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Yuan J, Zhang YJ, Wen W, Liu XC, Chen FL, Yang Y. Afferent loop syndrome of a patient with recurrent fever: A case report. World J Radiol 2024; 16:678-682. [PMID: 39635310 PMCID: PMC11612805 DOI: 10.4329/wjr.v16.i11.678] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/20/2024] [Revised: 09/14/2024] [Accepted: 10/23/2024] [Indexed: 11/27/2024] Open
Abstract
BACKGROUND Afferent loop syndrome (ALS) is a rare complication, Aoki et al reported that the incidence of distal gastrectomy in Billroth-II is 0.3%-1.0%. The clinical manifestations of ALS are atypical, which can manifest as severe abdominal pain, vomiting, obstructive jaundice, malnutrition, etc. CASE SUMMARY The patient was a 58-year-old man who complained of recurrent high fever for more than 1 week. Laboratory tests showed an increase in neutrophil ratio, procalcitonin, C-reactive protein, and abnormal liver function. Enhanced computed tomography scan of the abdomen showed small intestinal obstruction between the anastomosis of the gastrojejunum, bile duct, and pancreaticoduodenum. Gastroscopy revealed significant narrowing of the lumen 15 cm from the anastomosis into the afferent loop. After performing balloon dilation and placement of the nutrition tube, the patient did not experience further fever. CONCLUSION ALS is relatively rare after pancreaticoduodenectomy, and the treatment depends on the nature of the obstructive lesion. The traditional treatment method is surgery, and in recent years, endoscopy has provided a new treatment method for ALS.
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Affiliation(s)
- Jing Yuan
- Department of Gastroenterology and Hepatology, Chengdu Second People’s Hospital, Chengdu 610017, Sichuan Province, China
| | - Ying-Jie Zhang
- Department of Digestive Diseases, Chengdu Second People’s Hospital, Chengdu 610000, Sichuan Province, China
| | - Wu Wen
- Department of Digestive Diseases, Chengdu Second People’s Hospital, Chengdu 610000, Sichuan Province, China
| | - Xiao-Cong Liu
- Department of Gastroenterology and Hepatology, Chengdu Second People's Hospital, Chengdu 610017, Sichuan Province, China
| | - Feng-Lin Chen
- Graduate School, Chengdu Medical College, Chengdu 610000, Sichuan Province, China
| | - Ye Yang
- Department of Digestive Diseases, Chengdu Qingbaijiang District People's Hospital, Chengdu 610300, Sichuan Province, China
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Sakai A, Shiomi H, Masuda A, Kobayashi T, Yamada Y, Kodama Y. Clinical management for malignant afferent loop obstruction. World J Gastrointest Oncol 2021. [DOI: 10.4251/wjgo.v13.i7.509] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
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Sakai A, Shiomi H, Masuda A, Kobayashi T, Yamada Y, Kodama Y. Clinical management for malignant afferent loop obstruction. World J Gastrointest Oncol 2021; 13:684-692. [PMID: 34322197 PMCID: PMC8299933 DOI: 10.4251/wjgo.v13.i7.684] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/04/2021] [Revised: 04/05/2021] [Accepted: 06/18/2021] [Indexed: 02/06/2023] Open
Abstract
Afferent loop obstruction (ALO) is defined as duodenal or jejunal mechanical obstruction at the proximal anastomosis site of a gastrojejunostomy. With advances in chemotherapy, the incidence of malignant ALO is increasing. Malignant ALO can be complicated by ischemia, gangrenous bowel, pancreatitis, and ascending cholangitis. Moreover, the general condition of patients with recurrent cancer is often poor. Therefore, accurate and rapid diagnosis and minimally invasive treatments are required. However, no review articles on the diagnosis and treatment of malignant ALO have been published. Through literature searching, we reviewed related articles published between 1959 and 2020 in the PubMed database. Herein, we present recent advances in the diagnosis and treatment of malignant ALO and describe future perspectives. Endoscopic transluminal self-expandable metal stent (SEMS) placement is considered the standard treatment for malignant ALO, as this procedure is well established and less invasive. However, with the development of interventional endoscopic ultrasound (EUS) in recent years, the usefulness of EUS-guided gastrojejunostomy has been reported. Moreover, through indirect comparison, this approach has been reported to be superior to transluminal SEMS placement. It is expected that a safer and less invasive treatment method will be established through the continued advancement and innovation of interventional endoscopy techniques.
