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Image of Issue Benign case of afferent loop syndrome after subtotal gastrectomy: endoscopic ultrasound-guided jejunojejunostomy for rescue
Jahnvi Dhar1orcid, Sanish Ancil2orcid, Jayanta Samanta2orcid
Clinical Endoscopy 2026;59(1):144-146.
DOI: https://doi.org/10.5946/ce.2025.160
Published online: September 26, 2025

1Department of Gastroenterology and Hepatology, Punjab Institute of Liver and Biliary Sciences, Mohali, India

2Department of Gastroenterology, Post Graduate Institute of Medical Education and Research, Chandigarh, India

Correspondence: Jayanta Samanta Department of Gastroenterology, Post Graduate Institute of Medical Education and Research, Sector-12, Chandigarh 160012, India E-mail: dj_samanta@yahoo.co.in
• Received: May 20, 2025   • Revised: July 2, 2025   • Accepted: July 5, 2025

© 2026 Korean Society of Gastrointestinal Endoscopy

This is an Open Access article distributed under the terms of the Creative Commons Attribution Non-Commercial License (https://creativecommons.org/licenses/by-nc/4.0/) which permits unrestricted non-commercial use, distribution, and reproduction in any medium, provided the original work is properly cited.

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A 43-year-old man presented with abdominal pain, vomiting, and loss of appetite for 3 weeks. He had undergone a subtotal gastrectomy (Billroth type II) for gastric adenocarcinoma 1 month ago. On presentation (postoperative day 21), the patient had anemia, hypoalbuminemia, hypokalemia, with normal serum bilirubin. Abdominal imaging revealed dilatation of the duodenal and proximal jejunal loops with a kink in the afferent limb and no obvious internal hernia, adhesions, or mass near the anastomotic site (Fig. 1A, B). Gastroscopy revealed stasis of food residue in the afferent limb with a distal kink, which was not negotiable and normal efferent loop (Fig. 1C, D). With a clinical diagnosis of benign afferent loop syndrome (ALS), a modified diet plan and prokinetics were prescribed, but the patient showed no symptomatic improvement. As a poor candidate for repeat surgery, a multidisciplinary team decided for endoscopic ultrasound-guided jejunojejunostomy (EUS-JJ). Under fluoroscopic and EUS guidance, the scope was positioned in the afferent loop, and the efferent limb was visualized as a dilated bowel loop. Subsequently, freehand EUS-JJ was performed, and a 15×10 mm lumen-apposing metal stent (LAMS, Hot-AXIOS; Boston Scientific) was deployed (Fig. 2). The patient was started on a soft diet after 24 hours and subsequently discharged. Post-procedure gastroscopy and computed tomography performed 1-month revealed no food/bile stasis in the afferent loop at both ends of the Hot-AXIOS stent (Fig. 3). At 9 months, gastroscopy revealed resolution of the kink in the afferent loop, and LAMS was removed, and the patient was asymptomatic at the 1-year follow-up.
Currently, there is no consensus on the optimal treatment strategy for ALS. Historically, surgery has been the mainstay of management.1-3 EUS-JJ has been described in isolated case reports of malignant ALS.4 The use of EUS-JJ for benign ALS appears promising, facilitating recovery and reducing the need for reintervention.5,6
Fig. 1.
(A, B) Contrast-enhanced computed tomography of abdomen shows dilatation of duodenal and proximal jejunal loops (maximum diameter of afferent loop: 4.6 cm; yellow solid asterisk) with a kink in the afferent limb, with no obvious internal hernia, adhesions, or mass near the anastomotic site, suggestive of afferent loop syndrome; (C) Gastroscopy reveals residue stasis in the afferent limb; (D) Gastroscopy shows a normal efferent limb, with no obvious mass or ulceration near the anastomotic site.
ce-2025-160f1.jpg
Fig. 2.
Endoscopic ultrasound guided-jejunojejunostomy; (A) Fluoroscopic image showing nasojejunal tube positioned in the efferent limb (yellow solid arrow) with methylene blue contrast highlighting the jejunal loops (yellow solid asterisk); (B) Endoscopic ultrasound (EUS) image reveals a dilated efferent jejunal loop (target site for puncture; yellow solid asterisk); (C) Under EUS guidance, after puncture of efferent loop with electrocautery-enhanced lumen-apposing metal stent (LAMS) (Hot-AXIOS), distal flange deployed in the efferent loop and stent pulled back; (D) Fluoroscopic image confirms deployment of Hot-AXIOS stent (yellow solid arrow), creating a jejunojejunostomy; (E) Post-procedure gastroscopy confirms the stent position with one end in afferent loop; (F) Gastroscopy confirms the position of stent with one end in efferent loop.
ce-2025-160f2.jpg
Fig. 3.
(A) Post-procedure computed tomography of the abdomen shows the lumen-apposing metal stent (LAMS, yellow solid arrow) between afferent and efferent loops, confirming the creation of a jejunojejunostomy; (B) Gastroscopy performed 1 month after the procedure shows a patent stent in the afferent loop, with no evidence of food/bile stasis; (C) Efferent loops visualized through the LAMS, with gastroscope positioned in the afferent limb.
ce-2025-160f3.jpg
  • 1. Shiomi H, Sakai A, Nakano R, et al. Endoscopic ultrasound-guided gastroenterostomy for afferent loop syndrome. Clin Endosc 2021;54:810–817.ArticlePubMedPMCPDF
  • 2. Grisé K, McFadden D. Anastomotic technique influences outcomes after partial gastrectomy for adenocarcinoma. Am Surg 2001;67:948–950.ArticlePubMedPDF
  • 3. Wu CC, Brindise E, Abiad RE, et al. The role of endoscopic management in afferent loop syndrome. Gut Liver 2023;17:351–359.ArticlePubMedPMC
  • 4. van der Merwe SW, van Wanrooij RL, Bronswijk M, et al. Therapeutic endoscopic ultrasound: European Society of Gastrointestinal Endoscopy (ESGE) guideline. Endoscopy 2022;54:185–205.ArticlePubMed
  • 5. Ghoz H, Foulks C, Gómez V. Management of afferent limb obstruction by use of EUS-guided creation of a jejunojejunostomy and placement of a lumen-apposing metal stent. VideoGIE 2019;4:337–340.ArticlePubMedPMC
  • 6. Ligresti D, Amata M, Messina M, et al. Single-step EUS-guided jejunojejunostomy with a lumen-apposing metal stent as treatment for malignant afferent limb syndrome. VideoGIE 2020;5:154–156.Article

