Afferent loop obstruction following laparoscopic distal gastrectomy with Billroth-II gastrojejunostomy

Abstract

Purpose: Afferent loop (A-loop) obstruction is an uncommon postgastrectomy complication following Billroth-II (B-II) or Roux-en-Y reconstruction. Moreover, its development after laparoscopic gastrectomy has not been reported. Here we report 4 cases of A-loop obstructions after laparoscopic distal gastrectomy (LDG) with B-II reconstruction.

Methods: Among the 396 patients who underwent LDG with a B-II anastomosis between April 2004 and December 2011, 4 patients had A-loop obstruction. Their data were obtained from a prospectively maintained institutional database and analyzed for outcomes.

Results: Four patients (1.01%) developed A-loop obstruction. All were male, and their median age was 52 years (range, 30 to 73 years). The interval between the initial gastrectomies and the operation for A-loop obstruction ranged from 4 to 540 days (median, 33 days). All 4 patients had symptoms of vomiting and abdominal pain and were diagnosed by abdominal computed tomographic (CT) scan. The causes of the A-loop obstructions were adhesions (2 cases) and internal herniations (2 cases) that were treated with Braun anastomoses and reduction of the herniated small bowels, respectively. All patients recovered following the emergency operations.

Conclusion: A-loop obstruction is a rare but serious complication following laparoscopic and open gastrectomy. It should be considered when a patient complains of continuous abdominal pain and/or vomiting after LDG with B-II reconstruction. Prompt CT scan may play an important role in diagnosis and treatment.

Keywords: Afferent loop obstruction; Billroth-II operation; Ileus; Laparoscopy.

Fig. 1

(A) Illustration of afferent obstruction in case 1. (B) Illustration of afferent obstruction in case 2. (C) Illustration of internal herniation in cases 3 and 4.

Fig. 2

(A) Stitch between the afferent limb and transverse mesocolon. (B) Closure of mesenteric gap following Billroth-II gastrojejunostomy. S, remnant stomach; A, afferent limb; E, efferent limb.

Fig. 3

(A) Markedly dilated duodenal c-loop. (B) A whirling appearance of the mesenteric vessels, suggestive of internal herniation through Petersen's space.