Afferent Loop Syndrome After Subtotal Gastrectomy With Billroth-II Reconstruction: Etiology and Treatment

Afferent loop syndrome (ALS) is an infrequent mechanical complication that occurs after reconstruction of Billroth-II (B-II) gastrojejunostomy or Roux-en-Y esophagojejunostomy.¹ Moreover, ALS can occur in any surgical procedure that includes anastomosis of the jejunum and stomach or esophagus, such as B-II gastrojejunostomy, Roux-en-Y gastrojejunostomy, Roux-en-Y esophagojejunostomy, and the Whipple procedure.² ALS is defined by dilatation of the afferent loop with accumulation of bile acid and pancreatic fluid on an abdominal CT scan.³ Common causes of ALS are adhesions, recurrent cancer, inflammatory thickening of the anastomosis, kinking at the anastomosis, internal hernia, stoma stenosis, or inflammation surrounding the anastomosis.^4,5

ALS can be divided into 2 types, according to the time of occurrence. Most cases of acute ALS occur during the first few postoperative days, while chronic ALS occurs weeks, months, or even years after surgery.⁶ In some patients, acute ALS occurs within hours or days after surgery. Some cases progress rapidly and complications such as peritonitis develop, which can be fatal. Mortality from these complications has been reported to be 30% to 60%.^7,8 Therefore, early diagnosis is important and proper surgical treatment is strongly recommended to prevent exacerbation of the patients' condition.^9,10 Traditionally, surgery has been the treatment of choice for ALS. In acute ALS, emergency surgery may be necessary to prevent rupture of the loop. The surgical procedure is dependent on the cause of the obstruction. In some cases, the anastomosis may need to be taken down and redone. If the afferent loop has become scarred and narrowed, it may need to be excised.

To date, no reports of ALS following open or laparoscopic subtotal gastrectomy for gastric cancer have been published. Moreover, nonsurgical treatment for ALS is not currently recommended. The aim of this study was to evaluate the clinical characteristics, treatment, and prognosis of ALS following radical subtotal gastrectomy with B-II reconstruction in gastric cancer patients.

Patients and Methods

From 2002 through 2010, 672 patients who had undergone subtotal gastrectomy with B-II reconstruction for gastric cancer at Dong-A University Medical Center, Korea, were enrolled. Data were prospectively retrieved from operative and pathology reports, with follow-up data obtained from the outpatient clinical database, which included the following: age; sex; body mass index (BMI); comorbidity disease; early gastric cancer (EGC) or advanced gastric cancer (AGC); tumor location; resection margin; TNM stage; retrieved lymph nodes; postoperative outcomes; and recurrences. The clinicopathologic characteristics and postoperative outcomes were retrospectively compared between the 2 groups. Clinical data, symptom interval, cause, and treatment of 13 ALS patients were reviewed. Gastric cancer stage was classified according to the 7th edition of the American Joint Committee on Cancer (AJCC) staging criteria.¹¹ Lymph node dissection was performed according to the standard D2 lymphadenectomy, based on 2010 Japanese gastric cancer treatment guidelines (ver.3).¹²

Surgical procedure of B-II reconstruction in open or laparoscopic surgery

After gastric resection, a stoma was made in the proximal jejunum 10 to 15 cm from the ligament of Treitz. Then, another stoma was made in the greater curvature of the gastric remnant 1 to 1.5 cm from the stapling line of the artificial lesser curvature. When making stomata, care should be taken to minimize thermal injuries to the intestines and limit stoma size. The side-to-side gastrojejunostomy is done via the antecolic and anisoperistaltic method, using the endoscopic linear stapler on the stomata. We usually used a 45- or 60-mm stapler (Blue color) for anastomosis. After stapling, the entry site is closed by the hand-sewn method: 2 layers of a continuous simple running suture with 1 absorbable monofilament. At the beginning of the first layer of the running suture, the common entry stoma is closed with full-thickness continuous running sutures (usually 5 sutures). Then, the second layer of a seromuscular running suture is placed from 1 end of the incision to the other with the same suture material (Fig. 1).

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Results

Clinicopathologic characteristics between the ALS and NALS groups

The median age of ALS patients (8 men and 5 women) was 57.2 years (range: 42–77). There were no statistical differences in clinicopathologic characteristics except BMI. The BMI of patients who suffered ALS was significantly less than that of patients who did not (P = 0.0244; Table 1).

Table 1 Clinicopathologic characteristics of the ALS and NALS groups

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Postoperative outcomes between the ALS and NALS groups

Table 2 presents postoperative outcomes. There were no differences in surgical procedure, surgery time, or intra-abdominal complications. However, there were significant differences in rates of recurrence (P = 0.0032) and follow-up duration (P = 0.0119) between the 2 groups.

Table 2  Postoperative outcomes of the ALS and NALS groups

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Clinical data, cause, and treatment of ALS

Among the 672 patients, ALS occurred in 13 (1.9%) patients during 5 years of follow-up. Among the 13 ALS patients, acute ALS within 1 month occurred in 5 patients (38.5%). Most of the findings were relatively nonspecific gastrointestinal symptoms. Obstructive jaundice or acute pancreatitis occurred in 4 patients (30.1%). The causes were anastomosis inflammation (6 patients); recurrent cancer (4 patients); adhesions (2 patients); and acute pancreatitis (1 patient). All ALS cases were successfully treated; and patients without recurrence fully recovered. Only 2 patients required surgery. Most patients with ALS were treated conservatively with or without percutaneous transhepatic biliary drainage (PTBD; Table 3).

