Skip to main content
Key Specialties
Cardiology Diabetology Endocrinology Gastroenterology Geriatrics and Gerontology Gynecology and Obstetrics Hematology Infectious Disease Internal Medicine Nephrology Neurology Oncology Pediatrics Respiratory Medicine Rheumatology Surgery
Congress Coverage
2024 ACC Congress 2023 ESMO Congress 2023 EASD Congress 2023 ERS Congress 2023 ESC Congress
Clinical Collections
Advances in Alzheimer’s

Keynote webinar | Spotlight on medication adherence

LIVE: Thursday 27th June 2024, 18:00-19:30 (CEST)
Join our expert panel to discover why you need to understand the drivers of non-adherence in your patients, and how you can optimize medication adherence in your clinics to drastically improve patient outcomes.
ADVANCED SEARCH
Log in
Top
Clinical Journal of Gastroenterology
Published in: Clinical Journal of Gastroenterology 5/2020

01-10-2020 | Gastrectomy | Clinical Review

Diagnosis and treatment of the afferent loop syndrome

Authors: Panotpol Termsinsuk, Tanyaporn Chantarojanasiri, Nonthalee Pausawasdi

Published in: Clinical Journal of Gastroenterology | Issue 5/2020

Login to get access

Abstract

Afferent loop syndrome (ALS) is a mechanical complication that arises after gastric surgery with gastrojejunostomy reconstruction. This condition was first described in 1950 by Roux, Pedoussaut, and Marchal to post-gastrectomy patients with bilious vomiting. Acute ALS is associated with complete obstruction and considered a surgical emergency, whereas chronic ALS is mostly related to partial obstruction of the afferent loop. The delay in diagnosis may lead to intestinal ischemia, perforation and can be associated with a high mortality rate up to 60%. Surgery is usually the mainstay treatment of ALS, but endoscopic therapy, including stent placement in malignancy-related, anastomotic stricture dilation, has been evolving over the past recent years.
Literature
1.
Roux G, Pedoussaut R, Marchal G. Le syndrome de l’anse afferent des gastrectomies. Lyon Chir. 1950;45:773.PubMedCentral
2.
Blouhos K. Management of afferent loop obstruction: reoperation or endoscopic and percutaneous interventions. World J Gastrointest Surg. 2015;7:190.PubMedCentral
3.
Woodfield CA, Levine MS. The postoperative stomach. Eur J Radiol. 2005;53:341–52.
4.
Grisé K, McFadden D. Anastomotic technique influences outcomes after partial gastrectomy for adenocarcinoma. Am Surg. 2001;67:948–50.
5.
Kim DJ, Lee JH, Kim W. Afferent loop obstruction following laparoscopic distal gastrectomy with Billroth-II gastrojejunostomy. J Korean Surg Soc. 2013;84:281.PubMedCentral
6.
Aoki M, Saka M, Morita S, et al. Afferent loop obstruction after distal gastrectomy with Roux-en-Y reconstruction. World J Surg. 2010;34:2389–92.
7.
Bolton JS, Conway WC. Postgastrectomy syndromes. Surg Clin N Am. 2011;91:1105–22.
8.
Vettoretto N, Pettinato G, Romessis M, et al. Laparoscopy in afferent loop obstruction presenting as acute pancreatitis. JSLS. 2006;10:270–4.PubMedCentral
9.
Barajas-Fregoso EM, Romero-Hernández T, Macías-Amezcua MD. Acute pancreatitis and afferent loop syndrome. Case report. Cirugía y Cirujanos. 2013;81:441–4.
10.
Park JW, Lee JH, Kim SJ, et al. A case of acute pancreatitis due to afferent loop syndrome with internal hernia. Korean J Gastroenterol. 2011;57:194.
11.
Wimmer L, Kirchgatterer A, Aschl G, et al. Verschlussikterus und akute Pankreatitis durch Obstruktion der zuführenden Schlinge nach Billroth-II-Resektion. Z Für Gastroenterol. 2002;40:77–9.
12.
Spiliotis J, Karnabatidis D, Vaxevanidou A, et al. Acute cholangitis due to afferent loop syndrome after a Whipple procedure: a case report. Cases J. 2009;2:633–9.
13.
Ruiz Pardo J, Llàcer-Millán E, Jimeno Griñó P, et al. Cholangitis due to afferent loop obstruction after cephalic duodenopancreatectomy. Cir Esp Engl Ed. 2016;94:106–8.
