Published online Sep 27, 2015. doi: 10.4240/wjgs.v7.i9.190
Peer-review started: March 26, 2015
First decision: June 3, 2015
Revised: June 21, 2015
Accepted: July 21, 2015
Article in press: July 23, 2015
Published online: September 27, 2015
Afferent loop obstruction is a purely mechanical complication that infrequently occurs following construction of a gastrojejunostomy. The operations most commonly associated with this complication are gastrectomy with Billroth II or Roux-en-Y reconstruction, and pancreaticoduodenectomy with conventional loop or Roux-en-Y reconstruction. Etiology of afferent loop obstruction includes: (1) entrapment, compression and kinking by postoperative adhesions; (2) internal herniation, volvulus and intussusception; (3) stenosis due to ulceration at the gastrojejunostomy site and radiation enteritis of the afferent loop; (4) cancer recurrence; and (5) enteroliths, bezoars and foreign bodies. Acute afferent loop obstruction is associated with complete obstruction of the afferent loop and represents a surgical emergency, whereas chronic afferent loop obstruction is associated with partial obstruction. Abdominal multiple detector computed tomography is the diagnostic study of choice. CT appearance of the obstructed afferent loop consists of a C-shaped, fluid-filled tubular mass located in the midline between the abdominal aorta and the superior mesenteric artery with valvulae conniventes projecting into the lumen. The cornerstone of treatment is surgery. Surgery includes: (1) adhesiolysis and reconstruction for benign causes; and (2) by-pass or excision and reconstruction for malignant causes. However, endoscopic enteral stenting, transhepatic percutaneous enteral stenting and direct percutaneous tube enterostomy have the principal role in management of malignant and radiation-induced obstruction. Nevertheless, considerable limitations exist as a former Roux-en-Y reconstruction limits endoscopic access to the afferent loop and percutaneous approaches for enteral stenting and tube enterostomy have only been reported in the literature as isolated cases.
Core tip: Management strategy of afferent loop obstruction (ALO) depends on: (1) the benign or malignant nature of the obstruction. ALO caused by a benign lesion needs definitive repair of the primary cause by surgery. ALO caused by a malignant lesion needs palliative treatment (percutaneous and endoscopic interventions, by-pass surgery) or excision; and (2) the site of obstruction. An obstruction at the inframesocolic portion of the afferent loop can be easily reconstructed, whereas an obstruction at the supramesocolic portion needs copious mobilization and may require revision of the hepaticojejunostomy or pancreaticojejunostomy and/or a modified Puestow procedure in the setting of a preceded pancreaticoduodenectomy.