Retrospective Clinical Study of Afferent Loop Syndrome Report of 29 cases of postgastrectomy afferent loop obstruction

ABSTRACT

BACKGROUND: Afferent loop syndrome is an uncommon complication of a gastric resection in which intestinal continuity has been restored by using a gastrojejunostomy. It may cause symptoms at any time from the first postoperative day to many years after the gastrectomy, although most symptoms are manifestated during the second postoperative week. Due to difference in the degree and the permanence of the obstruction, the symptoms and the courses of patients with afferent loop syndrome may be acute or chronic. METHODS: We performed a retrospective clinical analysis of 29 patients who had been treated with operations from January 1982 to December 1996 at the Department of Surgery, Catholic University Medical Center. RESULTS: Afferent loop syndrome occurred in 29 cases (0.46%) of gastric surgery involving 1882 peptic-ulcer cases and 4390 stomach cancer cases. The original conditions requiring gastric surgery were gastric ulcers (8/752, 1.06%), duodenal ulcers (10/1130, 0.88%), and stomach cancer (11/4390, 0.25%). This syndrome occurred more frequently for a truncal vagotomy and a Billroth II type antrectomy (1.76%) than for other surgical procedures. The etiologic factors of afferent loop syndrome were an adhesive band (41.4%), volvulus (24.1%), retroanastomotic internal herniation (20.7%), and stomal stenosis (13.8%). The time interval from the first operation to the onset of symptoms was less than two weeks in 58.6% of the patient. Epigastric pain was the most common symptom (93.1%), followed by nausea and/or vomiting (51.7%), tachycardia (41.3%), and fever (27.5%). The diagnostic procedure mainly performed was an upper gastrointestinal series (69%). Hyperamylasemia was noted in 17 patients (65%). Theoperations performed included a bypass jejunojejunostomy in 17 patients (58.6%), a Roux-en-Y enterostomy in 6 patients (20.7%), a tube duodenostomy in 2 patients (6.9%), a bypass jejunostomy with tube duodenostomy in 2 patients, and a pancreaticoduodenectomy in 2 patients. The postoperative complications were wound infections (34.5%), pleural effusion (13.8%), enterocutaneous fistulas (17.2%), and subphrenic abscesses (13.8%). The operative mortality rate (within 2 months) was 13.8%. CONCLUSIONS: If afferent loop syndrome is suspected, it may be demonstrated by using an upper gastrointestinal contrast study. Endoscopy should be performed in all patients in whom the diagnosis of afferent loop obstruction is suspected. It's main value is to rule out other causes for the patient's complaints, especially in alkaline reflux gastritis. Once the diagnosis is made, surgical correction is indicated. The most satisfactory measure to prevent afferent loop syndrome is to avoid a long afferent loop. If a Billroth I or a Roux-en-Y pattern gastrointestinal anastomosis is difficult, this complication is best avoided by using a short afferent loop and by fashioning the anastomosis to prevent an obstruction at the stoma.