Navigating Obstacles: A Case Report on Endoluminal Treatment of Afferent Limb Syndrome Post-Whipple Procedure for Cholangiocarcinoma

Document Type

Conference Proceeding

Publication Date

10-1-2024

Publication Title

Am J Gastroenterol

Abstract

Introduction: Afferent limb syndrome (ALS) is a rare complication of the Whipple pancreaticoduodenectomy (0.3%-1%). While optimal treatment is not established, surgical revision is a traditional approach for malignant ALS. Recently, endoscopic or radiologic interventions, such as stenting or percutaneous biliary drainage, have emerged as palliative alternatives. Case Description/Methods: This is a 74-year-old man with history of metastatic cholangiocarcinoma stage IIB status post neoadjuvant therapy followed by Whipple procedure. Course was complicated by obstructive jaundice due to partially obstructing afferent limb jejunal mass seen on enteroscopy, biopsy-proven to be recurrent cholangiocarcinoma. The resultant severe stricture could not be traversed endoscopically hence an internal-external percutaneous transhepatic cholangiography (PTC) drain was inserted, complicated by persistent leak around the insertion site requiring several tube exchanges. He was later admitted for jaundice & poor oral intake. Abdominal imaging re-demonstrated the mass with an abrupt transition point (Figure 1). A cholangiogram revealed dilated small bowel loop in the afferent limb concerning for ALS. Based on imaging, there was no good window for an endoscopic ultrasound-guided jejuno- or gastrojejunostomy to bypass the obstruction. Therefore, a 22 mm x 6 cm uncovered metal Wallflex stent (Boston Scientific, Marlborough, MA) was inserted across the site (Figure 1B), which improved his symptoms & oral intake without further PTC leaks. Discussion: Malignant ALS post-Whipple negatively impacts outcomes & quality of life in a population with already limited life expectancy. Diagnosis can be a challenge as it may not present with typical gastrointestinal (GI) obstruction symptoms, requiring clinical suspicion & imaging (commonly computerized tomography as upper GI series may not detect its presence). Management requires a multidisciplinary approach with surgeons, therapeutic endoscopists, &/or interventional radiologists. Our case underscores the importance of prompt recognition to allow for an early intervention. Palliative surgical revision is limited by low success rates given overall poor patient condition or from tumor burden causing kinks. Percutaneous approaches introduce risk of retrograde biliary infection, & in this case failed due to downstream obstruction. Endoluminal interventions, despite technical difficulty, emerge as promising alternatives which warrant further prospective trials comparing outcomes with other modalities. (Figure Presented).

Volume

119

Issue

10

First Page

S2596

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