Afferent loop syndrome

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Afferent loop syndrome
Specialty Gastroenterology

Afferent loop syndrome is an uncommon side effect of gastric surgery. [1] The afferent loop is made up of a segment of duodenum and/or proximal jejunum located upstream of a double-barrel gastrojejunostomy anastomosis. Abdominal pain and distension are signs of increased intraluminal pressure resulting from the accumulation of enteric secretions in the obstructed afferent loop. [2]

Contents

Afferent loop syndrome may result from volvulus, recurring cancer, stomal stenosis, adhesions, kinking at the anastomotic site, internal herniation, and gastrointestinal stones. [1]

Laboratory investigations can help diagnose afferent loop syndrome, but imaging scans are required for a confirmation diagnosis. [2] When diagnosing afferent loop syndrome, abdominal CT is regarded as the preferred radiographic investigation. [3]

The treatment of afferent loop syndrome is determined by the underlying cause. [1] Surgical therapy, such as adhesiolysis, bypass, or limb reconstruction, can usually eliminate the source in patients with benign etiologies. [4] Treatment for patients with afferent loop syndrome due to recurrent tumors shifts to palliation. [1]

Signs and symptoms

Nonbilious vomiting, nausea, and abrupt onset stomach pain in the right upper quadrant are common symptoms in patients with acute afferent loop syndrome. Abdominal distension and postprandial epigastric discomfort lasting anywhere from a few minutes to an hour are common symptoms experienced by patients with chronic afferent loop syndrome. Bilious projectile vomiting is a typical symptom of chronic afferent loop syndrome that relieves symptoms quickly. In patients with persistent afferent loop syndrome, steatorrhea and diarrhea may exacerbate intestinal stasis. Iron deficiency anemia and/or vitamin B12 deficiency can arise from the deconjugation of bile salts by bacteria. In order to avoid postprandial pain, patients frequently quit eating, which can result in significant weight loss. [2]

Right upper quadrant abdominal and/or epigastric tenderness is the most common physical finding in afferent loop syndrome patients. There is a palpable abdominal bulge in the right upper quadrant in about one-third of people suffering from acute afferent loop syndrome. Patients may exhibit symptoms of pancreatitis, such as obstructive jaundice or abdominal discomfort radiating to the side or back. Patients may show up with guarding, which is symptomatic of peritonitis, and a stiff abdomen if intestinal perforation has occurred. [2]

Causes

Afferent loop syndrome can have either a benign or malignant etiology, depending on the type of obstructive lesion. Depending on where the lesion is located, there are three primary pathways that lead to benign etiology. [5]

Anastomotic stricture, foreign body impaction, bezoars, and enteroliths are all potential causes of intraluminal blockage. [6]

Radiation enteritis and scarring from marginal gastrojejunostomy ulceration are the causes of mechanical blockage of the intramural area. [7] [8]

Conditions that cause external compression include internal hernia, volvulus, entrapment, compression, kinking of the afferent loop, postoperative adhesion, and intussusception of the afferent loop. [9] [10] [11]

An antecolic afferent loop's redundancy increases the danger of kinking, volvulus, and adhesion-induced limb entrapment when the bowel length exceeds 30 to 40 cm. Conversely, the risk of an internal herniation developing in a retrocolic afferent loop is increased by incorrectly closed mesocolic abnormalities. [12]

Locoregional tumor recurrence impeding the afferent loop at the anastomotic site or gastric residual is frequently linked to malignant afferent loop syndrome. [13] Additional factors contributing to blockage include peritoneal carcinomatosis and regional lymphadenopathy. [5]

Diagnosis

The preferred radiographic study for diagnosing afferent loop syndrome is thought to be abdominal CT. [3] An blocked intestinal segment can be directly visualized with CT scanning. It is also possible to look at other organs that could be affected by the obstruction, like the biliary tree and pancreas. [2] When afferent loop syndrome first manifests, the abdominal midline is often crossed by a fluid-filled tubular formation that lies between the super mesenteric artery and the aorta. [14]

