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

Abstract

PurposeAfferent 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.MethodsAmong 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.ResultsFour 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.ConclusionA-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.

Acute afferent loop syndrome in the early postoperative period following pancreaticoduodenectomy

“…It has since been used successfully to treat both acute and chronic forms of ALS. [4][5][6]10 He initially described a side-to-side jejunojejunostomy although the eponym has been applied to subsequent modifications, including end-to-side and double side-to-side anastomoses. 5,6 Following PDs, the extra anastomosis ensures that an obstructed afferent limb can decompress into the efferent limb, preventing a rise in intraluminal pressure, distension and mechanical disruption to other anastomoses.…”

“…[1][2][3] The Braun anastomosis has been used effectively to treat ALS following gastrectomy. [4][5][6] This consists of an enteroenterostomy between the afferent and efferent limbs of a gastroenterostomy, and allows digestive juices in the afferent limb to flow into the efferent limb, thereby bypassing any obstruction at the gastrojejunostomy (Figs 1 and 2).…”

Treatment of Afferent Loop Obstruction by Percutaneous Trans-Hepatic Biliary and Intestinal Drainage

“…Afferent loop obstruction often occurs after a subtotal gastrectomy with Billroth II anastomosis, especially in patients with the duodenal jejunal curve inclining extremely to the left side [1]. The anastomosis can cause distortion in the afferent section.…”

Endoscopic nasogastric tube insertion for treatment of benign afferent loop obstruction after radical gastrectomy for gastric cancer

“…On the contrary, for patients with benign obstruction, surgical intervention including adhesiolysis, [7] jejunojejunostomy with Braun procedure or Roux-en-Y conversion have been recommended as the choice. [9,10] However, the dilated afferent loop is edematous that may result in anastomotic fistula after jejunojejunostomy. Therefore, some treatment with decompression of the afferent loop should be suggested because even if it is not a radical treatment, it can improve the intestinal wall edema and provide a favorable condition for next surgical treatment.…”