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Affiliation(s)
- Arata Sakai
- Division of Gastroenterology, Department of Internal Medicine, Kobe University Graduate School of Medicine, Kobe 650-0017, Hyogo, Japan
| | - Hideyuki Shiomi
- Division of Gastroenterology, Department of Internal Medicine, Kobe University Graduate School of Medicine, Kobe 650-0017, Hyogo, Japan
| | - Atsuhiro Masuda
- Division of Gastroenterology, Department of Internal Medicine, Kobe University Graduate School of Medicine, Kobe 650-0017, Hyogo, Japan
| | - Takashi Kobayashi
- Division of Gastroenterology, Department of Internal Medicine, Kobe University Graduate School of Medicine, Kobe 650-0017, Hyogo, Japan
| | - Yasutaka Yamada
- Division of Gastroenterology, Department of Internal Medicine, Kobe University Graduate School of Medicine, Kobe 650-0017, Hyogo, Japan
| | - Yuzo Kodama
- Division of Gastroenterology, Department of Internal Medicine, Kobe University Graduate School of Medicine, Kobe 650-0017, Hyogo, Japan
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Zwicky S, Inauen W, Pfefferkorn U. Case Report: Phytobezoar Causing Gastric Outlet Obstruction as a Late Complication After Biliopancreatic Diversion with Duodenal Switch. Obes Surg 2021; 30:3233-3235. [PMID: 32232642 DOI: 10.1007/s11695-020-04531-2] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
Case report of a phytobezoar causing gastric outlet obstruction as a late complication after biliopancreatic diversion with duodenal switch, review of the literature and discussion of bezoars as a differential diagnosis in patients after bariatric surgery presenting with signs of intestinal obstruction.
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Affiliation(s)
- Simone Zwicky
- Department of Surgery, Bürgerspital Solothurn, Schöngrünstrasse 38, CH-4500, Solothurn, Switzerland
| | - Werner Inauen
- Department of Gastroenterology, Bürgerspital Solothurn, Schöngrünstrasse 38, CH-4500, Solothurn, Switzerland
| | - Urs Pfefferkorn
- Department of Surgery, Kantonsspital Olten, Baslerstrasse 150, CH-4600, Olten, Switzerland.
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Abstract
Afferent loop syndrome (ALS) is a mechanical complication that arises after gastric surgery with gastrojejunostomy reconstruction. This condition was first described in 1950 by Roux, Pedoussaut, and Marchal to post-gastrectomy patients with bilious vomiting. Acute ALS is associated with complete obstruction and considered a surgical emergency, whereas chronic ALS is mostly related to partial obstruction of the afferent loop. The delay in diagnosis may lead to intestinal ischemia, perforation and can be associated with a high mortality rate up to 60%. Surgery is usually the mainstay treatment of ALS, but endoscopic therapy, including stent placement in malignancy-related, anastomotic stricture dilation, has been evolving over the past recent years.
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Sugimoto S, Shimono T, Takeshita T, Yamamoto A, Shindo D, Miki Y. Clinical and CT findings of small bowel obstruction caused by rice cakes in comparison with bezoars. Jpn J Radiol 2019; 37:301-307. [PMID: 30649674 DOI: 10.1007/s11604-019-00811-9] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/21/2018] [Accepted: 01/10/2019] [Indexed: 12/19/2022]
Abstract
PURPOSE Rice cakes have not been recognized as a cause of small bowel obstruction (SBO) worldwide. We compared clinical and CT findings of rice cake SBO versus SBO due to bezoars, the most common cause of food-induced SBO. METHODS Twenty-four patients with rice cake SBO (n = 17) or bezoar SBO (n = 7) were retrospectively evaluated for clinical findings and the following multi-detector CT (MDCT) features: identification of the transition zone, presence of intraluminal lesions, degree of obstruction, and length and attenuation of obstructing materials. Categorical variables were compared by Fisher's exact test, and continuous variables by independent t test. RESULTS None of the rice cake SBO patients required surgery, whereas 4/7 (57%) bezoar SBO patients underwent surgery. On MDCT, rice cake residues were recognized as well-defined intraluminal lesions of shorter length (29.8 ± 4.6 mm vs. 47.7 ± 10.8 mm for bezoars; p < 0.0001) and higher attenuation (106 ± 27.8 HU vs. - 62.8 ± 14.7 HU for bezoars; p < 0.0001). CONCLUSIONS Rice cake SBO patients did not require surgery. On MDCT, rice cake residues were significantly shorter and higher in attenuation than bezoars. These findings facilitate diagnosis and support the conservative management of rice cake SBO.
