Endoscopic Self-Expandable Metal Stent Placement for Malignant Afferent Loop Obstruction After Pancreaticoduodenectomy: A Case Series and Review

Arata Sakai; Hideyuki Shiomi; Takao Iemoto; Ryota Nakano; Takuya Ikegawa; Takashi Kobayashi; Atsuhiro Masuda; Yuzo Kodama

doi:10.5946/ce.2019.145

Articles

Page Path: HOME > Clin Endosc > Volume 53(4); 2020 > Article

Case Report Endoscopic Self-Expandable Metal Stent Placement for Malignant Afferent Loop Obstruction After Pancreaticoduodenectomy: A Case Series and Review: Arata Sakai¹, Hideyuki Shiomi¹, Takao Iemoto^1,2, Ryota Nakano¹, Takuya Ikegawa¹, Takashi Kobayashi¹, Atsuhiro Masuda¹, Yuzo Kodama¹; Clinical Endoscopy 2020;53(4):491-496.
DOI: https://doi.org/10.5946/ce.2019.145
Published online: March 3, 2020

¹Division of Gastroenterology, Department of Internal Medicine, Kobe University Graduate School of Medicine, Kobe, Japan

²Department of Gastroenterology, Kitaharima Medical Center, Ono, Japan

Correspondence: Hideyuki Shiomi Division of Gastroenterology, Department of Internal Medicine, Kobe University Graduate School of Medicine, 7-5-1 Kusunoki-cho, Chuo-ku, Kobe 650-0017, Japan Tel: +81-78-382-6305, Fax: +81-78-382-6309, E-mail: hshiomi@med.kobe-u.ac.jp

• Received: July 25, 2019 • Revised: August 29, 2019 • Accepted: September 17, 2019

This is an Open Access article distributed under the terms of the Creative Commons Attribution Non-Commercial License (http://creativecommons.org/licenses/by-nc/3.0/) which permits unrestricted non-commercial use, distribution, and reproduction in any medium, provided the original work is properly cited.

7,539 Views
121 Download
11 Web of Science
14 Crossref
12 Scopus

prev next

Full Article

Download PDF

Abstract
INTRODUCTION
CASE REPORT
DISCUSSION
NOTES
Acknowledgments
REFERENCES

Abstract

In this study, we assessed a series of our cases in which endoscopic self-expandable metal stents (SEMSs) were used to treat malignant afferent loop obstruction (ALO) that arose after pancreaticoduodenectomy (PD). We retrospectively examined the records of 7 patients who underwent endoscopic SEMS placement for malignant ALO following PD. Clinical success was achieved in all cases. The median procedure time was 30 min (range, 15–50 min). There were no cases of stent occlusion, and no procedure-related adverse events were encountered. All patients died of their primary disease, and the median overall survival period was 155 days (range, 96–374 days). A re-intervention involving endoscopic ultrasound-guided hepaticogastrostomy combined with antegrade stenting was performed for obstructive jaundice and acute cholangitis in 1 case. In conclusion, endoscopic SEMS placement may be an effective and safe treatment for malignant ALO that arises after PD.
Keywords: Endoscopic self-expandable metal stent; Endoscopic ultrasound-guided hepaticogastrostomy combined with antegrade stenting; Malignant afferent loop obstruction

INTRODUCTION

Afferent loop obstruction (ALO) caused by recurrent cancer (malignant ALO) that arises after pancreaticoduodenectomy (PD) can lead to an increase in internal pressure, which can block the outflow of bile or pancreatic juice. In addition, it often leads to the development of cholangitis or jaundice due to a loss of papillary function [1]. Conventionally, malignant ALO that arises after PD has been managed surgically. However, the general condition of patients with recurrent cancer is often not good enough to undergo surgery. Recently, endoscopic self-expandable metal stents (SEMSs) have been widely used to treat malignant gastric outlet obstruction (mGOO), whereas endoscopic SEMS placement for malignant ALO that arises after PD has only been described in case reports. Previously, we reported a case of malignant ALO arising after PD that was successfully treated by endoscopic SEMS placement [2]. However, the clinical outcomes of endoscopic SEMS placement for malignant ALO following PD remain to be evaluated. Herein, we report 7 cases of endoscopic SEMS placement for malignant ALO that arose after PD.

CASE REPORT

Patients

In this study, we retrospectively examined the records of 7 patients (3 males, 4 females; median age, 68 years; range, 56–82 years) who underwent endoscopic SEMS placement for malignant ALO that arose after PD at Kobe University Hospital between April 2010 and May 2018. The primary diseases included 5 cases of pancreatic cancer, 1 case of duodenal cancer, and 1 case of bile duct cancer. Subtotal stomach-preserving PD was performed for the primary disease in all cases. The indications for endoscopic SEMS placement included symptoms caused by cholangitis and a distended afferent loop. Six of 7 patients developed fever and elevated levels of biliary enzymes. One patient experienced severe abdominal pain due to marked distention of the afferent loop but did not develop a fever or elevated biliary enzyme levels (Table 1). The study protocol was in accordance with the Declaration of Helsinki and approved by the ethics committee of Kobe University Hospital (No. 170100).

