Afferent Loop Syndrome After Whipple Procedure

Michael Lalla, MD, Maurice Arregui, MD. St. Vincent’s Hospital Indianapolis

Introduction:
We present a retrospective review of post-whipple patients who have developed symptoms suspicious for afferent loop syndrome and the outcomes from re-operation. Afferent loop syndrome is a rare entity that may be the cause of abdominal pain, nausea and vomiting in patients who have had a gastrojejunostomy and is diagnosed primarily by clinical suspicion. Whipple procedures are mainly used to treat patients with pancreatic head and periampullary tumors as well as for those with chronic pain syndrome.

Methods:
We reviewed our patient database over the last 5 years for patients undergoing pylorus sparing Whipple procedures identifying their diagnosis, preoperative symptoms, postoperative symptoms, re-operations and their symptoms after a second operation.

Results:
Of the 74 Whipple procedures 58 were for malignant or pre-malignant lesions and 16 were for chronic pain symptoms. Eighty percent of patients who underwent operation for suspected or known malignancy were asymptomatic or had mild GI symptoms. The remaining 20% had prolonged nausea, vomiting or abdominal pain with two suspicious for afferent loop syndrome; one from obstruction through the colonic mesentery and the other possibly from stasis or from stenosis of the pancreaticojejunostomy. We have used 2 hour quantitative HIDA scans to show evidence of stasis in the afferent loop of patients with clinical suspicion of afferent loop syndrome.
The patients with chronic pain usually had a latency period of up to one year where they were symptom free and then began to have a return of the pain, nausea and vomiting. 7 of 16 had suspected afferent loop syndrome some with stasis noted on HIDA scan. Of these; three had significant improvement of their symptoms with a Braun enteroenterostomy, one had improvement with a Braun combined with a Puestow, one had improvement with revision of the afferent loop and another did not have any pain improvement with laparoscopic exploration and Braun enteroenterostomy.

Conclusion:
We suspect that afferent loop syndrome is more common in patients who have had a Whipple procedure for chronic pain than for cancer. This may be due to increased narcotic intake or slower bowel transit times in these patients.