Clin Endosc.  2021 Nov;54(6):810-817. 10.5946/ce.2021.234.

Endoscopic Ultrasound-Guided Gastroenterostomy for Afferent Loop Syndrome

• Shiomi H
• Sakai A
• Nakano R
• Ota S
• Kobayashi T
• Masuda A
• Iijima H

• KMID: 2522700
• DOI: http://doi.org/10.5946/ce.2021.234

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.

Keyword

Afferent limbs; Afferent loop syndrome; Endoscopic ultrasound; Gastroenterostomy; Lumen-apposing metal stent

Figure

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  Fig. 1. Endoscopic ultrasound-guided gastroenterostomy using an EC-LAMS. (A) Contrast-enhanced computed tomography reveals that the dilated afferent limbs are associated with a recurrence of pancreatic cancer (*, stomach; **, dilated afferent limbs). (B) EUS shows dilatation of the afferent limbs from the stomach. (C) The dilated afferent limbs are punctured using an EC-LAMS, and the distal flange is then deployed under EUS guidance (yellow arrow: distal flange). (D) The proximal flange is deployed under endoscopic imaging. EC-LAMS, electrocautery-enhanced lumen-apposing metal stent; EUS, endoscopic ultrasound.

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  Fig. 2. Endoscopic ultrasound-guided gastroenterostomy using a fully covered self-expandable metal stent combined with a large loop double-pigtail stent. (A) On the endoscopic ultrasound image, the dilated afferent limbs can be visualized from the stomach. (B) The dilated afferent limbs are punctured using a 19-G needle, and a contrast medium is injected. (C) A guidewire is inserted to the afferent limbs, and the fistula is dilated using a balloon catheter. (D) A fully covered self-expandable metal stent is deployed to appose the afferent limbs and stomach. (E, F) A large loop double-pigtail plastic stent is placed through the fully covered self-expandable metal stent.

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