Derek Lim, DO, Kevin Bain, DO, Prashant Sinha, MD. NYU Langone Hospital – Brooklyn
Introduction: Efferent loop syndrome (ELS) is defined as a mechanical obstruction of the efferent enteric jejunal limb. ELS can occur after a Whipple, Billroth II gastrectomy, or Roux-en-Y gastric bypass. Gastrojejunal anastomotic stenosis rates in these surgeries range from 0.2-1.7%. However, these documented rates include afferent limb syndrome and roux limb obstruction.
Case Presentation: We present the case of a 60 year old female with gastric adenocarcinoma presenting for elective resection. The patient underwent a hemi-gastrectomy with Billroth II reconstruction. On postoperative day (POD) three, the patient was started on a clear liquid diet.
On POD four through six, the patient continued to have bowel movements, however, was unable to tolerate oral intake. An UGI series was obtained, with findings suspicious for obstruction of the efferent limb. The patient was taken for esophagogastroduodenoscopy, and there was evidence of a stenosed Billroth II gastrojejunal anastomosis. The anastomosis was transversed, and a covered stent was placed under fluoroscopic guidance. Post procedurally a repeat UGI series confirmed a patent stent. The patient’s diet was advanced and tolerated, and the patient was discharged home.
Discussion: There are two types of “loop syndromes” which may occur after gastric surgery – afferent and efferent. Efferent loop syndrome is less common of the two. Both syndromes are characterized by a mechanical obstruction of the gastrojejunostomy, causing obstruction of gastric emptying.
The gold standard to diagnosing ELS is an upper endoscopy; however, radiographic imaging can aid in the diagnosis. UGI series can demonstrate regurgitation of oral contrast into the afferent limb and gastric pouch. The mainstay treatment of ELS has historically been surgical intervention. However, with recent advancements in endoscopic procedures, there have been published techniques using metal stents, double pigtail stents and naso-jejunal tube stenting to bypass areas of stenosis.
In 2016, Chang et al. described the effectiveness of endoscopic stent therapy in the management of postoperative foregut surgery complications (anastomotic leak, lumen stenosis, fistula formation). They reported an 88.9% success rate in treating stenosis with the end point of being able to tolerate a diet. Double pigtail and naso-jejunal tube stenting have also been documented to have success rates as high as 95%.
Conclusion: This case describes a rare post-gastrectomy complication which was successfully treated with modern endoscopic technique. With modern advancements in endoscopic techniques, patients suffering from efferent loop syndrome are able to avoid the morbidity associated with operative repairs.
Presented at the SAGES 2017 Annual Meeting in Houston, TX.
Abstract ID: 91981
Program Number: P489
Presentation Session: Poster Session (Non CME)
Presentation Type: Poster