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Affiliation(s)
- Shigehiro Sugimoto
- Department of Diagnostic and Interventional Radiology, Osaka City University Graduate School of Medicine, 1-4-3 Asahi-cho, Abeno-ku, Osaka, Osaka, 545-8585, Japan.
| | - Taro Shimono
- Department of Diagnostic and Interventional Radiology, Osaka City University Graduate School of Medicine, 1-4-3 Asahi-cho, Abeno-ku, Osaka, Osaka, 545-8585, Japan
| | - Tohru Takeshita
- Department of Diagnostic and Interventional Radiology, Osaka City University Graduate School of Medicine, 1-4-3 Asahi-cho, Abeno-ku, Osaka, Osaka, 545-8585, Japan
| | - Akira Yamamoto
- Department of Diagnostic and Interventional Radiology, Osaka City University Graduate School of Medicine, 1-4-3 Asahi-cho, Abeno-ku, Osaka, Osaka, 545-8585, Japan
| | - Daisuke Shindo
- Department of Diagnostic and Interventional Radiology, Osaka City University Graduate School of Medicine, 1-4-3 Asahi-cho, Abeno-ku, Osaka, Osaka, 545-8585, Japan
| | - Yukio Miki
- Department of Diagnostic and Interventional Radiology, Osaka City University Graduate School of Medicine, 1-4-3 Asahi-cho, Abeno-ku, Osaka, Osaka, 545-8585, Japan
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Yue P, Meng W, Luo Z, Bai B, Li X. Double pigtail stents healed acute pancreatitis resulting from afferent loop obstruction. TURKISH JOURNAL OF GASTROENTEROLOGY 2018; 29:705-707. [PMID: 30289398 DOI: 10.5152/tjg.2018.17685] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/02/2023]
Affiliation(s)
- Ping Yue
- Department of Special Minimally Invasive Surgery, The Frist Hospital of Lanzhou University, Lanzhou, China; Hepatopancreatobiliary Surgery Institute of Gansu Province, Clinical Medical College Cancer Center of Lanzhou University, Lanzhou, China
| | - Wenbo Meng
- Department of Special Minimally Invasive Surgery, The Frist Hospital of Lanzhou University, Lanzhou, China; Hepatopancreatobiliary Surgery Institute of Gansu Province, Clinical Medical College Cancer Center of Lanzhou University, Lanzhou, China
| | - Zhiwen Luo
- The First Clinical Medical College of Lanzhou University, Lanzhou, China
| | - Bing Bai
- Department of Special Minimally Invasive Surgery, The Frist Hospital of Lanzhou University, Lanzhou, China; Hepatopancreatobiliary Surgery Institute of Gansu Province, Clinical Medical College Cancer Center of Lanzhou University, Lanzhou, China
| | - Xun Li
- Hepatopancreatobiliary Surgery Institute of Gansu Province, Clinical Medical College Cancer Center of Lanzhou University, Lanzhou, China; The Fifth General Surgery Department, The First Hospital of Lanzhou University, Lanzhou, China
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Sato K, Banshodani M, Nishihara M, Nambu J, Kawaguchi Y, Shimamoto F, Sugino K, Ohdan H. Afferent loop obstruction with obstructive jaundice and ileus due to an enterolith after distal gastrectomy: A case report. Int J Surg Case Rep 2018; 50:9-12. [PMID: 30064120 PMCID: PMC6077837 DOI: 10.1016/j.ijscr.2018.06.005] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/16/2018] [Accepted: 06/10/2018] [Indexed: 02/07/2023] Open
Abstract
INTRODUCTION Afferent loop obstruction is an uncommon complication associated with Billroth II reconstruction or Roux-en-Y reconstruction after gastrectomy. Moreover, cases where the obstruction is caused by enterolith are rare. Here, we report a rare case of afferent loop obstruction caused by an enterolith after Roux-en-Y reconstruction of gastrectomy; subsequently, leading to ileus in the ileum. PRESENTATION OF CASE An 84-year-old man who received a Roux-en-Y distal gastrectomy for gastric cancer presented with symptoms of fever and jaundice 14 months later. Computed tomography (CT) scan revealed an enterolith in the duodenal afferent loop and a dilated intrahepatic bile duct. Although the obstructive jaundice and fever disappeared with conservative therapy, ileus occurred due to the movement of the enterolith into the ileum, which was refractory to conservative therapy. Therefore, enterotomy was performed to remove the enterolith, and the patient had an uneventful recovery. Histologically, the enterolith derived from food residue. No postsurgical sign of recurrence has been noted for 6 months. CONCLUSION We report a rare case where an enterolith in a duodenal afferent loop after distal gastrectomy led to obstructive jaundice, and subsequently, caused ileus by its movement into the ileum.
