1/41. Enterolith: an unusual cause of afferent loop obstruction. Most cases of enterolith have been reported in association with the diverticula of small bowel. We report here a case of a patient in whom a huge enterolith developed in the afferent loop of Billroth II anastomosis with ensuing obturation obstruction. The enterolith was clearly shown on the preoperative abdominal computed tomograph and was removed through a duodenotomy. The postulated mechanism of the enterolith formation is impaired duodenal evacuatory motor activity due to previous gastrectomy. ( info) |
2/41. Percutaneous bowel drainage for jaundice due to afferent loop obstruction following pancreatoduodenectomy: report of a case. A case of jaundice due to an obstruction of the afferent loop following a pancreatoduodenectomy is presented. The dilated loop of the jejunum was drained percutaneously with a 12-F gastrostomy tube. Localized peritonitis around the puncture site was managed conservatively and the obstructive jaundice improved. The treatment strategy for this type of jaundice is discussed. ( info) |
3/41. Jejunal limb obstruction caused by a cholesterol stone 15 years after a total gastrectomy and 20 years after a cholecystectomy: report of a case. We present herein the rare case of a 74-year-old woman found to have jejunal limb obstruction caused by a cholesterol stone 15 years after a total gastrectomy with Roux-en-Y anastomosis, and 20 years after a cholecystectomy. The patient complained of repeated episodes of upper abdominal distress on three separate occasions over a period of 20 months, and jejunal limb obstruction was diagnosed by abdominal computed tomography scanning and (99m)Tc scintigraphy. Surgery revealed a stone incarcerated in the jejunal limb, where the anastomosis had become slightly stenotic. The removed stone was 3.5 cm in diameter and was subsequently demonstrated to be a cholesterol stone by chemical analysis. This report is thought to be the first to describe jejunal limb obstruction caused by a gallstone incarcerated in the jejunal limb after a total gastrectomy in a patient with a history of cholecystectomy. ( info) |
4/41. afferent loop syndrome presenting as enterolith after Billroth II subtotal gastrectomy: a case report. We present a rare late-onset (after 24 years) complication of gastric surgery with a combination of afferent loop syndrome associated with a large duodenal stone. The patient, who had undergone Billroth II partial gastrectomy for benign ulcer 24 years before, developed abdominal pain in the right upper quadrant, associated with nausea, vomiting, and high grade fever. Abnormal laboratory values included elevated liver function test, suggesting a pressure-related phenomenon. leukocytosis and a high level of platelets were also found. Only computed tomography and endoscopy of the upper gastrointestinal tract confirmed the diagnosis of a huge stone in the dilated duodenal afferent loop. To our knowledge, a case like this has not been reported previously in the literature. ( info) |
5/41. Sonographic detection of visceral adhesion in percutaneous drainage of afferent-loop small-intestine obstruction. To facilitate the percutaneous drainage of an afferent-loop small-intestine obstruction, we used sonography to detect visceral adhesions and select a safe puncture route. The portion of the small intestine that was fixed to the anterior abdominal wall was sonographically identified by using a high-frequency transducer to locate the area of restricted visceral sliding. The needle was then inserted into the intestine. In 3 cases, we have found that this technique improves the confidence of the physicians who perform the percutaneous drainage and may help to minimize the risks associated with the percutaneous drainage. ( info) |
6/41. Transhepatic insertion of a metallic stent for the relief of malignant afferent loop obstruction. A 65-year-old man with a polya gastrectomy presented with biliary obstruction. Percutaneous cholangiography indicated strictures of the distal common bile duct and afferent duodenal loop due to an inoperable carcinoma of the head of the pancreas. The patient was unfit for bypass surgery, and a previous gastrectomy precluded endoscopic intervention. Successful palliation of the biliary obstruction was achieved by placing metallic stents across the duodenal and biliary strictures via the transhepatic route. The use of stents for gastrointestinal stricture is reviewed. ( info) |
7/41. afferent loop syndrome: the role of Tc-99m mebrofenin hepatobiliary scintigraphy. afferent loop syndrome is caused by intermittent mechanical obstruction of the afferent loop of a gastrojejunostomy and may present early as an acute type or late as a chronic type. The authors describe two patients who were examined for a history of bilious vomiting after gastrojejunostomy, and who were thought to have afferent loop syndrome (chronic type) based on clinical findings. Results of routine investigations, such as upper gastrointestinal endoscopy, and ultrasonography were inconclusive. Findings from the barium meal follow-through studies were normal in the first patient and revealed a dilated duodenum in the second patient. Tc-99m bromotriethyl-iminodiacetic acid has been used to identify afferent loop obstruction as represented in these studies. ( info) |
8/41. A woman with abdominal pain and bilious vomiting. A very late aftermath of Billroth II gastrectomy. patients with a history of Billroth II gastrojejunostomy who present with a symptom complex of postprandial nausea, fullness, and bilious vomiting leading to relief should be suspected of having an afferent loop syndrome. diagnosis depends on barium radiography and upper intestinal endoscopy. Surgical correction is the treatment. The current age of medical therapy has dramatically decreased the frequency and necessity of surgery for peptic ulcer disease. However, we should not forget the lessons of the past and fail to diagnose a patient who has a chronic complication of a previously common operation. ( info) |
9/41. Non-surgical treatment for afferent loop syndrome in recurrent gastric cancer complicated by peritoneal carcinomatosis: percutaneous transhepatic duodenal drainage followed by 24-hour infusion of high-dose fluorouracil and leucovorin. afferent loop syndrome (ALS) is a debilitating complication of recurrent gastric cancer. Surgical intervention is usually not feasible in the face of poor general performance, presence of advanced peritoneal carcinomatosis and limited survival of the patients. Non-surgical approaches include internal drainage by stenting at the stenotic or anastomotic site and external drainage via the percutaneous routes. Percutaneous transhepatic duodenal drainage (PTDD) has been shown to provide effective palliation for ALS, but long-term catheterization is usually inevitable. We hereby present two cases of recurrent gastric cancer whose ALS was successfully treated with PTDD followed by weekly 24-h infusion of high-dose 5-fluorouracil and leucovorin (HDFL). PTDD rapidly ameliorated the incapacitating symptoms of ALS, and the effective, low-toxicity chemotherapy subsequently led to tumor regression, restoration of bowel patency and removal of the drainage tube. At present, both patients have remained ALS-free and drainage-free for 16 and 17 months, respectively. Our results indicate that this non-surgical approach with PTDD followed by weekly HDFL could serve as a safe and effective treatment for ALS in recurrent gastric cancer complicated by peritoneal carcinomatosis. ( info) |
10/41. A decreased number of c- kit-expressing cells in a patient with afferent loop syndrome. Following gastrectomy, stasis in the afferent jejunal loop accompanied by an overgrowth of bacteria leads to a number of clinical symptoms, including the so-called afferent loop syndrome. The disturbances in intestinal motility may be related to stagnation of the intestinal contents in the afferent loop. The pacemaker cells for the basic contractile activity of the intestine are thought to be the interstitial cells of cajal (ICCs). We and others have reported that ICCs express the c- kit receptor, and that a decreased number of c- kit-expressing ICCs is generally thought to result in disturbed intestinal motility. We report here a patient with postgastrectomy afferent loop syndrome with a decreased number of c- kit-expressing cells in the external muscle layer of the dilated intestine, suggesting damage to the ICCs. ( info) |