Treatment

Three parameters determine the treatment plan: the type of obstructive lesion, the blockage site (inframesocolic or supramesocolic), and the patency of the major anastomoses for the hepaticojejunostomy and pancreaticojejunostomy. The standard of care for afferent loop syndrome patients is typically surgery. Adhesiolysis, bypass surgery, and excision with repair of the obstructive malignant lesions are the surgical therapy options available. [15]

Outlook

The prognosis is good for patients who receive an early diagnosis and have surgery, with the exception of cases of advanced or recurring cancer. A delay in diagnosis is associated with a mortality rate that varies from 30% to 60%. [16] Patients who experience afferent limb perforation and subsequent peritonitis and shock have poor prognoses. [17]

Epidemiology

According to reports, 0.2% of patients after distal gastrectomy with Roux-en-Y reconstruction, 1% after laparoscopic distal gastrectomy with Billroth II reconstruction, and 0.3–1.0% of patients following total gastrectomy with Billroth II or Roux-en-Y reconstruction have afferent loop syndrome. [15]

History

In 1950, Roux, Pedoussaut, and Marchal initially reported afferent loop syndrome in patients who had undergone gastric surgery and were experiencing bilious vomiting. [15]

See also

Related Research Articles

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<span class="mw-page-title-main">Abdominal pain</span> Stomach aches

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<span class="mw-page-title-main">Gastrectomy</span> Surgical removal of the stomach

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<span class="mw-page-title-main">Ileus</span> Medical condition

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<span class="mw-page-title-main">Volvulus</span> Twisting of part of the intestine, causing a bowel obstruction

A volvulus is when a loop of intestine twists around itself and the mesentery that supports it, resulting in a bowel obstruction. Symptoms include abdominal pain, abdominal bloating, vomiting, constipation, and bloody stool. Onset of symptoms may be rapid or more gradual. The mesentery may become so tightly twisted that blood flow to part of the intestine is cut off, resulting in ischemic bowel. In this situation there may be fever or significant pain when the abdomen is touched.

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<span class="mw-page-title-main">Bowel resection</span> Surgical procedure in which a part of an intestine is removed

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<span class="mw-page-title-main">Gastric outlet obstruction</span> Medical condition

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<span class="mw-page-title-main">Billroth II</span> Operation removing part of the stomach

Billroth II, more formally Billroth's operation II, is an operation in which a partial gastrectomy is performed and the cut end of the stomach is closed. The greater curvature of the stomach is then connected to the first part of the jejunum in end-to-side anastomosis. The Billroth II always follows resection of the lower part of the stomach (antrum). The surgical procedure is called a partial gastrectomy and gastrojejunostomy. The Billroth II is often indicated in refractory peptic ulcer disease and gastric adenocarcinoma.

<span class="mw-page-title-main">Roux-en-Y anastomosis</span> Type of surgery

In general surgery, a Roux-en-Y anastomosis, or Roux-en-Y, is an end-to-side surgical anastomosis of bowel used to reconstruct the gastrointestinal tract. Typically, it is between stomach and small bowel that is distal from the cut end.

Megaduodenum is a congenital or acquired dilation and elongation of the duodenum with hypertrophy of all layers that presents as a feeling of gastric fullness, abdominal pain, belching, heartburn, and nausea with vomiting sometimes of food eaten 24 hours prior.

Stump blow-out, or duodenal blow-out, is the leakage of the blind end of the duodenum. It occurs as a complication of Billroth II gastrectomy, usually on the fourth or fifth day after surgery. It is due to improper closure of duodenal stump, especially when the duodenum is inflamed and oedematous. It can also occur because of afferent loop block, local pancreatitis and distal obstruction. The patient who was previously convalescing satisfactorily may suddenly present with severe abdominal pain, fever and shock-like state. Jaundice may develop within 48 hours owing to the absorption of bile from peritoneal cavity. If the abdomen is drained, bile-stained fluid may be seen emerging at the drain site. Intravenous fluids should be started and adequate surgical drainage should be provided. Surgery is indicated when there is peritonitis, unresponsive fistula or distal obstruction. Once the life-threatening phase is over, the priority should be to give adequate nutrition. Surgical loop connection relieves the obstruction distally.

