Percutaneous transhepatic metallic stent insertion for malignant afferent loop obstruction following pancreaticoduodenectomy: a case report

Abstract

Introduction: Malignant afferent loop obstruction following pancreaticoduodenectomy is a rare complication and may be fatal if suppurative cholangitis or obstructive jaundice develops. Effective and safe therapeutic strategies for malignant afferent loop obstruction following pancreaticoduodenectomy are scarce at present.

Case presentation: A 51-year-old Japanese man underwent pancreaticoduodenectomy for carcinoma of the papilla of Vater. Seven months postoperatively, he developed a high-grade fever, jaundice, and right upper abdominal pain. Abdominal contrast-enhanced computed tomography showed afferent loop obstruction and intrahepatic bile duct dilatation due to nodal recurrence. Percutaneous transhepatic biliary drainage was performed, and a self-expanding metallic stent (WallFlex™ duodenal stent) was placed across the stricture using the transhepatic route.

Conclusions: There are surgical and nonsurgical treatments for malignant afferent loop obstruction following pancreaticoduodenectomy. Nonsurgical treatments include either an endoscopic or percutaneous approach to the afferent loop. Of these methods, percutaneous transhepatic insertion of a self-expanding metallic stent is the preferred treatment for malignant afferent loop obstruction following pancreaticoduodenectomy because it is more prompt and less invasive.

Figure 1

Abdominal contrast-enhanced computed tomography on admission. Abdominal contrast-enhanced computed tomography showed afferent loop obstruction and intrahepatic bile duct dilatation due to nodal recurrence (white arrow).

Figure 2

Percutaneous transhepatic biliary drainage for treatment of malignant afferent loop obstruction. (a) A 7 French pigtail catheter was inserted into the afferent loop from the tributary of segment 3. (b) The guide wire was advanced into the proximal aspect of the obstruction, and an 8 French endoprosthesis catheter was inserted.

Figure 3

Stent placement. (a) Jejunography confirmed an approximately 4cm-long stricture of the afferent loop. (b) A 22mm × 12cm self-expanding metallic stent was placed across the stenosis via the transhepatic route.