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Affiliation(s)
- Koki Sato
- Department of Surgery, Akane-Foundation, Tsuchiya General Hospital, Hiroshima, Japan; Department of Gastroenterological and Transplant Surgery, Applied Life Sciences, Institute of Biomedical and Health Sciences, Hiroshima University, Hiroshima, Japan
| | - Masataka Banshodani
- Department of Artificial Organs, Akane-Foundation, Tsuchiya General Hospital, Hiroshima, Japan.
| | - Masahiro Nishihara
- Department of Surgery, Akane-Foundation, Tsuchiya General Hospital, Hiroshima, Japan
| | - Junko Nambu
- Department of Surgery, Akane-Foundation, Tsuchiya General Hospital, Hiroshima, Japan
| | - Yasuo Kawaguchi
- Department of Surgery, Akane-Foundation, Tsuchiya General Hospital, Hiroshima, Japan
| | - Fumio Shimamoto
- Department of Pathology, Faculty of Health Sciences, Hiroshima Shudo University, Hiroshima, Japan
| | - Keizo Sugino
- Department of Surgery, Akane-Foundation, Tsuchiya General Hospital, Hiroshima, Japan
| | - Hideki Ohdan
- Department of Gastroenterological and Transplant Surgery, Applied Life Sciences, Institute of Biomedical and Health Sciences, Hiroshima University, Hiroshima, Japan
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Endoscopic versus Surgical Intervention for Jejunal Bezoar Formation. ACG Case Rep J 2018. [DOI: 10.14309/02075970-201805120-00003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
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Gastroduodenal and pancreatic surgeries: indications, surgical techniques, and imaging features. Abdom Radiol (NY) 2017; 42:2054-2068. [PMID: 28493073 DOI: 10.1007/s00261-017-1165-9] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Abstract
This review article focuses on gastroduodenal and pancreatic surgeries with the goal of identifying radiologic findings that translate to important surgical considerations. The topics covered include partial gastrectomy with reconstruction techniques, total gastrectomy, pancreaticoduodenectomy, and pancreaticojejunostomy. Indications, contraindications, surgical techniques, and postoperative imaging are described within each of these topics. Knowledge of these surgical techniques is extremely helpful for the interpreting radiologists to identify expected postoperative anatomy and related complications that would remain clinically relevant to our surgical colleagues and direct timely patient management.
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Mullan D, Uberoi R. The obstructed afferent loop: Percutaneous options. INTERNATIONAL JOURNAL OF GASTROINTESTINAL INTERVENTION 2016. [DOI: 10.18528/gii160019] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Affiliation(s)
- Damian Mullan
- Department of Interventional Radiology, The Christie Hospital NHS Foundation Trust, Manchester, UK
| | - Raman Uberoi
- Department of Interventional Radiology, Oxford University Hospitals NHS Trust, Oxford, UK
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Blouhos K, Boulas KA, Tsalis K, Hatzigeorgiadis A. Management of afferent loop obstruction: Reoperation or endoscopic and percutaneous interventions? World J Gastrointest Surg 2015; 7:190-195. [PMID: 26425267 PMCID: PMC4582236 DOI: 10.4240/wjgs.v7.i9.190] [Citation(s) in RCA: 42] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/25/2015] [Revised: 06/21/2015] [Accepted: 07/23/2015] [Indexed: 02/06/2023] Open
Abstract
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.