Diagnosis of malignant afferent loop obstruction

The diagnosis of malignant ALO was determined based on the clinical presentation, laboratory data, and computed tomography (CT) findings of each case. In each case, CT scans revealed marked distention of the afferent loop due to bowel obstruction caused by a recurrent tumor (Fig. 1A). Upper gastrointestinal endoscopy was performed to confirm the diagnosis of neoplastic stenosis and manage the case.

Therapeutic technique

An endoscope was inserted into the afferent loop (Fig. 1B). After reaching the neoplastic stenotic lesion, a guidewire was advanced across the stricture and into the dilated afferent loop. Then, a nasojejunal tube (N-tube) was placed over the guidewire to decompress the dilated afferent loop (Fig. 1C). After decompressing the afferent loop, the length and location of the obstruction were accurately evaluated by injecting contrast medium through the N-tube to allow safe and effective endoscopic SEMS placement. Subsequently, the endoscope was inserted into the afferent loop along the N-tube, and an SEMS was deployed across the stricture using the standard through-the-scope technique (Fig. 1D). The procedure was performed using a therapeutic gastrointestinal endoscope (GIF 1T260; Olympus Optical Co., Tokyo, Japan) with a 3.7-mm working channel, under conscious sedation. In 6 patients, Niti-S uncovered duodenal stents (Taewoong Medical, Seoul, Korea), measuring 22 mm in diameter and 80, 100, or 120 mm in length, were used. In the remaining patient, an Evolution uncovered duodenal stent (Cook Medical, Bloomington, IN, USA), measuring 22 mm in diameter and 60 mm in length, was used. The expansion of the SEMS and amelioration of the ALO were assessed on CT scans after the SEMS placement.

Definitions

Clinical success was defined as decompression of the anastomotic proximal afferent loop after SEMS placement combined with symptom relief. The procedure time was defined as the time between the insertion and removal of the endoscope. The severity of adverse events was evaluated according to the American Society for Gastrointestinal Endoscopy’s grading system [3].

Statistical analysis

Results are expressed as medians and ranges or absolute values and percentages. Overall survival was estimated using the Kaplan-Meier method. All analyses were performed using the JMP Pro software version 11.2.0 (SAS Institute, Cary, NC, USA).

Results

The results of this study are summarized in Table 2. Clinical success was achieved in all 7 cases postoperatively (100%). The median procedure time was 30 min (range, 15–50 min). There were no cases of stent occlusion. After the SEMS placement, 2 of the 7 patients received chemotherapy, while the 5 remaining patients received best supportive care. No adverse events associated with the procedure were encountered in this series. All the patients died of their primary disease, and the median overall survival period was 155 days (range, 96–374 days).

A re-intervention for obstructive jaundice and acute cholangitis was performed in 1 case (case 2). This patient presented with biliary obstruction due to tumor recurrence at a bilioenteric anastomosis at 253 days after SEMS placement. SEMS obstruction was not observed under endoscopy and fluoroscopy. The patient’s jaundice and cholangitis were treated by endoscopic ultrasound-guided hepaticogastrostomy combined with antegrade stenting (EUS-HGAS) owing to failed biliary stenting via bilioenteric anastomosis (Fig. 2).

DISCUSSION

Endoscopic SEMS placement for malignant ALO that arises after PD has only been reported sporadically in case reports [3]. Our case series is the first to focus on the clinical outcomes of endoscopic SEMS placement for malignant ALO that arises after PD.

Malignant ALO following PD can be managed via surgical or non-surgical treatment. While surgery is effective, it is also highly invasive. Many patients with recurrent pancreaticobiliary cancer are not well enough to tolerate surgery. Hence, a non-surgical treatment option is clearly preferable. Previously, malignant ALO had been treated with percutaneous transhepatic biliary drainage (PTBD). However, biliary access can be challenging in patients without jaundice or sufficiently dilated intrahepatic bile ducts. Furthermore, PTBD is known to cause severe adverse events, such as bleeding, bile peritonitis, or ascending cholangitis [4]. Endoscopic treatment approaches for ALO have emerged as feasible alternatives to surgery. Recently, endoscopic duodenal SEMS placement has been implemented as an alternative to surgical bypass for the palliation of mGOO in light of its low morbidity and mortality rates. In contrast, endoscopic SEMS placement for malignant ALO has only been reported sporadically in case reports.