Table 3  Clinical data, cause, and treatment of 13 ALS cases

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Discussion

There are many late complications following gastrectomy including dumping syndrome, metabolic disturbance, ALS, efferent loop syndrome, alkaline reflux gastritis, retained antrum syndrome, and postvagotomy syndrome. Recently, many investigators in Korea and Japan have focused on not only immediate surgical outcomes, but also long-term outcomes after gastric surgery; the latter is due to the rapidly increasing incidence of early gastric cancer.^16,17 However, the incidence, causes, clinical manifestations, and treatment of these late complications have not been properly investigated to date.

A gastrojejunostomy with blind loop such as B-II anastomosis, Roux-en-Y reconstruction, or any anastomosis with small bowel and stomach, might be complicated with afferent loop obstruction. A bowel obstruction should be treated appropriately; if not, further complications can develop such as bowel strangulation, perforation, and panperitonitis.^18,19 Although the incidence of ALS was 0.3% in another study,²⁰ in the present study ALS had an incidence of 1.9% in B-II anastomosis after radical subtotal gastrectomy for gastric cancer with long-term follow-up. This is the first report of a large series of patients who underwent radical subtotal gastrectomy and B-II reconstruction with laparoscopic surgery; however, it was a single-center study.

The incidence of ALS could affect an antecolic anastomosis or a long afferent loop. In the present study, the BMI was lower in the ALS group than in the NALS group. Among lower BMI patients, ALS can be associated with a redundant afferent loop because of loss of mesenteric fat and a thin transverse colon and jejunum. However, results are conflicting because, in general, postoperative intra-abdominal adhesions occur more frequently in obese patients. The length of the afferent loop in laparoscopic gastrectomy can be longer than that of open surgery. However, no difference of incidence of ALS between laparoscopic and open gastrectomy was found in the present study. In the ALS group, the incidence of recurrence was higher than that of the NALS group because recurrence is one of the causes of ALS. Furthermore, recurrent malignancy in itself can produce a mass effect: adhesions or thickening of tissue. Consequently, recurrent cancer might cause afferent loop obstruction. The follow-up duration was shorter in the ALS group than in the NALS group because the ALS group had recurrent cancer. Nine patients died of recurrent gastric cancer.

In the present study, the patients with ALS had nonspecific gastrointestinal symptoms such as abdominal discomfort, nausea, vomiting, weakness, and abdominal distension. Among 13 ALS patients, only 1 had the classic symptom of chronic ALS, which has been described as bilious vomiting resulting in relief of the abdominal pain. Two patients with afferent loop dilatation on CT scan had no symptoms (Fig. 2). One of the two underwent a completion total gastrectomy because he had recurrent cancer caused by ALS. However, 3 patients with recurrences died of their cancers after resolution of ALS. ALS may be due to internal herniation, adhesions, kinking, a gastrointestinal stone, or stenosis caused by inflammatory change or malignancy.^4,20 The most common cause of ALS in the present study was anastomosis inflammation. Three afferent loop syndromes occurred during the postoperative hospital stay. These acute ALS cases were successfully treated conservatively with or without PTBD. Most acute and chronic ALS cases without recurrent cancer also were successfully treated conservatively with or without PTBD. Only 2 chronic ALS patients underwent surgery.

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Surgical management options for ALS after B-II gastrojejunostomy depends on the etiology and acuteness of the ALS as well as patient status. Conversion to a Billroth I anastomosis, Roux-en-Y reconstruction, and construction of a Braun-type enteroenterostomy between the afferent and efferent limbs are commonly used techniques. Other treatment options include resection of the stenotic or ischemic segment with reconstruction of the afferent loop, revision of the gastric stoma, and interposition of a jejunal segment between the gastric pouch and duodenum.^20,21

In our experience, PTBD is an extremely useful treatment for decompressing an acutely dilated afferent loop.²² Endoscopic treatment such as ballooning or stent placement after reducing inflammation of a dilated afferent loop by PTBD can be performed. Technically, sufficient aspiration of accumulated fluid in a dilated afferent loop is required for symptom relief by placing the PTBD catheter tip in the duodenum (Fig. 3). Then, the PTBD catheter tip can be placed in the distal common bile duct. Only 1 patient with acute pancreatitis as a cause of ALS required additional surgery, which was a side-to-side duodenojejunostomy after PTBD, 2 weeks after its onset. In the present study, all patients with jaundice or acute pancreatitis first underwent PTBD. ALS can be treated conservatively if neither jaundice nor acute pancreatitis is present. With post-PTBD management, we should pay close attention to metabolic acidosis as well as electrolyte imbalance in patients with complete afferent loop obstruction.

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In conclusion, clinical suspicion is of significant importance because ALS is not common and the symptoms are nonspecific. ALS can be related to patients with low rather than high BMI. PTBD can be considered as a primary treatment option for ALS if rupture of afferent loop is not present. Following PTBD, various procedures such as endoscopic, radiologic, or surgical treatment can be performed based on the cause of ALS and patient status.