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        Benign case of afferent loop syndrome after subtotal gastrectomy: endoscopic ultrasound-guided jejunojejunostomy for rescue
        Clin Endosc. 2026;59(1):144-146.   Published online September 26, 2025
        DOI: https://doi.org/10.5946/ce.2025.160
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      Benign case of afferent loop syndrome after subtotal gastrectomy: endoscopic ultrasound-guided jejunojejunostomy for rescue
      Image Image Image
      Fig. 1. (A, B) Contrast-enhanced computed tomography of abdomen shows dilatation of duodenal and proximal jejunal loops (maximum diameter of afferent loop: 4.6 cm; yellow solid asterisk) with a kink in the afferent limb, with no obvious internal hernia, adhesions, or mass near the anastomotic site, suggestive of afferent loop syndrome; (C) Gastroscopy reveals residue stasis in the afferent limb; (D) Gastroscopy shows a normal efferent limb, with no obvious mass or ulceration near the anastomotic site.
      Fig. 2. Endoscopic ultrasound guided-jejunojejunostomy; (A) Fluoroscopic image showing nasojejunal tube positioned in the efferent limb (yellow solid arrow) with methylene blue contrast highlighting the jejunal loops (yellow solid asterisk); (B) Endoscopic ultrasound (EUS) image reveals a dilated efferent jejunal loop (target site for puncture; yellow solid asterisk); (C) Under EUS guidance, after puncture of efferent loop with electrocautery-enhanced lumen-apposing metal stent (LAMS) (Hot-AXIOS), distal flange deployed in the efferent loop and stent pulled back; (D) Fluoroscopic image confirms deployment of Hot-AXIOS stent (yellow solid arrow), creating a jejunojejunostomy; (E) Post-procedure gastroscopy confirms the stent position with one end in afferent loop; (F) Gastroscopy confirms the position of stent with one end in efferent loop.
      Fig. 3. (A) Post-procedure computed tomography of the abdomen shows the lumen-apposing metal stent (LAMS, yellow solid arrow) between afferent and efferent loops, confirming the creation of a jejunojejunostomy; (B) Gastroscopy performed 1 month after the procedure shows a patent stent in the afferent loop, with no evidence of food/bile stasis; (C) Efferent loops visualized through the LAMS, with gastroscope positioned in the afferent limb.

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      Benign case of afferent loop syndrome after subtotal gastrectomy: endoscopic ultrasound-guided jejunojejunostomy for rescue
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