Treatment of afferent limb syndrome: novel approach with endoscopic ultrasound-guided creation of a gastrojejunostomy fistula and placement of lumen-apposing stent.

A44-year-oldwoman,with recurrent pancreatic cancer after a Whipple procedure, presented with afferent limb syndrome that manifested as sepsis secondary to cholangitis thought to be due to obstruction of the Roux limb by tumor recurrence. Endoscopy revealed an obstruction of the afferent limb (●" Fig.1) that could not be traversed with an endoscope or a guidewire under fluoroscopy. A dilated loop of small bowel was seen on endoscopic ultrasound (EUS) and was thought to be the obstructed afferent limb (●" Fig.2). A 19-gauge needle was inserted, contrast was injected (●" Fig.3) and a fistula was created. A 15mm×10mm lumen-apposing stent (Axios; Xlumena, Mountain View, California, USA) was deployed with the distal end in the afferent limb and the proximal end in the stomach (●" Fig.4), with the intention of allowing further intervention as needed regarding the biliary tree. A single 7 Fr×15cm double-pigtail catheter was placed through the stent. The patient’s cholangitis resolved and there were no complications. Given the tumor recurrence, the patient decided not to pursue further treatment and was lost to follow-up after choosing hospice care. Afferent limb syndrome is a known complication following pancreaticoduodenectomy. In a retrospective review of 186 patients who underwent a Whipple procedure, 13% developed afferent limb syndrome [1]. Treatment options are limited and may require surgery or placement of a percutaneous transhepatic cholangiography tube. Case reports have described successful endoscopic management of the obstruction with placement of stents across the stricture [1,2]. Pannala et al. described successful treatment in 15 patients with balloon dilation, stenting, or both [1]. However, endoscopic access to the afferent limb may not be possible because of long enteric segment, completely obstructing mass, tight angulation, or long stricture. Successful endoscopic ultrasound (EUS)guided transgastric access into the afferent limb, with insertion of 7-Fr plastic stents and with no adverse events, has been described in case reports [4]. In the present case, we chose an Axios stent to take advantage of the intendedwall apposition. The use of this stent has been described in pseudocyst drainage, gallbladder drainage, and creation of choledochoduodenal fistulas [5]. To our knowledge this is the first case of EUS-guided decompression with creation of a gastroenteric fistula using an Axios stent in a patient presenting with afferent limb syndrome. Fig.2 Endoscopic ultrasound (EUS) view showing tumor recurrence. EUS also revealed a dilated loop of smallbowel consistent with afferent limb syndrome.