14.
Woodward ER. The pathophysiology of afferent loop syndrome. Surg Clin N Am. 1966;46:411–23.
15.
Banwell JG. Small intestinal bacterial overgrowth syndrome. Gastroenterology. 1981;80:834–45.
16.
Halsted JA, Lewis PM, Gasster M. Absorption of radioactive vitamin B12 in the syndrome of megaloblastic anemia associated with intestinal stricture or anastomosis. Am J Med. 1956;20:42–52.
17.
Starzl TE, Butz GW, Hartman CF. The blind-loop syndrome after gastric operations. Surgery. 1961;50:849–58.PubMedCentral
18.
Rana SV, Bhardwaj SB. Small intestinal bacterial overgrowth. Scand J Gastroenterol. 2008;43:1030–7.
19.
Sarli L, Iusco D, Violi V, et al. Enterolith ileus complicating afferent loop syndrome simulating acute pancreatitis. Int Surg. 2003;88:129–32.
20.
Ballas KD, Rafailidis SE, Konstantinidis HD, et al. Acute afferent loop syndrome: a true emergency. A case report. Acta Chir Belg. 2009;109:101–3.
21.
Blouhos K, Boulas KA, Tsiomita E, et al. Pancreaticojejuno-jejunostomy during reconstruction of the afferent loop in surgery of radiation-induced afferent loop obstruction following pancreaticoduodenectomy with Roux-en-Y reconstruction. Updates Surg. 2014;66:51–7.
22.
Kasahara M. Urgent living donor liver transplantation for biliary atresia complicated by a strangulated internal hernia at Roux-en Y limb: a case report. Ann Transplant. 2014;19:149–52.
23.
Lee S-Y, Lee J-C, Yang D-H. Early postoperative retrograde jejunojejunal intussusception after total gastrectomy with Roux-en-Y esophagojejunostomy: a case report. J Gastric Cancer. 2013;13:263.PubMedCentral
24.
Dumon K, Dempsey DT. Postgastrectomy syndromes. In: Charles JY, Steven RD, David WM, editors. Shackelford’s surgery of the alimentary tract. 8th ed. New York: Elsevier Inc; 2019. p. 719–734.
25.
De Martino C, Caiazzo P, Albano M, et al. Acute afferent loop obstruction treated by endoscopic decompression. Case report and review of literature. Ann Ital Chir. 2012;83:555–8.
26.
Yoshida H, Mamada Y, Taniai N, et al. Afferent loop obstruction treated by percutaneous transhepatic insertion of an expandable metallic stent. Hepatogastroenterology. 2008;55:1767–9.
27.
Lee MC, Bui JT, Knuttinen M-G, et al. Enterolith causing afferent loop obstruction: a case report and literature review. Cardiovasc Interv Radiol. 2009;32:1091–6.
28.
Ramos-Andrade D, Andrade L, Ruivo C, et al. Imaging the postoperative patient: long-term complications of gastrointestinal surgery. Insights Imaging. 2016;7:7–20.
29.
Zissin R. CT findings of afferent loop syndrome after a subtotal gastrectomy with Roux-en-Y reconstruction. Emerg Radiol. 2004;10:201–3.
30.
Juan Y-H, Yu C-Y, Hsu H-H, et al. Using multidetector-row CT for the diagnosis of afferent loop syndrome following gastroenterostomy reconstruction. Yonsei Med J. 2011;52:574–80.PubMedCentral
31.
Lomanto D, Pavone P, Laghi A, et al. Magnetic resonance-cholangiopancreatography in the diagnosis of biliopancreatic diseases. Am J Surg. 1997;174:33–8.PubMedCentral
32.
Kim HJ, Park JY, Bang S, et al. Self-expandable metal stents for recurrent malignant obstruction after gastric surgery. Hepatogastroenterology. 2009;56:914–7.PubMedCentral
33.
Sasaki T, Isayama H, Kogure H, et al. Double-balloon enteroscope-assisted enteral stent placement for malignant afferent-loop obstruction after Roux-en-Y reconstruction. Endoscopy. 2014;46:541–2.
34.
Pannala R, Brandabur JJ, Gan S-I, et al. Afferent limb syndrome and delayed GI problems after pancreaticoduodenectomy for pancreatic cancer: single-center, 14-year experience. Gastrointest Endosc. 2011;74:295–302.
35.
Kida A, Matsuda K, Noda Y. Endoscopic metallic stenting by double-balloon enteroscopy and its overtube for malignant gastrointestinal obstruction as palliative treatment. Dig Endosc. 2013;25:552–3.