During a PubMed search, we found 12 reports (23 patients) on the use of SEMS to treat malignant ALO that arises after PD (Table 3) [5-16]. Clinical success was achieved in all cases, and no adverse events were encountered. Although the data were limited, no cases of SEMS obstruction were found. In addition, none of these previous cases required re-intervention after the SEMS placement. In our case series, no procedure-related adverse events were encountered, the procedure time was not prolonged, and technical success was achieved in all 7 cases. Two of the 7 cases received chemotherapy after the SEMS placement, and both exhibited prolonged survival. There was no clinical suspicion of stent dysfunction in any patient. One patient presented with obstructive jaundice after the SEMS placement. Biliary obstruction occurred due to tumor recurrence at the bilioenteric anastomosis without SEMS obstruction. We determined that direct biliary drainage was required in this situation. However, biliary stenting via the bilioenteric anastomosis failed due to difficult cannulation of the bile duct. In this case, EUS-HGAS was performed as an alternative biliary drainage method, which led to an improvement in the patient’s condition. Furthermore, our cases were followed up until death, and no recurrent cholangitis due to obstruction of the SEMS was detected. Thus, our case series exhibited satisfactory clinical outcomes.

We speculated that the two-step approach would be useful for the safe and accurate deployment of endoscopic SEMS for malignant ALO. A N-tube was inserted into the distended afferent loop under fluoroscopy guidance for all cases, and then SEMS was deployed across the stricture after improvement of the clinical condition. This approach has 3 advantages. First, it is more reliable for achieving drainage of the distended afferent loop because the amount of drainage can be checked, which leads to the alleviation of obstructive jaundice and ascending cholangitis. Second, in the determination of the therapeutic strategy, it is important to evaluate whether the bilioenteric anastomosis is involved in the obstruction site. If the bilioenteric anastomosis is obstructed by tumor recurrence, double stenting is required to achieve decompression of both the afferent loop and the biliary duct. However, it is often difficult to diagnose the comorbid obstruction of a bilioenteric anastomosis by CT or ultrasonography. Contrast medium injection through the nasojejunal drain is helpful for assessing bilioenteric obstruction. Finally, evaluating the length and location of the obstruction site after decompressing the afferent loop enables a suitable SEMS placement. This approach may facilitate an accurate diagnosis as well as the selection of therapeutic strategies for ALO with ascending cholangitis.

All the patients in our series were treated using endoscopes of the conventional length. Recently, the use of balloon-assisted endoscopy during SEMS placement for malignant ALO has been reported [4,7,9,11-14,16]. Shimatani et al. reported a case in which SEMS placement was used to treat ALO caused by cancer recurrence after PD, in which a newly developed, shorttype, double-balloon endoscope (S-DBE) (EI-580BT; Fujifilm, Tokyo, Japan) was used [13]. They claimed that the combined use of the new S-DBE, which had a 3.2-mm working channel, and SEMS with a 9 Fr delivery system enabled through-the-scope SEMS placement, which had been previously challenging because the large diameter of the SEMS delivery system did not allow stent deployment through the 2.8-mm working channels of the conventional S-DBE.

If the stricture is long or an angulated loop, endoscopic SEMS placement across the stricture is challenging. Recently, endoscopic ultrasound-guided gastrojejunostomy (EUS-GJ) using a lumen-apposing metal stent has been reported [17-19]. In addition, we developed a method involving a conventional SEMS with antimigration properties, comprising a largeloop double-pigtail plastic stent within a fully covered biliary SEMS [20]. While further studies are needed, EUS-GJ may be considered an alternative treatment for selected malignant ALO cases.

In conclusion, endoscopic SEMS placement may represent an effective and safe treatment for malignant ALO.

Conflicts of Interest: The authors have no financial conflicts of interest.

Acknowledgments

This work was supported by JSPS KAKENHI Grant Number JP19K07938.

Fig. 1.

(A) A computed tomography scan revealed marked distention of the afferent loop, which was suggestive of bowel obstruction caused by a recurrent tumor. (B) An endoscope was inserted into the afferent loop. A neoplastic stenotic lesion blocked further passage of the endoscope. (C) A nasojejunal tube was placed over a guidewire to decompress the dilated afferent loop. (D) A self-expandable metal stent was inserted using the standard through-the-scope technique.

Fig. 2.

(A) Case 2 presented with obstructive jaundice due to invasive cancer involving a bilioenteric anastomosis after self-expandable metal stent (SEMS) insertion. (B) Endoscopic ultrasound-guided biliary drainage was selected. An echoendoscope was advanced into the stomach, and a 19-gauge fine needle aspiration needle was advanced into a left-sided intrahepatic bile duct (B3). Cholangiography showed stenosis of the bilioenteric anastomosis, and a guidewire was advanced through the stenotic lesion and into the afferent loop. (C) An uncovered SEMS was placed across the stenotic lesion, and a plastic stent was placed through the fistula between the gastric body and the intrahepatic bile duct.

