J Korean Surg Soc.  2013 May;84(5):281-286.

Afferent loop obstruction following laparoscopic distal gastrectomy with Billroth-II gastrojejunostomy

• Kim DJ
• Lee JH
• Kim W

Abstract

PURPOSE
Afferent loop (A-loop) obstruction is an uncommon postgastrectomy complication following Billroth-II (B-II) or Roux-en-Y reconstruction. Moreover, its development after laparoscopic gastrectomy has not been reported. Here we report 4 cases of A-loop obstructions after laparoscopic distal gastrectomy (LDG) with B-II reconstruction.
METHODS
Among the 396 patients who underwent LDG with a B-II anastomosis between April 2004 and December 2011, 4 patients had A-loop obstruction. Their data were obtained from a prospectively maintained institutional database and analyzed for outcomes.
RESULTS
Four patients (1.01%) developed A-loop obstruction. All were male, and their median age was 52 years (range, 30 to 73 years). The interval between the initial gastrectomies and the operation for A-loop obstruction ranged from 4 to 540 days (median, 33 days). All 4 patients had symptoms of vomiting and abdominal pain and were diagnosed by abdominal computed tomographic (CT) scan. The causes of the A-loop obstructions were adhesions (2 cases) and internal herniations (2 cases) that were treated with Braun anastomoses and reduction of the herniated small bowels, respectively. All patients recovered following the emergency operations.
CONCLUSION
A-loop obstruction is a rare but serious complication following laparoscopic and open gastrectomy. It should be considered when a patient complains of continuous abdominal pain and/or vomiting after LDG with B-II reconstruction. Prompt CT scan may play an important role in diagnosis and treatment.

Keyword

Afferent loop obstruction; Billroth-II operation; Laparoscopy; Ileus

MeSH Terms

Abdominal Pain
Emergencies
Gastrectomy
Gastric Bypass
Humans
Ileus
Laparoscopy
Male
Prospective Studies
Vomiting

Figure

• 

  Fig. 1 (A) Illustration of afferent obstruction in case 1. (B) Illustration of afferent obstruction in case 2. (C) Illustration of internal herniation in cases 3 and 4.

• 

  Fig. 2 (A) Stitch between the afferent limb and transverse mesocolon. (B) Closure of mesenteric gap following Billroth-II gastrojejunostomy. S, remnant stomach; A, afferent limb; E, efferent limb.

• 

  Fig. 3 (A) Markedly dilated duodenal c-loop. (B) A whirling appearance of the mesenteric vessels, suggestive of internal herniation through Petersen's space.

Reference

1. Aoki M, Saka M, Morita S, Fukagawa T, Katai H. Afferent loop obstruction after distal gastrectomy with Roux-en-Y reconstruction. World J Surg. 2010. 34:2389–2392.

2. Mitty WF Jr, Grossi C, Nealon TF Jr. Chronic afferent loop syndrome. Ann Surg. 1970. 172:996–1001.

3. Ballas KD, Rafailidis SE, Konstantinidis HD, Pavlidis TE, Marakis GN, Anagnostara E, et al. Acute afferent loop syndrome: a true emergency: a case report. Acta Chir Belg. 2009. 109:101–103.

4. Bastable JR, Huddy PE. Retro-anastomotic hernia. Eight cases of internal hernia following gastrojejunal anastomosis, with a review of the literature. Br J Surg. 1960. 48:183–189.

5. Lee HJ, Jang YJ, Kim JH, Park SS, Park SH, Park JJ, et al. Clinical outcomes of gastrectomy after incomplete EMR/ESD. J Gastric Cancer. 2011. 11:162–166.

6. Jeong O, Park YK. Clinicopathological features and surgical treatment of gastric cancer in South Korea: the results of 2009 nationwide survey on surgically treated gastric cancer patients. J Gastric Cancer. 2011. 11:69–77.

7. The Information Committee of the Korean Gastric Cancer Association. 2004 nationwide gastric cancer report in Korea. J Korean Gastric Cancer Assoc. 2007. 7:47–54.

8. Wise SW. Case 24: afferent loop syndrome. Radiology. 2000. 216:142–145.

9. Zissin R. CT findings of afferent loop syndrome after a subtotal gastrectomy with Roux-en-Y reconstruction. Emerg Radiol. 2004. 10:201–203.

10. Kim HC, Han JK, Kim KW, Kim YH, Yang HK, Kim SH, et al. Afferent loop obstruction after gastric cancer surgery: helical CT findings. Abdom Imaging. 2003. 28:624–630.

11. Southam JA. Acute afferent loop obstruction. Ann Surg. 1967. 165:323–324.

12. Mithofer K, Warshaw AL. Recurrent acute pancreatitis caused by afferent loop stricture after gastrectomy. Arch Surg. 1996. 131:561–565.

13. Kim HJ, Kim JW, Kim KH, Jo KW, Hong JH, Baik SK, et al. A case of afferent loop syndrome treated by endoscopic drainage procedure using nasogastric tube. Korean J Gastroenterol. 2007. 49:173–176.

14. Yoshida H, Mamada Y, Taniai N, Kawano Y, Mizuguchi Y, Shimizu T, et al. Percutaneous transhepatic insertion of metal stents with a double-pigtail catheter in afferent loop obstruction following distal gastrectomy. Hepatogastroenterology. 2005. 52:680–682.

15. 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.

16. Quinn WF, Gifford JH. The syndrome of proximal jejunal loop obstruction following anterior gastric resection. Calif Med. 1950. 72:18–21.