Recurrent Acute Pancreatitis Caused by Afferent Loop Stricture After Gastrectomy

Mithöfer, Kai; Warshaw, Andrew L.

doi:10.1001/archsurg.1996.01430170107021

Cited by 17 publications

(7 citation statements)

References 16 publications

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“…The 50% risk increase among patients treated with partial gastric resection is in line with most previous epidemiological studies 3, 14, 18, 22, 23. A conceivable alternative mechanism, instead of the action of endogenously formed N ‐nitrosamines in the gastric remnant, is recurrent acute pancreatitis due to “afferent loop syndrome” following Billroth II resection 34, 35, 36, 37. As suggested in several case reports, occlusion of the afferent jejunal loop results in increased intraluminal pressure that may be transmitted into the pancreatic duct, causing recurrent pancreatitis—a proposed risk factor for pancreatic cancer 38, 39, 40, 41.…”

Section: Discussionsupporting

confidence: 75%

The risk of pancreatic cancer in patients with gastric or duodenal ulcer disease

Luo

Nordenvall

Nyrén

et al. 2006

Intl Journal of Cancer

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Although Helicobacter pylori (H. pylori) seropositivity is linked to an excess risk of pancreatic cancer, the biologic mechanism is unknown. Gastric ulcer is primarily associated with corpus colonization of H. pylori, atrophic gastritis and formation of N-nitrosamines. Duodenal ulcer is a marker of antral colonization, hyperacidity and uninhibited secretin release. We estimated relative risks for pancreatic cancer among patients with gastric or duodenal ulcer, based on a register-based retrospective cohort study with 88,338 patients hospitalized for gastric ulcer and 70,516 patients for duodenal ulcer recorded in the Swedish Inpatient Register between 1965 and 2003. Following operation, the 14,887 patients who underwent gastric resection and 8,205 with vagotomy were analyzed separately. Multiple record-linkages allowed complete follow-up and identification of all incident cases of pancreatic cancer until December 31, 2003. Standardized incidence ratios (SIRs) estimated relative risks. During years 3-38 of follow-up, we observed a 20% excess risk (95% confidence interval [CI] 10-40%) for pancreatic cancer among unoperated gastric ulcer patients. The excess increased to 50% (95% CI 10-110%) 15 years after first hospitalization (p for trend 5 0.03). SIR was 2.1 (95% CI 1.4-3.1) 20 years after gastric resection. Unoperated duodenal ulcer was not associated with pancreatic cancer risk, nor was vagotomy. Our results lend indirect support to the nitrosamine hypothesis, but not to the hyperacidity hypothesis in the etiology of pancreatic cancer. ' 2006 Wiley-Liss, Inc.Key words: pancreatic cancer; gastric ulcer; duodenal ulcer; gastrectomy; vagotomy; risk; cohort Pancreatic cancer is the most deadly neoplasm in humans.1 Little is known about its etiology apart from known relationships with smoking, a family history, and some rare genetic susceptibility syndromes. Alleged causal links with diabetes and nonhereditary chronic pancreatitis remain under debate.2 Possible association between a history of gastroduodenal diseases and pancreatic cancer was first suggested by an early case-control study, 3 in which a strong association between subtotal gastrectomy and pancreatic cancer was reported. The authors postulated that one of the possible mechanisms is via increased Nnitroso compounds in gastric juice after the operation. Recently, a moderately strong association with Helicobacter pylori (H. pylori) infection was reported. 4,5 Although confounding from unknown causal factors cannot be ruled out as an explanation, there are at least three hypothetical models for the influence of H. pylori on pancreatic carcinogenesis. Firstly, bacterial invasion of the organ and local chronic inflammation, is conceivable but there are no reports in the literature of H. pylori growth in pancreatic tissue or ducts. The second, more plausible, hypothesis involves predominantly gastric antral colonization, hyperchlorhydria, uninhibited secretin release, attendant elevations in basal pancreatic bicarbonate output and pancreatic ductular hyperp...

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Section: Discussionsupporting

confidence: 75%

The risk of pancreatic cancer in patients with gastric or duodenal ulcer disease

Luo

Nordenvall

Nyrén

et al. 2006

Intl Journal of Cancer

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“…Vomitus not containing bile, which suggests complete obstruction of the afferent limb, may be helpful to distinguish between A-loop obstruction and ordinary small bowel obstruction. Stagnation of pancreatic and bile juice in the distended duodenum may lead to elevation of the serum amylase level, which is a frequent finding with acute pancreatitis and can result in an erroneous diagnosis [12]. Elevated serum amylase was observed in only 1 case in this series.…”

Section: Discussionmentioning

confidence: 87%

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

2013

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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.

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“…Other treatment options include resection of the stenotic or ischemic segment with reconstruction of the afferent loop, revision of the gastric stoma, and interposition of a jejunal segment between the gastric pouch and duodenum. 26,27 PTBD is an interventional radiologic procedure for bile drainage resulting from biliary or intrahepatic obstruction due to calculus, malignancy, or benign tumor. Recently, the use of PTBD was expanded to the management of complications after gastrectomy.…”

Section: Discussionmentioning

confidence: 99%

Role of Percutaneous Transhepatic Biliary Drainage in Patients With Complications After Gastrectomy

Kim

Lee

Kim

et al. 2016

International Surgery

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The aim of this study was to elucidate the role of percutaneous transhepatic biliary drainage (PTBD) in patients with duodenal stump leakage (DSL) and afference loop syndrome (ALS) postgastrectomy for malignancy or benign ulcer perforation. Percutaneous transhepatic biliary drainage (PTBD) is an interventional radiologic procedure used to promote bile drainage. Duodenal stump leakage (DSL) and afferent loop syndrome (ALS) can be serious complications after gastrectomy. From January 2002 through December 2014, we retrospectively reviewed 19 patients who underwent PTBD secondary to DSL and ALS postgastrectomy. In this study, a PTBD tube was placed in the proximal duodenum near the stump or distal duodenum in order to decompress and drain bile and pancreatic fluids. Nine patients with DSL and 10 patients with ALS underwent PTBD. The mean hospital stay was 34.3 days (range, 12 to 71) in DSL group and 16.4 days (range, 6 to 48) in ALS group after PTBD. A liquid or soft diet was started within 2.6 days (range, 1 to 7) in the ALS group and within 3.4 days (range, 0 to 15) in the DSL group after PTBD. One patient with DSL had PTBD changed, and 2 patients with ALS underwent additional surgical interventions after PTBD. The PTBD procedure, during which the tube was inserted into the duodenum, was well-suited for decompression of the duodenum as well as for drainage of bile and pancreatic fluids. This procedure can be an alternative treatment for cases of DSL and ALS postgastrectomy.Key words: Gastrectomy -PTBD -Duodenal stump leakage -Afferent loop syndrome P ostoperative complications after gastrectomy are difficult for both patients and surgeons. In the past, most of the major complications after gastrectomy required re-operation. The rate of reoperation for these complications ranges from 2.8% to 10%. 1-3 After gastrectomy, duodenal stump leak-

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Recurrent Acute Pancreatitis Caused by Afferent Loop Stricture After Gastrectomy

Cited by 17 publications

References 16 publications

The risk of pancreatic cancer in patients with gastric or duodenal ulcer disease

The risk of pancreatic cancer in patients with gastric or duodenal ulcer disease

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

Role of Percutaneous Transhepatic Biliary Drainage in Patients With Complications After Gastrectomy

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