Afferent Loop Syndrome Due to Malignant Obstruction When Luminal Stenting Has Failed to Relieve the Obstruction
This protocol addresses afferent loop syndrome caused by malignant obstruction — including cancer recurrence at the anastomosis or surgical bed, locoregional lymphadenopathy, or peritoneal carcinomatosis — specifically in patients where the initial endoscopic approach did not achieve adequate obstruction relief.
Clinical Scenario
Recurrence of malignancy at the anastomosis or in the surgical bed, locoregional lymphadenopathy, or peritoneal carcinomatosis can each cause malignant afferent loop obstruction. Endoscopic treatment is the method of choice for patients with cancer recurrence.
Previous Treatment — Insufficient Response
The prior approach — enteroscopy-assisted luminal stenting of the afferent loop stricture using an endoscopic self-expanding metal stent (SEMS), or alternatively two double-pigtail plastic stents traversing the stricture — did not achieve its intended goal: relief of the afferent loop obstruction (clinical success). This protocol represents the next management step after that failure.
Next-Line Approach (Partial Overview)
The next-line strategy uses an endoscopic ultrasound-guided technique to create a bypass anastomosis between bowel segments, decompressing the obstructed loop without traversing the stricture directly. The complete procedural steps, device selection criteria, and adjunctive measures are detailed in the full protocol.
Treatment Goals
Successful biliary drainage confirmed by serum bilirubin and transaminases.
References
DOI: 10.5009/gnl220205
- Recurrence of malignancy at the anastomosis or in the surgical bed, locoregional lymphadenopathy or peritoneal carcinomatosis can all be causes of malignant obstruction.
- As such, endoscopic treatment is the method of choice for patients with cancer recurrence.
- Obstructed small bowel loops can often be imaged from adjacent segments of the foregut, allowing for creation of an entero-enteric anastomosis which bypasses the obstruction.
- Serum biochemistry (including serum bilirubin and transaminases) is performed to confirm successful biliary drainage.
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