Afferent limb syndrome (ALS) is an uncommon postoperative complication typically resulting from tumor recurrence after pancreaticoduodenectomy, causing obstruction of the afferent or biliopancreatic limb. We present 4 cases of malignant ALS treated with endoscopic techniques.
Case 1: A 76-year-old male with history of pancreatic cancer underwent a surgical gastrojejunostomy. Fourteen months later, he developed gastric outlet obstruction symptoms and cholestasis. A computed tomography (CT) demonstrated obstruction of the biliopancreatic limb. He was managed initially with endoscopic placement of an enteral self expandable metal stent (SEMS) across the obstructed limb. One month later, the stent migrated into the stomach, causing symptom recurrence. The stent was removed endoscopically and attempted EUS-guided enteroenterostomy (EUS-EE) resulted in colonic luminal apposing metal stent (LAMS) misdeployment. Ultimately, the patient was successfully treated with repeat enteral SEMS, and the LAMS was removed endoscopically 7 weeks later. After two months follow up, the patient remained tolerating soft diet and with no recurrence of cholestasis.
Case 2: A 62-year-old male with pancreatic cancer was treated with pancreaticoduodenectomy. Fourteen months after surgery, he developed diet intolerance and jaundice. A CT revealed new dilation of the afferent jejunal limb, likely due to metastatic recurrence, as well as biliary dilation. The patient was deemed unsuitable for EUS-GE in the setting of ascites and gastric varices. Enteral SEMS was placed endoscopically with good initial response; however, recurrent cholestasis developed several days later and a percutaneous biliary drain was placed. Despite this, the patient maintained improved oral intake and CT scan demonstrated interval improvement of afferent-limb dilation.
Cases 3 and 4: 69- and 75-year-old males with pancreatic adenocarcinoma treated surgically with pancreaticoduodenectomy. Thirty-one and 41 months postoperatively, they presented with acute gastric outlet obstruction symptoms; one of them developed cholestasis and cholangitis. Imaging confirmed tumor recurrence with new dilation of the afferent limb. Both patients underwent EUS-GE successfully using a 10 × 10-mm LAMS. Rapid symptom resolution, improved oral intake, and normalization of liver enzymes occured in both cases. Early postoperative imaging confirmed decompression of the afferent limb. Clinical response was sustained at 1-month follow-up.
In this case series, EUS-GE provided an effective and safe treatment option for malignant ALS. Unfavorable anatomy can increase the risk of technical failure and stent misdeployment. Enteral SEMS remains a meaningful alternative for patients who are not suitable candidates for EUS-GE or who have limited life expectancy.