H, Masuda A, Kobayashi T, Yamada Y, Kodama Y. Clinical management for malignant afferent loop obstruction. World J Gastrointest Oncol 2021; 13:684-692. [PMID: 34322197 PMCID: PMC8299933 DOI: 10.4251/wjgo.v13.i7.684] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/04/2021] [Revised: 04/05/2021] [Accepted: 06/18/2021] [Indexed: 02/06/2023] Open
Abstract
Afferent loop obstruction (ALO) is defined as duodenal or jejunal mechanical obstruction at the proximal anastomosis site of a gastrojejunostomy. With advances in chemotherapy, the incidence of malignant ALO is increasing. Malignant ALO can be complicated by ischemia, gangrenous bowel, pancreatitis, and ascending cholangitis. Moreover, the general condition of patients with recurrent cancer is often poor. Therefore, accurate and rapid diagnosis and minimally invasive treatments are required. However, no review articles on the diagnosis and treatment of malignant ALO have been published. Through literature searching, we reviewed related articles published between 1959 and 2020 in the PubMed database. Herein, we present recent advances in the diagnosis and treatment of malignant ALO and describe future perspectives. Endoscopic transluminal self-expandable metal stent (SEMS) placement is considered the standard treatment for malignant ALO, as this procedure is well established and less invasive. However, with the development of interventional endoscopic ultrasound (EUS) in recent years, the usefulness of EUS-guided gastrojejunostomy has been reported. Moreover, through indirect comparison, this approach has been reported to be superior to transluminal SEMS placement. It is expected that a safer and less invasive treatment method will be established through the continued advancement and innovation of interventional endoscopy techniques.
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Affiliation(s)
- Arata Sakai
- Division of Gastroenterology, Department of Internal Medicine, Kobe University Graduate School of Medicine, Kobe 650-0017, Hyogo, Japan
| | - Hideyuki Shiomi
- Division of Gastroenterology, Department of Internal Medicine, Kobe University Graduate School of Medicine, Kobe 650-0017, Hyogo, Japan
| | - Atsuhiro Masuda
- Division of Gastroenterology, Department of Internal Medicine, Kobe University Graduate School of Medicine, Kobe 650-0017, Hyogo, Japan
| | - Takashi Kobayashi
- Division of Gastroenterology, Department of Internal Medicine, Kobe University Graduate School of Medicine, Kobe 650-0017, Hyogo, Japan
| | - Yasutaka Yamada
- Division of Gastroenterology, Department of Internal Medicine, Kobe University Graduate School of Medicine, Kobe 650-0017, Hyogo, Japan
| | - Yuzo Kodama
- Division of Gastroenterology, Department of Internal Medicine, Kobe University Graduate School of Medicine, Kobe 650-0017, Hyogo, Japan
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