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Chen YC, Liu CH, Hsu HH, Yu CY, Wang HH, Fan HL, Chen RC, Chang WC. Imaging differentiation of phytobezoar and small-bowel faeces: CT characteristics with quantitative analysis in patients with small- bowel obstruction. Eur Radiol 2014; 25:922-31. [PMID: 25417124 DOI: 10.1007/s00330-014-3486-1] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/12/2014] [Revised: 09/03/2014] [Accepted: 11/03/2014] [Indexed: 01/15/2023]
Abstract
OBJECTIVE The objective is to use multidetector computed tomography (MDCT) to differentiate phytobezoar impaction and small-bowel faeces in patients with small-bowel obstruction (SBO). METHODS We retrospectively reviewed 91 consecutive SBO patients with surgically proven phytobezoars (n = 31) or adhesion with small-bowel faeces (n = 60). Two readers blinded to the diagnosis recorded the following MDCT features: degree of obstruction, transition point, mesenteric fatty stranding, intraperitoneal fluid, air-fluid level, pneumatosis intestinalis, and portal venous gas. MDCT measurements of the food debris length, attenuation, luminal diameter, and wall thickness of the obstructed bowel were also compared. RESULTS A higher grade of obstruction with an absence of mesenteric fatty stranding and intraperitoneal fluid was more commonly seen in the phytobezoar group than in the small-bowel faeces group (p < 0.01). The food debris length (phytobezoar, 5.7 ± 2.8 cm; small-bowel feces, 20.3 ± 7.9 cm, p < 0.01) and mean attenuation (phytobezoar, -59.6 ± 43.3 Hounsfield units (HU); small-bowel faeces, 8.5 ± 7.7 HU, p <0.01) were significantly different between the two groups. The ROC curve showed that food debris length <9.5 cm and mean attenuation value < -11.75 HU predicted phytobezoar impaction. CONCLUSIONS MDCT features with measurements of the food debris length and mean attenuation assist the differentiation of phytobezoar impaction and small-bowel faeces. KEY POINTS • MDCT examination helps to differentiate phytobezoar and small-bowel faeces. • A higher grade of obstruction is commonly associated with phytobezoar impaction. • Mesenteric fatty stranding and intraperitoneal fluid are frequently associated with small-bowel faeces. • Quantitative measurement of the obstructed bowel adds the diagnostic accuracy.
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Affiliation(s)
- Ya-Cheng Chen
- Department of Radiology, Tri-Service General Hospital, National Defense Medical Center, Taipei, Taiwan, Republic of China
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Gaetke-Udager K, Wasnik AP, Kaza RK, Al-Hawary MM, Maturen KE, Cohan RH. A guide to imaging in bariatric surgery. Emerg Radiol 2013; 21:309-19. [DOI: 10.1007/s10140-013-1171-3] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/24/2013] [Accepted: 10/14/2013] [Indexed: 01/07/2023]
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Kim DJ, Lee JH, Kim W. Afferent loop obstruction following laparoscopic distal gastrectomy with Billroth-II gastrojejunostomy. JOURNAL OF THE KOREAN SURGICAL SOCIETY 2013; 84:281-6. [PMID: 23646313 PMCID: PMC3641367 DOI: 10.4174/jkss.2013.84.5.281] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 12/24/2012] [Revised: 02/12/2013] [Accepted: 03/05/2013] [Indexed: 12/15/2022]
Abstract
Purpose Afferent loop (A-loop) obstruction is an uncommon postgastrectomy complication following Billroth-II (B-II) or Roux-en-Y reconstruction. Moreover, its development after laparoscopic gastrectomy has not been reported. Here we report 4 cases of A-loop obstructions after laparoscopic distal gastrectomy (LDG) with B-II reconstruction. Methods Among the 396 patients who underwent LDG with a B-II anastomosis between April 2004 and December 2011, 4 patients had A-loop obstruction. Their data were obtained from a prospectively maintained institutional database and analyzed for outcomes. Results Four patients (1.01%) developed A-loop obstruction. All were male, and their median age was 52 years (range, 30 to 73 years). The interval between the initial gastrectomies and the operation for A-loop obstruction ranged from 4 to 540 days (median, 33 days). All 4 patients had symptoms of vomiting and abdominal pain and were diagnosed by abdominal computed tomographic (CT) scan. The causes of the A-loop obstructions were adhesions (2 cases) and internal herniations (2 cases) that were treated with Braun anastomoses and reduction of the herniated small bowels, respectively. All patients recovered following the emergency operations. Conclusion A-loop obstruction is a rare but serious complication following laparoscopic and open gastrectomy. It should be considered when a patient complains of continuous abdominal pain and/or vomiting after LDG with B-II reconstruction. Prompt CT scan may play an important role in diagnosis and treatment.
