Total Reconstruction of the Afferent Loop for Treatment of Radiation-Induced Afferent Loop Obstruction with Segmental Involvement after Pancreaticoduodenectomy with Roux-en-Y Reconstruction
A 65-year-old man was referred to our hospital due to recurrent episodes of crampy periumbilical pain and associated episodes of emesis over the previous 2 months. The patient had undergone PD 2 years earlier in our surgical department. The initial operation comprised PD along with distal gastrectomy, complete omentectomy, extended lymphadenectomy and Roux-en-Y reconstruction for a moderate differentiated, pT2pN1(2/39)MO, ly(+), v(+), R0 pancreatic ductal adenocarcinoma of the head. After the operation, the patient received concomitant flat infusional 5-FU chemotherapy (300 mg/m2/day, 5 days/week) during the entire course of external beam irradiation (50.4 Gy in 33 fractions over 7 weeks). No recurrence was found at the follow-up visits (assessment of CA19.9 levels every 3 months and abdominal CT scan every 6 months).\nAbdominal examination was remarkable for tenderness in the right upper quadrant. The laboratory workup revealed a normal white blood cell count, transaminases and slight elevation of bilirubin, alkaline phosphatase, γ-glutamyl transpeptidase and amylase. Plain abdominal X-rays were normal. Multidetector CT (MDCT) revealed: (a) segmental afferent loop wall thickening and lumen narrowing; (b) absence of lymphadenopathy, and (c) dilatation of the hepatic duct (9 mm) and the pancreatic duct (2.9 mm). Ductal pathology was further assessed though magnetic resonance cholangiopancreatography (MRCP) examination which revealed a fixed filling defect at the HJ and PJ with associated postobstructive hepatic and pancreatic duct dilation.\nThe diagnosis of chronic ALO along with HJ and PJ stricture was established; radiation enteritis of the afferent loop and/or the overlap of radiation enteritis and local recurrence in the length of involvement were presumed to be the causes of the obstruction. Elective laparotomy was performed via an extended upper midline incision. Once adhesions from the previous surgery were taken down and the free peritoneal cavity was entered, the liver, hepatoduodenal ligament, stomach, efferent loop, jejunojejunostomy and afferent loop were recognized (fig. ). The gastric remnant, efferent loop and afferent loop were released from adhesions and fully mobilized. Copious dissection in a field of dense adhesions and scar tissue on either side of the afferent loop enabled recognition of the HJ, PJ and pancreatic body. Peripherally, the afferent loop was transected distal to the involved segment (fig. ). Proximally, mobilization of the afferent loop exposed the surgical bed of the previous PD; no macroscopic evidence of local recurrence in the pancreatic bed, the liver or the peritoneal surface was observed (fig. ). The HJ was disconnected and a new end-to-side HJ was performed. Moreover, the PJ was taken down and examined. A short segment (1.5 cm) of the remnant pancreas was resected until the dilated pancreatic duct was revealed and a revised duct-to-mucosa PJ was performed using an anastomotic stent (fig. ). The distal remnant of the afferent loop, which was pulled toward the pancreas through the transverse mesocolon, had a sufficient redundancy to provide construction of the anastomoses without tension. A closed suction drain was placed at the subhepatic space near the anastomoses, and the abdomen was closed with a running No. 1 looped nonabsorbable suture and staples. Histology of the surgical specimen revealed microscopic findings of radiation enteritis without evidence of malignancy. The postoperative course was uneventful, and the patient was discharged home on postoperative day 9. At a follow-up time of 11 months, the patient was alive and asymptomatic; MRCP revealed no evidence of stenosis or diminished flow across the revised anastomoses.