Table 1.

Summary of the Patients

Case	Age/Sex	Chief complaint	Primary disease	Period from operation (mo)	PS	T-Bil (mg/dL)	AST (U/L)	ALT (U/L)	Alp (U/L)	WBC (count/μL)	CRP (mg/dL)
1	63/F	Abdominal pain	Pancreatic cancer	36	0	1.1	146	86	2,759	3,000	0.1
2	66/M	Fever	Pancreatic cancer	10	0	3.0	124	126	802	3,800	3.6
3	56/F	Fever	Pancreatic cancer	12	1	2.8	79	84	1,121	12,800	6.9
4	80/F	Fever	Pancreatic cancer	10	2	2.5	55	58	1,665	11,600	8.3
5	61/M	Fever	Pancreatic cancer	14	2	4.1	50	61	1,031	15,200	9.7
6	67/M	Fever	Duodenal cancer	41	0	0.8	69	33	774	8,200	7.0
7	82/F	Fever	Bile duct cancer	15	1	6.0	179	109	1,842	10,000	14.5

Alp, alcaline phosphatase; ALT, alanine transaminase; AST, asparate transaminase; CRP, C-reactive protein; PS, performance status; T-Bil, total bililubin; WBC, white blood cell.

Table 2.

Clinical Outcomes of the Patients

Case	Clinical success	Treatment time (min)	Adverse events	Stent obstruction	Re-intervention	Overall survival (days)	Treatment after SEMS placement
1	Yes	40	No	No	No	109	BSC
2	Yes	20	No	No	Yes	374	Chemo therapy
3	Yes	30	No	No	No	155	BSC
4	Yes	50	No	No	No	96	BSC
5	Yes	15	No	No	No	340	Chemo therapy
6	Yes	30	No	No	No	187	BSC
7	Yes	30	No	No	No	132	BSC

BSC, best supportive care; SEMS, self-expandable metal stent.

Table 3.

Reported Cases of Self-Expandable Metal Stent Placement for Malignant Afferent Loop Obstruction

no.	Study	Case no.	Age	Sex	Primary disease	Scope	Stent length (mm)	Stent diameter (cm)	Clinical succes	Adverse event	Prognosis
1	Burdick et al. (2002) [5]	1	47	M	Ampullary cancer	PCF140	20	6	Yes	None	ND
2	Kim et al. (2011) [6]	1	52	M	Pancreatic cancer	CS	24	6	Yes	None	ND
3	Kim et al. (2011) [6]	2	62	F	Pancreatic cancer	CS	20	10	Yes	None	ND
4	Kida et al. (2013) [7]	1	68	M	Pancreatic cancer	Standard DBE	ND	ND	Yes	None	ND
5	Kwong et al. (2014) [8]	1	75	M	Pancreatic cancer	EGD	22	12	Yes	None	After 3 wk died
6	Kwong et al. (2014) [8]	2	58	M	Pancreatic cancer	EGD	22	9	Yes	None	After 6 mo died
7	Sasaki et al. (2014) [9]	1	64	M	Pancreatic cancer	Standard DBE	22	6	Yes	None	ND
8	Huang et al. (2015) [10]	1	65	M	Pancreatic cancer	CS	20	6	Yes	None	After 3 mo died without obstruction
9		2	55	M	Pancreatic cancer	ND	20	8	Yes	None	After 3 mo died without obstruction
10		3	68	M	Pancreatic cancer	ND	ND	ND	Yes	None	ND
11	Fujii et al. (2015) [11]	1	61	M	Bile duct cancer	Short DBE	22	6	Yes	None	After 141 days died
12	Fujii et al. (2015) [11]	2	61	M	Ampullary cancer	Short DBE	22	6	Yes	None	After 140 days died
13	Nakahara et al. (2015) [12]	1	48	M	Pancreatic cancer	Standard DBE	22	12	Yes	None	After 4 mo died without obstruction
14	Nakahara et al. (2015) [12]	2	76	M	Bile duct cancer	Standard DBE	22	12	Yes	None	After 14 mo died without obstruction
15	Shimatani et al. (2016) [13]	1	71	F	Pancreatic cancer	Short DBE	18	6	Yes	None	ND
16	Minaga et al. (2016) [14]	1	70	M	Duodenal cancer	Short DBE	18	8	Yes	None	After 4 mo died without obstruction
17	Kanno et al. (2018) [15]	1	56	M	Pancreatic cancer	CS	22	6+9	Yes	None	After 2 mo died without obstruction
18		2	64	M	Bile duct cancer	Prototype	18	10	Yes	None	After 12 mo died without obstruction
19		3	67	M	Pancreatic cancer	CS	18	8	Yes	None	After 4 mo died without obstruction
20	Yane et al. (2018) [16]	1	76	M	Pancreatic cancer	Short DBE	22	12	Yes	None	After 219 days died without obstruction
21		2	65	M	Pancreatic cancer	Short DBE	22	8	Yes	None	After 103 days died without obstruction
22		3	59	F	Pancreatic cancer	Short DBE	22	10	Yes	None	After 109 days died without obstruction
23		4	77	M	Pancreatic cancer	Short DBE	22	6	Yes	None	After 84 days died without obstruction