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Affiliation(s)
- Dong Jin Kim
- Department of Surgery, Yeouido St. Mary's Hospital, The Catholic University of Korea College of Medicine, Seoul, Korea
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Oh SH, Namgung H, Park MH, Park DG. Bezoar-induced Small Bowel Obstruction. JOURNAL OF THE KOREAN SOCIETY OF COLOPROCTOLOGY 2012; 28:89-93. [PMID: 22606648 PMCID: PMC3349816 DOI: 10.3393/jksc.2012.28.2.89] [Citation(s) in RCA: 44] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 10/07/2011] [Revised: 11/10/2011] [Accepted: 11/20/2011] [Indexed: 12/22/2022]
Abstract
Purpose The aim of this study was to observe the clinical features of a bezoar-induced small bowel obstruction and to investigate the role of abdominal computed tomography (CT) in establishing the diagnosis. Methods We retrospectively reviewed 20 cases of bezoar-induced small bowel obstruction in our hospital from 1996 to 2010. Results Thirteen patients (65%) had a history of abdominal surgery. Nine patients (45%) were diagnosed with a bezoar before surgery, seven patients were diagnosed by using abdominal CT, and two patients were diagnosed with a small bowel series. Abdominal CT was performed in 15 patients, and the diagnostic accuracy was 47% (7/15). Surgery revealed ten bezoars in the jejunum and 11 in the ileum. Two patients had bezoars found concurrently in the stomach. Spontaneous removal took place in two patients. An enterotomy and bezoar extraction was performed in 15 patients. Fragmentation and milking, a small bowel resection, and a Meckel's diverticulectomy were performed in one patient each. Early operative treatment was possible (P = 0.036) once the bezoar had been diagnosed by using abdominal CT. There tended to be fewer postoperative complications in patients who were diagnosed with a bezoar by using abdominal CT, but the result was not statistically significant (P = 0.712). Conclusion A preoperative diagnosis of bezoar-induced small bowel obstruction by using clinical features was difficult. Increased use of abdominal CT led to a more accurate diagnosis and to earlier surgery for bezoar-induced small bowel obstructions, thereby reducing the rate of complications.
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Affiliation(s)
- Se Heon Oh
- Department of Surgery, Dankook University College of Medicine, Cheonan, Korea
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Aoki M, Saka M, Morita S, Fukagawa T, Katai H. Afferent loop obstruction after distal gastrectomy with Roux-en-Y reconstruction. World J Surg 2011; 34:2389-92. [PMID: 20458583 DOI: 10.1007/s00268-010-0602-5] [Citation(s) in RCA: 44] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
BACKGROUND The incidence of afferent loop obstruction after gastrectomy with Roux-en-Y reconstruction has not yet been reported. The aim of this study was to elucidate the incidence of afferent loop obstruction after distal gastrectomy with Roux-en-Y reconstruction performed through an open approach. METHODS We conducted a retrospective review of the data of 1908 patients who underwent distal gastrectomy followed by Roux-en-Y reconstruction through an open approach between January 1999 and December 2008. RESULTS Four patients (0.2%) developed afferent loop obstruction. The median age of the patients, consisting of three men and one woman, was 64 years (range 46-78 years). The cause of the afferent loop obstruction was internal herniation in two patients, adhesion in one patient, and peritoneal recurrence in one patient. The internal herniation occurred at the mesenteric gap in the region of the jejunojejunostomy. The interval between the initial gastrectomies and the emergency operations for afferent loop obstruction ranged from 3 weeks to 2 years (median 5 months). Three of the four patients were symptomatic, with vomiting and abdominal pain. All patients recovered following the emergency operations, and none died of this complication. CONCLUSIONS Afferent loop obstruction develops rarely after distal gastrectomy with Roux-en-Y reconstruction through an open approach. This rare but fatal complication should be considered when a patient complains of abdominal pain and/or vomiting after distal gastrectomy with Roux-en-Y reconstruction.
