Endoscopic enteroenterostomy for the treatment of A. pharyngeal syndrome after percutaneous decompression. A 65-year-old man with borderline resectable pancreatic adenocarcinoma is treated with neoadjuvant chemotherapy followed by a pancreatic oduodenectomy. Seven months later, he presented to the emergency department with nausea, diffuse abdominal pain, and fevers. Labs were notable for a leukocytosis of 27 and cholestatic liver injury with alkaline phosphatase of 315 and total bilirubin of 4.9. A CT scan demonstrated marked fluid-filled distension of the jejunum with obstruction both at the pancreatic jejunal anastomosis and near the gastrojejunal anastomosis related to infiltrative tumor compatible with a malignant closed-loop obstruction and causing severe biliary dilatation. The patient was found to have gram-negative bacteremia and sepsis from ascending cholangitis as a result of the afferent limb syndrome, and he underwent urgent decompression via percutaneous biliary-drained placement. At this point, gastroenterology was consulted for endoscopic management of afferent limb syndrome. Initially, the gastrojejunostomy was evaluated with a therapeutic upper endoscope, and while the afferent limb appeared patent, opening of the afferent limb appeared obstructed due to compression from recurrent malignancy. Endosonographic exam revealed no adjacent dilated small bowel loop. Instead, a lumen was identified containing a linear hyper-echoic structure consistent with the percutaneous drain, which was clearly responsible for decompression of the afferent limb. On concurrent fluoroscopy, the echoendoscope tip could be seen deflecting toward the region of the percutaneous drain, confirming the lumen seen endosonographically was the decompressed afferent limb. Using a sphincterotome, with some difficulty, a guide wire was ultimately advanced into the afferent limb. A nasocystic tube was then advanced over the guide wire, with placement confirmed by fluoroscopy. This was then connected to an irrigation pump to instill over a liter of a solution of saline contrast and mesaline blue into the afferent limb. Now, on endosonographic exam, the afferent limb lumen was visualized and dilated up to 6 cm. A 19-gauge needle was used to puncture the afferent limb. Blue-tinged fluid was aspirated for confirmation. Blue-tinged blelius fluid was also seen draining into the percutaneous drain. The decision was made to proceed with an EOS-guided gastroenterostomy. However, due to distortion at the gastrodejunal anastomosis and due to intervening vessels from all possible gastric windows, a site in the proximal efferent limb was instead identified and used to create a dejunal anastomosis. A 15 x 10 mm cautery-enhanced lumen-opposing metal stent was deployed freehand to create an anastomosis from the proximal efferent to afferent limb. A large efflux of blue-tinged blelius fluid drained from the stent. The stent appeared in correct position endoscopically and fluoroscopically. There were no periprocedural adverse events. The percutaneous drain was capped and the patient was discharged two days later. The percutaneous drain was later removed. A follow-up CT showed the lambs in place with complete resolution of the efferent limb obstruction. Efferent limb syndrome is a rare complication following pancreatic duodenectomy resulting from mechanical obstruction of the efferent limb, usually after local malignancy recurrence. In severe forms, it can present as ascending cholangitis. EOS-guided enteroenterostomy is a safe and effective palliative treatment for this condition.

pancreatic adenocarcinoma

afferent limb syndrome

endoscopic management

bile duct obstruction

EOS-guided enteroenterostomy