CS, colonoscope; DBE, double balloon endoscope; EGD, esophagogastroduodenoscope; ND, no data.

REFERENCES

1. Chevallier P, Novellas S, Motamedi JP, Gugenheim J, Brunner P, Bruneton JN. Percutaneous jejunostomy and stent placement for treatment of malignant Roux-en-Y obstruction: a case report. Clin Imaging 2006;30:283–286.Article PubMed
2. Sakai A, Shiomi H, Okabe Y, et al. Effectiveness of endoscopic self-expandable metal stent placement for afferent loop obstruction caused by pancreatic cancer recurrence after pancreaticoduodenectomy. Clin J Gastroenterol 2015;8:103–107.Article PubMed PDF
3. Cotton PB, Eisen GM, Aabakken L, et al. A lexicon for endoscopic adverse events: report of an ASGE workshop. Gastrointest Endosc 2010;71:446–454.Article PubMed
4. Morita S, Takemura T, Matsumoto S, Odani R. Septic shock after percutaneous transhepatic drainage of obstructed afferent loop: case report. Cardiovasc Intervent Radiol 1989;12:66–68.Article PubMed PDF
5. Burdick JS, Garza AA, Magee DJ, Dykes C, Jeyarajah R. Endoscopic management of afferent loop syndrome of malignant etiology. Gastrointest Endosc 2002;55:602–605.Article PubMed
6. Kim JK, Park CH, Huh JH, et al. Endoscopic management of afferent loop syndrome after a pylorus preserving pancreatoduodenecotomy presenting with obstructive jaundice and ascending cholangitis. Clin Endosc 2011;44:59–64.Article PubMed PMC PDF
7. Kida A, Matsuda K, Noda Y. Endoscopic metallic stenting by double-balloon enteroscopy and its overtube for malignant gastrointestinal obstruction as palliative treatment. Dig Endosc 2013;25:552–553.Article PubMed
8. Kwong WT, Fehmi SM, Lowy AM, Savides TJ. Enteral stenting for gastric outlet obstruction and afferent limb syndrome following pancreaticoduodenectomy. Ann Gastroenterol 2014;27:413–417.PubMed PMC
9. Sasaki T, Isayama H, Kogure H, et al. Double-balloon enteroscope-assisted enteral stent placement for malignant afferent-loop obstruction after Roux-en-Y reconstruction. Endoscopy 2014;46 Suppl 1 UCTN:E541–E542.Article PubMed PDF
10. Huang J, Hao S, Yang F, et al. Endoscopic metal enteral stent placement for malignant afferent loop syndrome after pancreaticoduodenectomy. Wideochir Inne Tech Maloinwazyjne 2015;10:257–265.Article PubMed PMC
11. Fujii M, Ishiyama S, Saito H, et al. Metallic stent insertion with double-balloon endoscopy for malignant afferent loop obstruction. World J Gastrointest Endosc 2015;7:665–669.Article PubMed PMC
12. Nakahara K, Okuse C, Matsumoto N, et al. Enteral metallic stenting by balloon enteroscopy for obstruction of surgically reconstructed intestine. World J Gastroenterol 2015;21:7589–7593.Article PubMed PMC
13. Shimatani M, Takaoka M, Tokuhara M, et al. Through-the-scope self-expanding metal stent placement using newly developed short double-balloon endoscope for the effective management of malignant afferent-loop obstruction. Endoscopy 2016;48 Suppl 1 UCTN:E6–E7.Article PubMed PDF
14. Minaga K, Kitano M, Takenaka M. Through-the-scope enteral metal stent placement using a short-type single-balloon enteroscope for malignant surgically reconstructed jejunal stenosis (with video). Dig Endosc 2016;28:758.Article PubMed
15. Kanno Y, Ohira T, Harada Y, et al. Metal stent placement in the afferent loop obstructed by peritoneal metastases-experience of five cases. Clin Endosc 2018;51:299–303.Article PubMed PMC PDF
16. Yane K, Katanuma A, Hayashi T, et al. Enteral self-expandable metal stent placement for malignant afferent limb syndrome using single-balloon enteroscope: report of five cases. Endosc Int Open 2018;6:E1330–E1335.Article PubMed PMC PDF
17. Ikeuchi N, Itoi T, Tsuchiya T, Nagakawa Y, Tsuchida A. One-step EUS-guided gastrojejunostomy with use of lumen-apposing metal stent for afferent loop syndrome treatment. Gastrointest Endosc 2015;82:166.Article PubMed
18. Toliopoulos P, Manière T, Désilets E. Treatment of neoplastic afferent limb syndrome by endoscopic gastrojejunostomy with a lumen-apposing metal stent. VideoGIE 2018;3:61–62.Article PubMed PMC
19. Yamamoto K, Tsuchiya T, Tanaka R, et al. Afferent loop syndrome treated by endoscopic ultrasound-guided gastrojejunostomy, using a lumen-apposing metal stent with an electrocautery-enhanced delivery system. Endoscopy 2017;49:E270–E272.Article PubMed PDF
20. Shiomi H, Kobayashi T, Sakai A, et al. Endoscopic ultrasound-guided gastrojejunostomy using fully covered metal stent combined with largeloop double-pigtail stent for malignant afferent loop syndrome. Endoscopy 2019;51:E303–E304.Article PubMed PDF