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Affiliation(s)
- Masaru Aoki
- Gastric Surgery Division, National Cancer Center Hospital, 5-1-1 Tsukiji, Chuo-ku, Tokyo, 104-0045, Japan
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Attene J, Pepe G, Vanni S, Chiarlone M, Dilaghi B, Grifoni S. A 64-year-old man admitted to the Emergency Department with an unusual case of intestinal obstruction: decision-making in the Emergency Department. Intern Emerg Med 2009; 4:45-51. [PMID: 18581198 DOI: 10.1007/s11739-008-0148-9] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/05/2008] [Accepted: 03/08/2008] [Indexed: 11/29/2022]
Affiliation(s)
- Jessica Attene
- Department of Emergency Medicine, Azienda Ospedaliera-Universitaria Careggi, University of Florence, Viale Morgagni 85, 50134, Florence, Italy
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Ballas KD, Rafailidis SE, Konstantinidis HD, Pavlidis TE, Marakis GN, Anagnostara E, Sakadamis AK. Acute afferent loop syndrome: a true emergency. A case report. Acta Chir Belg 2009; 109:101-103. [PMID: 19341207 DOI: 10.1080/00015458.2009.11680382] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
Afferent loop syndrome is a relatively rare complication after subtotal gastrectomy. We present a late onset of afferent loop obstruction, in a patient who underwent Billroth II gastrectomy with Roux-Y reconstruction for a gastric ulcer 27 years ago. A 60-year-old male was admitted to the hospital with an 8-hour history of acute epigastric pain, associated with vomiting, fever and signs of sepsis. Laboratory tests revealed leukocytosis, elevated liver function tests and high serum amylase. An obstructed afferent loop appeared on CT as a fluid filled tubular mass, crossing the middle line between the aorta and the mesenteric vessels. Advanced sepsis was also seen in the peripancreatic and retroperitoneal region. Although the patient was operated on immediately after diagnosis with reconstruction of Roux-Y anastomosis, he died 12 hours later. Afferent loop syndrome is quite uncommon, and must be suspected in patients who have undergone subtotal gastrectomy. Clinical manifestations of the syndrome are usually non-specific. CT is the examination of choice and surgery the first choice treatment.