36.
Minaga K, Kitano M, Takenaka M. Through-the-scope enteral metal stent placement using a short-type single-balloon enteroscope for malignant surgically reconstructed jejunal stenosis (with video). Dig Endosc Off J Jpn Gastroenterol Endosc Soc. 2016;28:758.
37.
Yane K, Katanuma A, Hayashi T, et al. Enteral self-expandable metal stent placement for malignant afferent limb syndrome using single-balloon enteroscope: report of five cases. Endosc Int Open. 2018;6:1330–5.
38.
Kida A, Kido H, Matsuo T, et al. Usefulness of endoscopic metal stent placement for malignant afferent loop obstruction. Surg Endosc. 2020;34:2103–12.PubMedCentral
39.
Toliopoulos P, Manière T, Désilets E. Treatment of neoplastic afferent limb syndrome by endoscopic gastrojejunostomy with a lumen-apposing metal stent. VideoGIE. 2018;3:61–2.PubMedCentral
40.
Hintze RE, Adler A, Veltzke W, et al. Endoscopic access to the papilla of Vater for endoscopic retrograde cholangiopancreatography in patients with billroth II or Roux-en-Y gastrojejunostomy. Endoscopy. 1997;29:69–73.
41.
Shah A, Khanna L, Sethi A. Treatment of afferent limb syndrome: novel approach with endoscopic ultrasound-guided creation of a gastrojejunostomy fistula and placement of lumen-apposing stent. Endoscopy. 2015;47:309–10.
42.
Yamamoto K, Tsuchiya T, Tanaka R, et al. Afferent loop syndrome treated by endoscopic ultrasound-guided gastrojejunostomy, using a lumen-apposing metal stent with an electrocautery-enhanced delivery system. Endoscopy. 2017;49:270–2.
43.
Mishima T, Iboshi Y, Harada N, et al. A case of afferent loop syndrome with severe anastomosis stricture that was successfully treated by endoscopic balloon dilation. Gastroenterol Endosc. 2018;60:131–7.
44.
Yasuda A, Imamoto H, Furukawa H, et al. Two cases of afferent loop syndrome caused by obstruction at the jejuno-jejunostomy site in the Roux-en-Y loop that were successfully treated by endoscopic balloon dilatation. Gan To Kagaku Ryoho. 2014;41:2322–5.
45.
Alves AR, Almeida N, Ferreira AM, et al. Endoscopic management of afferent loop syndrome caused by enteroliths and anastomotic stricture: a case report. Rev Esp Enferm Dig. 2017;109:457–457.
46.
Cho YS, Lee TH, Hwang SO, et al. Electrohydraulic lithotripsy of an impacted enterolith causing acute afferent loop syndrome. Clin Endosc. 2014;47:367.PubMedCentral
47.
Cao Y, Kong X, Yang D, et al. Endoscopic nasogastric tube insertion for treatment of benign afferent loop obstruction after radical gastrectomy for gastric cancer: a 16-year retrospective single-center study. Medicine (Baltimore). 2019;98:e16475.
48.
Kim H, Kim J, Kim K, et al. A case of afferent loop syndrome treated by endoscopic drainage procedure using nasogastric tube. Korean J Gastroenterol (Taehan Sohwagi Hakhoe Chi). 2007;49:173–6.
49.
Reddy JR, Saxena R, Singh RK, et al. Reoperation following pancreaticoduodenectomy. Int J Surg Oncol. 2012;2012:218–48.
50.
Morgan KA, Fontenot BB, Harvey NR, et al. Revision of anastomotic stenosis after pancreatic head resection for chronic pancreatitis: is it futile? HPB. 2010;12:211–6.PubMedCentral
51.
Han K, Song H-Y, Kim JH, et al. Afferent loop syndrome: treatment by means of the placement of dual stents. Am J Roentgenol. 2012;199:761–6.
52.
Bakes D. Management of afferent loop obstruction from recurrent metastatic pancreatic cancer using a venting gastrojejunostomy. World J Gastrointest Oncol. 2013;5:235.PubMedCentral
53.
Metadata
Title
Diagnosis and treatment of the afferent loop syndrome
Authors
Panotpol Termsinsuk
Tanyaporn Chantarojanasiri
Nonthalee Pausawasdi
Publication date
01-10-2020
Publisher
Springer Singapore
Published in
Clinical Journal of Gastroenterology / Issue 5/2020
Print ISSN: 1865-7257
Electronic ISSN: 1865-7265
DOI
https://doi.org/10.1007/s12328-020-01170-z

