S5212 Gastrojejunostomy With Lumen-Apposing Metal Stent for Afferent Loop Syndrome in Duodenal Adenocarcinoma

Introduction: Afferent loop syndrome (ALS) is a relatively uncommon mechanical complication of pancreaticoduodenectomy (∼13%). We present a case of ALS due to metastatic duodenal adenocarcinoma resulting in both jejunal and biliary obstruction ultimately treated with endoscopic ultrasound (EUS)-guided gastrojejunostomy (GJ) of the obstructed jejunal limb. Case Description: A 61-year-old man with recent Whipple surgery for pancreatic adenocarcinoma 8 months before and subsequent metastases to liver, lungs, and peritoneum presented with worsening abdominal pain and fever. Laboratory testing included AST 258, ALT 262, ALP 544 units/L, and TBIL 1.9 mg/dL. Abdominal ultrasound noted dilated intra and extrahepatic biliary dilation without choledocholithiasis or obvious hepaticojejunostomy (HJ) stricture. Computed tomography (CT) demonstrated biliary dilation and extrinsic compression of the afferent (biliopancreatic) limb consistent with ALS. On endoscopy, HJ and pancreatojejunostomy were not visualized due to extrinsic jejunal limb narrowing. A 0.035 in wire could not be passed into the afferent or efferent limb, precluding placement of a stent. Percutaneous transhepatic cholangiogram with internal-external biliary catheter placement into the distended afferent limb was then performed with improvement in bilirubin and abdominal pain. After discussions with the patient, EUS-guided GJ was offered to remove the external drain and drain the afferent limb into the stomach. Water mixed with methylene blue was then instilled into the afferent limb via the percutaneous biliary drain (PBD). With a linear echoendoscope, the distended afferent limb was easily identified. A 19G fine needle aspiration needle was used to aspirate the blue fluid to confirm the afferent limb and a 20 mm lumen-apposing metal stent (LAMS) was deployed. The blue fluid drained from the stent. LAMS position was confirmed on fluoroscopy. The external drain was then capped. CT scan 2 weeks later showed resolution of ALS and the external drain was removed. Discussion: EUS-guided GJ was used to treat ALS and ensuing biliary obstruction. We relied on a transhepatic PBD to gain access to the afferent limb. However, if PBD access is not available, the distended afferent limb may be identified on EUS and accessed with a needle. Subsequent contrast infusion into the bowel via needle may be used to confirm access into the closed-loop afferent limb and allow for proper LAMS placement to drain the afferent limb.