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Affiliation(s)
- K D Ballas
- Aristotle's University of Thessaloniki, 2nd Prop. Department of Surgery, Thessaloniki, Greece
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21
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Ho TW, Koh DC. Small-bowel obstruction secondary to bezoar impaction: a diagnostic dilemma. World J Surg 2007; 31:1072-8; discussion 1079-80. [PMID: 17420961 DOI: 10.1007/s00268-006-0619-y] [Citation(s) in RCA: 36] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
BACKGROUND Gastrointestinal bezoar (GIB) is uncommon and is reported to occur in 4% of all admissions for small-bowel obstruction (SBO). Because of a lack of diagnostic features, it is often associated with a delay in treatment, with increased morbidity. In this article, we report our experience with managing bezoar-induced SBO and the role of early computed tomography (CT) imaging in establishing the diagnosis. METHODS We retrospectively reviewed all cases of bezoar-induced SBO treated in our unit between 1999 and 2005. RESULTS There were 43 patients, of whom 2 had a recurrence, giving a total of 45 episodes. The frequency of bezoar in our patients presenting with SBO was 4.3%. All patients were of Asian origin: 41 Chinese, 1 Indian, and 1 Malay. Twenty-eight (65%) patients had previous abdominal surgery of which 26 were gastric surgery. Thirty-eight (88%) patients were edentulous. Forty-one (91%) underwent serial abdominal radiography, whereas only 4 patients (9%) had either CT imaging or contrast study alone. Only 11 (24%) cases had a correct diagnosis of bezoar impaction made preoperatively by CT imaging. The diagnostic accuracy of CT imaging in our series was 65%, with six cases of misdiagnosis. Overall, CT led to a change in management of 76% (13 in 17). The median time to surgery from admission was 2 (0-10) days. There were 2 cases of ischemic bowel that necessitated bowel resection. The median length of hospital stay was 11 (5-100) days. Ten patients (22%) had postoperative complications, and there was one death. CONCLUSION Bezoar-induced SBO is uncommon and remains a diagnostic and management challenge. It should be suspected in patients with an increased risk of formation of GIB, such as previous gastric surgery, poor dentition, and a suggestive history of increased fibre intake. We advocate that CT imaging be performed early in these at-risk patients and in patients presenting with SBO with or without a history of abdominal surgery in order to reduce unnecessary delays before appropriate surgical intervention.
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Affiliation(s)
- Thomas W Ho
- General Surgery, Tan Tock Seng Hospital, Singapore, 308433, Singapore.
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22
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Abstract
OBJECTIVE To report the case of a gastric bezoar in a patient with anorexia nervosa (AN). METHOD Case report of a bezoar of the stomach occurring in AN and a review of the literature relating to bezoars and AN from PubMed. RESULTS A 19 year-old female presented with a 2-year history of AN binge-purge subtype. After 7 days of complete adherence to diet and no purging in hospital, she complained of increased nausea. She vomited up a cylindrical mass that was sent for pathology. A literature search yielded only one report of a bezoar in AN. DISCUSSION Bezoars are agglomerations of food or foreign material in the intestine. They usually present with abdominal pain, intestinal obstruction, weight loss, poor appetite, or vomiting. The CT scan of the abdomen is the preferred method of diagnosis. Clinicians should consider the diagnosis of a bezoar in AN if there is concomitant pica, trichotillomania, or a change in gastrointestinal symptomatology.
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Affiliation(s)
- C Laird Birmingham
- Eating Disorders Program, University of British Columbia, St. Paul's Hospital, Vancouver, British Columbia V6Z 1Y6, Canada.
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Ozcan UA, Yilmaz S, Akansel S, Cizmeli MO, Ertem M. An unusual cause of small bowel obstruction: CT diagnosis of dried apricots. Emerg Radiol 2007; 14:417-9. [PMID: 17522905 DOI: 10.1007/s10140-007-0625-x] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/23/2007] [Accepted: 05/02/2007] [Indexed: 12/13/2022]
Affiliation(s)
- Umit Aksoy Ozcan
- Department of Radiology, Acibadem Hospital, Inonu cd. Okur sk. Kozyatagi, 34742, Istanbul, Turkey.
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Koktener A, Dilmen G, Turkay C, Erbayrak M. Small bowel obstruction caused by phytobezoar and associated with vitamin B12 deficiency. South Med J 2006; 99:1013-4. [PMID: 17004541 DOI: 10.1097/01.smj.0000235461.02543.3c] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Yavuz N, Ergüney S, Ogüt G, Alver O. Enteroliths developed in a chronically obstructed afferent loop coexisting with gastric remnant carcinoma: Case report and review of the literature. J Gastroenterol Hepatol 2006; 21:495-8. [PMID: 16638089 DOI: 10.1111/j.1440-1746.2006.04284.x] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/09/2022]
Abstract
A case of gastric remnant carcinoma coexisting with a chronic afferent loop syndrome harboring multiple enteroliths in a grossly dilated and elongated afferent loop is presented herein. The patient had undergone a Polya type antecolic Billroth II reconstruction for a stenosing duodenal ulcer 40 years previously. A concise review of the relevant literature is also presented.
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Affiliation(s)
- Nihat Yavuz
- Department of General Surgery, Cerrahpasa Medical School, University of Istanbul, Istanbul, Turkey.
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