Figure & Data

REFERENCES

Citations

Citations to this article as recorded by

PTCD-stent complex for recurrent malignant afferent loop obstruction after pancreaticoduodenectomy
Dongxue Geng, Yi Miao, Jingjing Tao
BMC Surgery.2026;[Epub] CrossRef
Endoscopic ultrasound-guided gastrointestinal anastomoses for the treatment of afferent limb syndrome: a systematic review and meta-analysis
Giacomo Emanuele Maria Rizzo, Giuseppe Vanella, Lorenzo Fuccio, Antonio Facciorusso, Stefano Mazza, Fausto Catena, Carlo Fabbri, Andrea Anderloni, Ilaria Tarantino
Surgical Endoscopy.2026; 40(5): 3944. CrossRef
Early and late effects of endoscopic interventions in patients with malignant afferent loop syndrome: A single‐center experience and literature review
Kenjiro Yamamoto, Takao Itoi, Yukitoshi Matsunami, Atsushi Sofuni, Takayoshi Tsuchiya, Shuntaro Mukai, Hiroyuki Kojima, Hirohito Minami, Ryosuke Nakatsubo, Ryosuke Tonozuka
Journal of Hepato-Biliary-Pancreatic Sciences.2024; 31(2): 120. CrossRef
Efficacy of endoscopic ultrasound‐guided gastroenterostomy using self‐expandable metallic stent for afferent loop syndrome: A single‐center retrospective study
Yuya Hagiwara, Susumu Hijioka, Yoshikuni Nagashio, Yuta Maruki, Akihiro Ohba, Yuki Kawasaki, Kotaro Takeshita, Tetsuro Takasaki, Daiki Agarie, Hidenobu Hara, Shin Yagi, Soma Fukuda, Masaru Kuwada, Daiki Yamashige, Kohei Okamoto, Mark Chatto, Shunsuke Kond
Journal of Gastroenterology and Hepatology.2024; 39(10): 2136. CrossRef
Successful metal stent placement using short single-balloon endoscope for afferent loop syndrome after pancreaticoduodenectomy
Takuto Furukawa, Yuichi Takano, Jun Noda, Masataka Yamawaki, Tetsushi Azami, Fumitaka Niiya, Fumiya Nishimoto, Naotaka Maruoka, Masatsugu Nagahama
Progress of Digestive Endoscopy.2024; 104(1): 98. CrossRef
Antegrade metallic stent placement using a slim cholangioscope for malignant afferent loop obstruction
Haruo Miwa, Ritsuko Oishi, Kazuki Endo, Hiromi Tsuchiya, Akihiro Funaoka, Yuichi Suzuki, Shin Maeda
Endoscopy.2024; 56(S 01): E774. CrossRef
The Role of Endoscopic Management in Afferent Loop Syndrome
Clement Chun Ho Wu, Elizabeth Brindise, Rami El Abiad, Mouen A. Khashab
Gut and Liver.2023; 17(3): 351. CrossRef
Simultaneous stent placement for biliary and afferent loop obstruction due to tumor recurrence after pancreatoduodenectomy
Tatsunori Satoh, Hirotoshi Ishiwatari, Kazuma Ishikawa, Hidenori Kimura, Hiroyuki Matsubayashi, Hiroyuki Ono
Endoscopy.2022; 54(09): E524. CrossRef
Extra-anatomic percutaneous stenting of a malignant afferent loop obstruction following pancreaticoduodenectomy
Stefan Lam, Sarah Khan, Robert Hutchins, Tim Fotheringham
International Journal of Gastrointestinal Intervention.2022; 11(2): 77. CrossRef
Endoscopic Transluminal Stent Placement for Malignant Afferent Loop Obstruction
Chinatsu Yonekura, Takashi Sasaki, Takafumi Mie, Takeshi Okamoto, Tsuyoshi Takeda, Takaaki Furukawa, Yuto Yamada, Akiyoshi Kasuga, Masato Matsuyama, Masato Ozaka, Naoki Sasahira
Journal of Clinical Medicine.2022; 11(21): 6357. CrossRef
Clinical management for malignant afferent loop obstruction
Arata Sakai, Hideyuki Shiomi, Atsuhiro Masuda, Takashi Kobayashi, Yasutaka Yamada, Yuzo Kodama
World Journal of Gastrointestinal Oncology.2021; 13(7): 684. CrossRef
Clinical management for malignant afferent loop obstruction
Arata Sakai, Hideyuki Shiomi, Atsuhiro Masuda, Takashi Kobayashi, Yasutaka Yamada, Yuzo Kodama
World Journal of Gastrointestinal Oncology.2021; 13(7): 509. CrossRef
Endoscopic Ultrasound-Guided Gastroenterostomy for Afferent Loop Syndrome
Hideyuki Shiomi, Arata Sakai, Ryota Nakano, Shogo Ota, Takashi Kobayashi, Atsuhiro Masuda, Hiroko Iijima
Clinical Endoscopy.2021; 54(6): 810. CrossRef
Percutaneous- and EUS-guided gastroenterostomy for malignant afferent limb syndrome
Dayyan Adoor, Zachary L. Smith
VideoGIE.2020; 5(11): 542. CrossRef

