Diagnosis and treatment of the afferent loop syndrome
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CLINICAL REVIEW
Diagnosis and treatment of the afferent loop syndrome Panotpol Termsinsuk1 · Tanyaporn Chantarojanasiri2 · Nonthalee Pausawasdi1 Received: 27 May 2020 / Accepted: 27 June 2020 © Japanese Society of Gastroenterology 2020
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. Keywords Afferent loop syndrome · Gastrectomy with gastrojejunostomy · Afferent loop · Diagnosis · Endoscopic treatment
Introduction
Incidence
Gastrectomy with gastrojejunostomy reconstruction is a surgical procedure in which a part of the stomach is removed, and an anastomosis is created between the remaining stomach and proximal jejunum with two exit limbs known as afferent loop and efferent loop [1, 2]. The afferent loop, also called “A-limb” or biliopancreatic limb, is the intestinal limb that consists of the duodenum and proximal jejunum that locate proximal to the gastrojejunostomy. Afferent loop transfers bile, pancreatic juice, and other proximal intestinal secretions toward gastrojejunostomy. The efferent loop, also called “E-limb” or alimentary limb, is the intestinal limb that transmits food contents from gastric remnant to small bowel and colon [3]. ALS is a mechanical obstruction of the afferent loop that occurs after gastrectomy with gastrojejunostomy reconstruction.
ALS is a rare condition with the incidence ranging from 0.2 to 1.0% depending on the type of operation and anastomotic limb reconstruction. ALS has been reported in 0.3–1.0% of patients after total gastrectomy with Billroth II or Roux-enY reconstruction, 1% after laparoscopic distal gastrectomy with Billroth II reconstruction, and 0.2% after distal gastrectomy with Roux-en-Y reconstruction [4–6]. Other operations of which ALS can occur include total gastrectomy with loop esophagojejunostomy with simple or pouch Roux-en-Y reconstruction and pancreaticoduodenectomy with conventional loop and Roux-en-Y reconstruction; nonetheless, the data on incidence were limited [7].
* Nonthalee Pausawasdi [email protected] 1
Division of Gastroenterology, Department of Medicine, Faculty of Medicine Siriraj Hospital, Mahidol University, Bangkok 10700, Thailand
Division of Gastroenterology, Department of Internal Medicine, Rajavithi Hospital, Bangkok, Thailand
2
Pathophysiology After a partial or complete afferent limb obstruction, the intraluminal pr
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