Other articles of this Issue 5/2020

Clinical Journal of Gastroenterology 5/2020 Go to the issue

Case Report

Double small bowel cancers leading to the diagnosis of Lynch syndrome with germline MSH6 mutation in an elderly patient

Case Report

A two-stage reconstruction for aortoesophageal fistula after replacement of thoracic aorta for Stanford Type B dissecting aortic aneurysm: esophagectomy and a double-tract reconstruction using the pedicled jejunum: a case report and literature review

Case Report

Spontaneous reactivation of hepatitis B virus with S gene mutations in an elderly patient with diabetic nephropathy

Case Report

Destructive thyroiditis presenting as thyrotoxicosis followed by hypothyroidism during lenvatinib therapy for hepatocellular carcinoma

Case Report

Portal vein aneurysm with complete spontaneous regression after 10 years using conservative treatment

Case Report

Mucin-producing bile duct tumor treated successfully with endoscopic ultrasound-guided hepaticogastrostomy
Live Webinar | 27-06-2024 | 18:00 (CEST)

Keynote webinar | Spotlight on medication adherence

Reserve your place

Live: Thursday 27th June 2024, 18:00-19:30 (CEST)

WHO estimates that half of all patients worldwide are non-adherent to their prescribed medication. The consequences of poor adherence can be catastrophic, on both the individual and population level.

Join our expert panel to discover why you need to understand the drivers of non-adherence in your patients, and how you can optimize medication adherence in your clinics to drastically improve patient outcomes.

Prof. Kevin Dolgin
Prof. Florian Limbourg
Prof. Anoop Chauhan
Developed by: Springer Medicine
Obesity Clinical Trial Summary

At a glance: The STEP trials

Read more

A round-up of the STEP phase 3 clinical trials evaluating semaglutide for weight loss in people with overweight or obesity.

Developed by: Springer Medicine

Highlights from the ACC 2024 Congress

Year in Review: Pediatric cardiology

Pediatric Cardiology Video

Watch Dr. Anne Marie Valente present the last year's highlights in pediatric and congenital heart disease in the official ACC.24 Year in Review session.

Year in Review: Pulmonary vascular disease

Cardiopulmonary Comorbidity Video

The last year's highlights in pulmonary vascular disease are presented by Dr. Jane Leopold in this official video from ACC.24.

Year in Review: Valvular heart disease

Valvular Heart Disease Video

Watch Prof. William Zoghbi present the last year's highlights in valvular heart disease from the official ACC.24 Year in Review session.

Year in Review: Heart failure and cardiomyopathies

Heart Failure Video

Watch this official video from ACC.24. Dr. Biykem Bozkurt discusses last year's major advances in heart failure and cardiomyopathies.

ACC 2024 Congress Coverage

Year in Review: Heart failure and cardiomyopathies

Heart Failure Video

Watch this official video from ACC.24. Dr. Biykem Bozkurt discusses last year's major advances in heart failure and cardiomyopathies.

Watch now

Semaglutide benefits people with type 2 diabetes and obesity-related heart failure

16-04-2024 Type 2 Diabetes News

Incentivised to exercise

11-04-2024 Lifestyle Modifications News

New intervention for STEMI-related cardiogenic shock

10-04-2024 Myocardial Infarction News

» View more highlights on the ACC 2024 congress hub page

Image Credits