PubReader
ePub Link

Cite

CITE: export Copy Download Format; Close

Download Citation

Download a citation file in RIS format that can be imported by all major citation management software, including EndNote, ProCite, RefWorks, and Reference Manager.

Format:

RIS — For EndNote, ProCite, RefWorks, and most other reference management software
BibTeX — For JabRef, BibDesk, and other BibTeX-specific software

Include:

Citation for the content below
Citation and abstract for the content below

Endoscopic Self-Expandable Metal Stent Placement for Malignant Afferent Loop Obstruction After Pancreaticoduodenectomy: A Case Series and Review

Clin Endosc. 2020;53(4):491-496. Published online March 3, 2020

DOI: https://doi.org/10.5946/ce.2019.145

XML Download

Figure

Endoscopic Self-Expandable Metal Stent Placement for Malignant Afferent Loop Obstruction After Pancreaticoduodenectomy: A Case Series and Review

Fig. 1. (A) A computed tomography scan revealed marked distention of the afferent loop, which was suggestive of bowel obstruction caused by a recurrent tumor. (B) An endoscope was inserted into the afferent loop. A neoplastic stenotic lesion blocked further passage of the endoscope. (C) A nasojejunal tube was placed over a guidewire to decompress the dilated afferent loop. (D) A self-expandable metal stent was inserted using the standard through-the-scope technique.

Fig. 2. (A) Case 2 presented with obstructive jaundice due to invasive cancer involving a bilioenteric anastomosis after self-expandable metal stent (SEMS) insertion. (B) Endoscopic ultrasound-guided biliary drainage was selected. An echoendoscope was advanced into the stomach, and a 19-gauge fine needle aspiration needle was advanced into a left-sided intrahepatic bile duct (B3). Cholangiography showed stenosis of the bilioenteric anastomosis, and a guidewire was advanced through the stenotic lesion and into the afferent loop. (C) An uncovered SEMS was placed across the stenotic lesion, and a plastic stent was placed through the fistula between the gastric body and the intrahepatic bile duct.

Fig. 1.

Fig. 2.

Endoscopic Self-Expandable Metal Stent Placement for Malignant Afferent Loop Obstruction After Pancreaticoduodenectomy: A Case Series and Review

Case	Age/Sex	Chief complaint	Primary disease	Period from operation (mo)	PS	T-Bil (mg/dL)	AST (U/L)	ALT (U/L)	Alp (U/L)	WBC (count/μL)	CRP (mg/dL)
1	63/F	Abdominal pain	Pancreatic cancer	36	0	1.1	146	86	2,759	3,000	0.1
2	66/M	Fever	Pancreatic cancer	10	0	3.0	124	126	802	3,800	3.6
3	56/F	Fever	Pancreatic cancer	12	1	2.8	79	84	1,121	12,800	6.9
4	80/F	Fever	Pancreatic cancer	10	2	2.5	55	58	1,665	11,600	8.3
5	61/M	Fever	Pancreatic cancer	14	2	4.1	50	61	1,031	15,200	9.7
6	67/M	Fever	Duodenal cancer	41	0	0.8	69	33	774	8,200	7.0
7	82/F	Fever	Bile duct cancer	15	1	6.0	179	109	1,842	10,000	14.5