Stomach Intestinal Pylorus-Sparing (SIPS) surgery is a type of weight-loss surgery. It was developed in 2013 by two U.S. surgeons, Daniel Cottam from Utah and Mitchell S. Roslin from New York.

<span class="mw-page-title-main">Antrectomy</span> Type of gastric resection surgery

Antrectomy, also called distal gastrectomy, is a type of gastric resection surgery that involves the removal of the stomach antrum to treat gastric diseases causing the damage, bleeding, or blockage of the stomach. This is performed using either the Billroth I (BI) or Billroth II (BII) reconstruction method. Quite often, antrectomy is used alongside vagotomy to maximise its safety and effectiveness. Modern antrectomies typically have a high success rate and low mortality rate, but the exact numbers depend on the specific conditions being treated.

References

  1. 1 2 3 4 Katagiri, Hideki; Tahara, Kana; Yoshikawa, Kentaro; Lefor, Alan Kawarai; Kubota, Tadao; Mizokami, Ken (2016). "Afferent Loop Syndrome after Roux-en-Y Total Gastrectomy Caused by Volvulus of the Roux-Limb". Case Reports in Surgery. Hindawi Limited. 2016: 1–3. doi: 10.1155/2016/4930354 . ISSN   2090-6900. PMC   4939196 . PMID   27429828.
  2. 1 2 3 4 5 Krampitz, Geoffrey W.; Walmsley, Graham G.; Norton, Jeffrey A. (2015). "Afferent Loop Syndrome". Gastrointestinal Surgery. New York, NY: Springer New York. pp. 137–145. doi:10.1007/978-1-4939-2223-9_14. ISBN   978-1-4939-2222-2.
  3. 1 2 Yilmaz, Sabri; Yekeler, Ensar; Dural, Cem; Dursun, Memduh; Akyol, Yakup; Acunas, Bulent (2007). "Afferent loop syndrome secondary to Billroth II gastrojejunostomy obstruction: Multidetector computed tomography findings". Surgery. Elsevier BV. 141 (4): 538–539. doi:10.1016/j.surg.2006.02.024. ISSN   0039-6060. PMID   17431956.
  4. ↑ Kim, H.-C.; Han, J. K.; Kim, K. W.; Kim, Y. H.; Yang, H.-K.; Kim, S. H.; Won, H. J.; Lee, K. H.; Choi, B. I. (2003). "Afferent loop obstruction after gastric cancer surgery: helical CT findings". Abdominal Imaging. Springer Science and Business Media LLC. 28 (5): 624–630. doi:10.1007/s00261-002-0070-y. ISSN   0942-8925. PMID   14628863. S2CID   21173387.
  5. 1 2 Blouhos, Konstantinos (2015). "Management of afferent loop obstruction: Reoperation or endoscopic and percutaneous interventions". World Journal of Gastrointestinal Surgery. Baishideng Publishing Group Inc. 7 (9): 190–195. doi: 10.4240/wjgs.v7.i9.190 . ISSN   1948-9366. PMC   4582236 . PMID   26425267.
  6. ↑ Sarli, Leopoldo; Iusco, Domenico; Violi, Vincenzo; Roncoroni, Luigi (2003). "Enterolith ileus complicating afferent loop syndrome simulating acute pancreatitis". International Surgery. 88 (3): 129–132. PMID   14584766 . Retrieved 23 February 2024.
  7. ↑ Ballas, K.D.; Rafailidis, S.F.; Konstantinidis, H.D.; Pavlidis, T.E.; Marakis, G.N.; Anagnostara, E.; Sakadamis, A.K. (2009). "Acute Afferent Loop Syndrome: a True Emergency. A Case Report". Acta Chirurgica Belgica. 109 (1): 101–103. doi:10.1080/00015458.2009.11680382. ISSN   0001-5458. PMID   19341207. S2CID   36853292.
