Endoscopic ultrasound-guided entero-enterostomy for the treatment of afferent loop syndrome: a multicenter experience.

BACKGROUND: Afferent loop syndrome (ALS) is traditionally managed surgically and, more recently, endoscopically. The role of endoscopic ultrasound-guided entero-enterostomy (EUS-EE) has not been well described. The aim of this study was to assess the technical and clinical success and safety of EUS-EE. METHODS: This was a multicenter, retrospective series at six centers in patients with ALS treated by EUS-EE. Data on patients treated with enteroscopy-assisted luminal stenting (EALS) at a single center were also collected. RESULTS: 18 patients (mean age 64.2 years, 72 % post-pancreaticoduodenectomy, 10 female) underwent EUS-EE. The most common symptoms were vomiting (27.8 %) and jaundice (33.3 %). Clinical success included resolution of symptoms in 88.9 % and improvement to allow hospital discharge in 11.1 %. Technical success was achieved in 100 % of cases, with a mean procedure time of 29.7 minutes. The most common procedure was a gastro-jejunostomy (72.2 %). Three adverse events (16.7 %) occurred (two mild, one moderate). When compared with data on EALS, patients treated with EUS-EE needed fewer re-interventions (16.6 % vs. 76.5 %; P < 0.001). CONCLUSION: EUS-EE seems to be safe and effective in the treatment of ALS. Indirect comparison with EALS suggested that EUS-EE is associated with a reduced need for re-intervention.

Management of postgastrectomy syndromes.

There is still much to learn about the cause of postgastrectomy syndromes. Fortunately, most patients can be managed by conservative measures unless a mechanical cause, amenable to operative correction, is found. Thus, it is important to determine the type of postgastrectomy problem that is affecting the patient. In carefully selected patients, remedial operations may ameliorate the patient's symptoms and permit him or her to return to a normal lifestyle. Humoral factors have attracted increasing attention, especially in patients with the dumping syndrome. The somatostatin analogue octreotide has provided relief from the vasomotor and gastrointestinal symptoms of severe dumping but must be given three to four times a day by injection.

[Endocrine aspects of pathology of the upper portions of the gastrointestinal tract]. / Endokrinnye aspekty patologii verkhnikh otdelov zhel udochnokishechnogo trakta.

Light and electron microscopic studies of endocrine cells of the stomach, duodenum, and jejunum, and A-cells of the pancreatic gland of 657 patients with chronic gastritis, peptic ulcer, and postgastroresection complications revealed quantitative and qualitative differences in the conditions of the cells in these diseases. A certain relationship between the content of certain types of endocrine cells of the digestive organs and the acid-producing function of the stomach was found. Duodenal ulcer and peptic ulcer of the anastomosis appear to be characterized by an increase in the number of endocrine cells associated with stimulation of acid production, and by the presence of functionally poorly active cell forms participating in inhibition of this process. Chronic gastritis and post-resection complications seem to be associated with decreased presence of acid-stimulating endocrine cells and increase in the number of cells whose function is connected with inhibition of the gastric secretion.

[Duodenal evacuatory motor disorders in patients with a resected stomach]. / Motorno-évakuatornye rasstroistva dvenadtsatiperstnoi kishki u bol'nykh s rezetsirovannym zheludkom.

The motor-evacuation disorders in the duodenum after resection of the stomach represent one of the main causes of unsatisfactory results of the operation. These disorders have distinct clinical manifestations and all of them result from stasis of the duodenum content. The main cause of duodenostasis is a mechanical obstacle. Reconstructive operations undertaken to restore the duodenal passage and to liquidate all mechanical obstacles give good results.

[Animal experiments in stagnant loop syndrome]. / Tierexperimentelle Untersuchungen zum Stagnant-Loop-Syndrom.

Using the perfusion technique, the absorption of water, sodium, and glucose was studied in a partial occlusion of the intestine. In this study we investigated the mucosal enzyme, the metabolic changes of the small bowel wall, and the morphology of the mucosa. The reason for the decreased absorption of glucose, sodium, and water in the prestenotic phase may be the increased proliferation of the mucosa. The decreased absorption of the glucose, sodium and water in the poststenotic phase may be caused by an atrophy of the mucosa.

[Hepato-biliary-pancreatic lesions in secondary duodenostasis]. / Porazheniia gepato-biliarno-pankreaticheskoi sistemy pri vtorichnom duodenostaze.

The secondary postoperative duodenal stasis (afferent loop syndrome, chronic vicious circle) is underlain by evacuational disturbance of the duodenum. The duodenal stasis and hypertension lead to the stasis of the bile and pancreatic-secretion, which in turn results in inflammatory-dystrophic changes in the hepato-biliary-pancreatic system. In such cases the success of surgical treatment will derive from the application of complex intervention both on the digestive tract and hepato-biliary system.

Pathophysiology in the acute afferent loop syndrome. A study in rats.

The afferent loop syndrome, i.e. occlusion of an afferent intestinal loop after a Billroth II partial gastrectomy, was induced in rats. After various time intervals the animals were killed and the haematocrit and serum osmolality were determined. The content of the occluded loop was analysed with respect to volume, bacterial flora and osmolality. In some cases a sample of the content was incubated at 37 degrees C and the osmolality determined at regular intervals. Groups of animals were studied in this way after 30 min or 1, 4, 8 or 12 h of occlusion. The haematocrit rose with time after the occlusion. The osmolality of the plasma and of the content of the occluded loop did not increase. The volume of fluid in the occluded loop increased continuously with time--from an average of 0.5 ml in the control cases to 6.1 ml after 12 h of occlusion. Experiments in vitro showed that the initial osmolality of the content of the loop was 300 mOsm. After incubation of the samples this increased by 43 to 146 percent. The bacterial content of the loop, including Clostridium perfringens, increased significantly. The results indicate that a marked breakdown of substances takes place in such an occluded intestinal loop, which increases the osmolality. As a result fluid is immediately attracted to the loop to keep the osmolality constant. A combination of this fluid increase due to osmosis and contractions of the intestinal wall leads to a pressure in the occluded loop which considerably exceeds the pressure in the common bile duct due to secretions from the pancreas and liver.

Gastric evacuation and propulsive intestinal motility in acute afferent loop syndrome in the rat.

The acute afferent loop syndrome, i.e. occlusion of the afferent loop after partial gastrectomy by the Billroth II method, was produced in the rat. In a primary session a gastrojejunostomy with division of the pylorus was performed. 2-3 months later the afferent loop was ligated. The gastric evacuation and the propulsive motility of the intestine were studied quantitatively, using an inert radioisotope. Both the gastric evacuation and the propulsive intestinal motility were considerably delayed in ALS, both in relation to the laparotomized controls and in relation to previous findings in mechanical intestinal obstruction and paralytic ileus due to retroperitoneal irritation or bacterial peritonitis.

[The chronic afferent loop syndrome (author's transl)]. / Das chronische Afferent-Loop-Syndrom

Between 1968 and 1973, 12 patients with a chronic afferent loop syndrome were treated at the University Surgical Hospital in Munich (6 from own hospital and 6 B II resected patients from external hospitals). 11 of them had to undergo reoperation (1 patient refused). X-ray and gastroscopy confirmed the diagnosis of chronic afferent loop syndrome type I in all 12 cases. The obstruction was caused by: adhesion and kinking of the loop (7 cases), too long and mobile loops (6 cases) incorrect anastomosis (3 cases), torsion and stenosis in the mesocolonic slit (2 cases), internal hernia (1 case). 8 patients showed good operative results, in 2 patients symptoms still persist; 1 patient died of sepsis postoperatively.