Case	Clinical success	Treatment time (min)	Adverse events	Stent obstruction	Re-intervention	Overall survival (days)	Treatment after SEMS placement
1	Yes	40	No	No	No	109	BSC
2	Yes	20	No	No	Yes	374	Chemo therapy
3	Yes	30	No	No	No	155	BSC
4	Yes	50	No	No	No	96	BSC
5	Yes	15	No	No	No	340	Chemo therapy
6	Yes	30	No	No	No	187	BSC
7	Yes	30	No	No	No	132	BSC

no.	Study	Case no.	Age	Sex	Primary disease	Scope	Stent length (mm)	Stent diameter (cm)	Clinical succes	Adverse event	Prognosis
1	Burdick et al. (2002) [5]	1	47	M	Ampullary cancer	PCF140	20	6	Yes	None	ND
2	Kim et al. (2011) [6]	1	52	M	Pancreatic cancer	CS	24	6	Yes	None	ND
3	Kim et al. (2011) [6]	2	62	F	Pancreatic cancer	CS	20	10	Yes	None	ND
4	Kida et al. (2013) [7]	1	68	M	Pancreatic cancer	Standard DBE	ND	ND	Yes	None	ND
5	Kwong et al. (2014) [8]	1	75	M	Pancreatic cancer	EGD	22	12	Yes	None	After 3 wk died
6	Kwong et al. (2014) [8]	2	58	M	Pancreatic cancer	EGD	22	9	Yes	None	After 6 mo died
7	Sasaki et al. (2014) [9]	1	64	M	Pancreatic cancer	Standard DBE	22	6	Yes	None	ND
8	Huang et al. (2015) [10]	1	65	M	Pancreatic cancer	CS	20	6	Yes	None	After 3 mo died without obstruction
9		2	55	M	Pancreatic cancer	ND	20	8	Yes	None	After 3 mo died without obstruction
10		3	68	M	Pancreatic cancer	ND	ND	ND	Yes	None	ND
11	Fujii et al. (2015) [11]	1	61	M	Bile duct cancer	Short DBE	22	6	Yes	None	After 141 days died
12	Fujii et al. (2015) [11]	2	61	M	Ampullary cancer	Short DBE	22	6	Yes	None	After 140 days died
13	Nakahara et al. (2015) [12]	1	48	M	Pancreatic cancer	Standard DBE	22	12	Yes	None	After 4 mo died without obstruction
14	Nakahara et al. (2015) [12]	2	76	M	Bile duct cancer	Standard DBE	22	12	Yes	None	After 14 mo died without obstruction
15	Shimatani et al. (2016) [13]	1	71	F	Pancreatic cancer	Short DBE	18	6	Yes	None	ND
16	Minaga et al. (2016) [14]	1	70	M	Duodenal cancer	Short DBE	18	8	Yes	None	After 4 mo died without obstruction
17	Kanno et al. (2018) [15]	1	56	M	Pancreatic cancer	CS	22	6+9	Yes	None	After 2 mo died without obstruction
18		2	64	M	Bile duct cancer	Prototype	18	10	Yes	None	After 12 mo died without obstruction
19		3	67	M	Pancreatic cancer	CS	18	8	Yes	None	After 4 mo died without obstruction
20	Yane et al. (2018) [16]	1	76	M	Pancreatic cancer	Short DBE	22	12	Yes	None	After 219 days died without obstruction
21		2	65	M	Pancreatic cancer	Short DBE	22	8	Yes	None	After 103 days died without obstruction
22		3	59	F	Pancreatic cancer	Short DBE	22	10	Yes	None	After 109 days died without obstruction
23		4	77	M	Pancreatic cancer	Short DBE	22	6	Yes	None	After 84 days died without obstruction

Table 1. Summary of the Patients

Alp, alcaline phosphatase; ALT, alanine transaminase; AST, asparate transaminase; CRP, C-reactive protein; PS, performance status; T-Bil, total bililubin; WBC, white blood cell.

Table 2. Clinical Outcomes of the Patients

BSC, best supportive care; SEMS, self-expandable metal stent.

Table 3. Reported Cases of Self-Expandable Metal Stent Placement for Malignant Afferent Loop Obstruction

CS, colonoscope; DBE, double balloon endoscope; EGD, esophagogastroduodenoscope; ND, no data.