  8. ↑ Blouhos, Konstantinos; Boulas, Konstantinos A.; Tsiomita, Evridiki; Papageorgiou, Irene; Ioannidis, Konstantinos; Hatzigeorgiadis, Anestis (2013-11-20). "Pancreaticojejuno-jejunostomy during reconstruction of the afferent loop in surgery of radiation-induced afferent loop obstruction following pancreaticoduodenectomy with Roux-en-Y reconstruction". Updates in Surgery. Springer Science and Business Media LLC. 66 (1): 51–57. doi:10.1007/s13304-013-0238-8. ISSN   2038-131X. PMID   24254381. S2CID   29611707.
  9. ↑ Kasahara, Mureo (2014). "Urgent living donor liver transplantation for biliary atresia complicated by a strangulated internal hernia at Roux-en Y limb: A case report". Annals of Transplantation. International Scientific Information, Inc. 19: 149–152. doi:10.12659/aot.890213. ISSN   2329-0358. PMID   24675002.
  10. ↑ Lee, Se-Youl; Lee, Jong-Chan; Yang, Doo-Hyun (2013). "Early Postoperative Retrograde Jejunojejunal Intussusception after Total Gastrectomy with Roux-en-Y Esophagojejunostomy: A Case Report". Journal of Gastric Cancer. The Korean Gastric Cancer Association. 13 (4): 263–265. doi:10.5230/jgc.2013.13.4.263. ISSN   2093-582X. PMC   3915189 . PMID   24511423.
  11. ↑ Dumon, Kristoffel; Dempsey, Daniel T. (2019). "Postgastrectomy Syndromes". Shackelford's Surgery of the Alimentary Tract, 2 Volume Set. Elsevier. pp. 719–734. doi:10.1016/b978-0-323-40232-3.00062-5. ISBN   978-0-323-40232-3. S2CID   261828456.
  12. ↑ Martino, Ciro De; Caiazzo, Paolo; Albano, Michele; Pastore, Mauro; Rocco Tramutoli, Pio; Rocca, Rosario; Botte, Manuela; Sigillito, Angelo (2012). "Acute afferent loop obstruction treated by endoscopic decompression. Case report and review of literature". Annali Italiani di Chirurgia. 83 (6): 555–558. PMID   23110908.
  13. ↑ Yoshida, Hiroshi; Mamada, Yasuhiro; Taniai, Nobuhiko; Mizuguchi, Yoshiaki; Kakinuma, Daisuke; Ishikawa, Yoshinori; Nakamura, Yoshiharu; Okuda, Takeshi; Kiyama, Teruo; Tajiri, Takashi (2008). "Afferent loop obstruction treated by percutaneous transhepatic insertion of an expandable metallic stent". Hepato-gastroenterology. 55 (86–87): 1767–1769. PMID   19102388.
  14. ↑ Kuwabara, Yasuo; Nishitani, Hiromu; Numaguchi, Yuji; Kamoi, Itsuma; Matsuura, Keiichi; Saito, Shoichiro (1980). "Afferent Loop Syndrome". Journal of Computer Assisted Tomography. Ovid Technologies (Wolters Kluwer Health). 4 (5): 687–689. doi:10.1097/00004728-198010000-00022. ISSN   0363-8715. PMID   7410648.
  15. 1 2 3 Termsinsuk, Panotpol; Chantarojanasiri, Tanyaporn; Pausawasdi, Nonthalee (2020-07-08). "Diagnosis and treatment of the afferent loop syndrome". Clinical Journal of Gastroenterology. Springer Science and Business Media LLC. 13 (5): 660–668. doi:10.1007/s12328-020-01170-z. ISSN   1865-7257. PMID   32638230. S2CID   220397964.
  16. ↑ Grotewiel, Rebecca K.; Cindass, Renford (2023-05-22). "Afferent Loop Syndrome". StatPearls Publishing. PMID   31536216 . Retrieved 2024-02-23.
  17. ↑ Uriu, Yuhei; Kuriyama, Akira; Ueno, Ayako; Ikegami, Tetsunori (2019). "Afferent loop syndrome of 10 years' onset after gastrectomy". Asian Journal of Surgery. Elsevier BV. 42 (10): 935–937. doi: 10.1016/j.asjsur.2019.06.008 . ISSN   1015-9584. PMID   31301932.

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