Management of afferent loop obstruction: Reoperation or endoscopic and percutaneous interventions?

Table 1 Classification of afferent loop obstruction and management strategy

Causes			Management
Benign	Intraluminal	Foreign bodies	Surgery[2]
		Bezoar
		Enteroliths
		Intussusception
	Intramural	Gastrojejunostomy ulceration
	Extrinsic	Adhesions
		Volvulus
		Internal hernia
Malignant	Recurrence	Gastric remnant	Endoscopy for enteral stenting[32]
		Anastomotic sites	Transhepatic percutaneous enteral stenting or direct percutaneous tube enterostomy[29]
		Lymph nodes	By-pass surgery[2]
		Peritoneum
		Carcinomatosis
Radiation enteritis			Excision of the former afferent loop and reconstruction[31,33]

Table 2 Management of afferent loop obstruction

Causes		Management
		Former Billroth II	Former Roux-en-Y
Benign	Enteroliths	Endoscopy and balloon dilation of anastomotic stenosis[34] or adhesiolysis, enterotomy, removal and repair of anastomotic stenosis (stricturoplasty, addition of Braun anastomosis, conversion to Roux-en-Y)[8,16]	Endoscopy and balloon dilation of anastomotic stenosis or adhesiolysis, enterotomy, removal and repair of anastomotic stenosis (stricturoplasty, revision of the Roux-en-Y reconstruction)
	Bezoar
	Foreign bodies
	Intussusception	Manual reduction or enterectomy and conversion to Roux-en-Y[4]	Manual reduction or enterectomy and revision of Roux-en-Y reconstruction
	Anastomotic ulceration	Balloon dilation[34], stricturoplasty or conversion to Roux-en-Y	Balloon dilation, stricturoplasty or revision of the Roux-en-Y reconstruction Adhesiolysis, excision of redundant loop and revision of the jejunojejunostomy
	Adhesions	Adhesiolysis, Braun anastomosis or excision of redundant loop and conversion to Roux-en-Y[35]
	Volvulus	Enterectomy and conversion to Roux-en-Y[36]	Enterectomy and revision of the Roux-en-Y reconstruction
	Internal hernia	Reduction and repair of the defect or reduction, repair of the defect, enterectomy and conversion to Roux-en-Y[37]	Reduction and repair of the defect or reduction, repair of the defect, enterectomy and revision of the Roux-en-Y reconstruction
Malignant		Endoscopy for enteral stenting[32]	Double-balloon endoscopy for enteral stenting
Radiation enteritis		Transhepatic percutaneous enteral stenting or direct percutaneous tube enterostomy[38]	Transhepatic percutaneous enteral stenting or direct percutaneous tube enterostomy
		Redo-surgery when other approaches fail: By-pass[2]	Redo-surgery when other approaches fail: By-pass
		Adhesiolysis, mobilization and excision of the afferent loop, Roux-en-Y reconstruction	Adhesiolysis, mobilization and excision of the afferent loop, revision of the Roux-en-Y reconstruction
		In preceded pancreaticoduodenectomy assessment of HJ and PJ patency with MRCP. Revision of the strictured HJ, revision of the strictured PJ and/or modified Puestow[31] or pancreaticojejuno-jejunostomy if primary PJ has normal patency[33]	In preceded pancreaticoduodenectomy assessment of HJ and PJ patency with MRCP. Revision of the strictured HJ, revision of the strictured PJ and/or modified Puestow or pancreaticojejuno-jejunostomy if primary PJ has normal patency

HJ: Hepaticojejunostomy; PJ: Pancreaticojejunostomy; MRCP: Magnetic resonance cholangiopancreatography.