title: Endoscopic metal enteral stent placement for malignant afferent loop syndrome after pancreaticoduodenectomy.
abstract: BACKGROUND
  Afferent loop syndrome (ALS) is a rare and dreaded complication after pancreaticoduodenectomy (PD). Malignant ALS after PD is usually difficult to manage due to patients' poor condition. Effective and safe therapeutic strategies for these patients are reported scarcely at present.
  
  
  OBJECTIVE
  To analyze and evaluate the clinical characteristics and treatment of these patients.
  
  
  METHODS
  We analyzed 3 patients with malignant ALS after PD. They were treated by endoscopic enteral metal stent placement in our hospital. Meanwhile we retrospectively reviewed 49 cases with ALS after PD through available English literature. All these patients' clinical features, laboratory study, treatment and outcome were evaluated.
  
  
  RESULTS
  A total of 52 cases were analyzed in the study. The most common presenting symptoms of ALS after PD were jaundice (56.5%), upper abdominal pain (45.7%), fever (26.1%), and vomiting (23.9%). Sixty percent of ALS cases were caused by tumor recurrence. The mean time from prior surgery to diagnosis of ALS was 13.3 months. The rates of treatment with the endoscopic approach, percutaneous stenting or drainage, surgery, and the conservative method were 40.4%, 32.7%, 11.5%, and 15.4%, respectively. Endoscopic enteral metal stent placement proved more effective and less invasive in the treatment of malignant ALS after PD.
  
  
  CONCLUSIONS
  Cholangitis and cholangiectasis are the major manifestations of malignant ALS after PD. Invasive interventions are enjoying more and more acceptance for treatment. Endoscopic enteral metal stent placement appears to be a promising technique with effective palliation in these patients.
authors.affiliation: Department of Pancreatic Surgery, Huashan Hospital, Fudan University, Shanghai, China.
authors.forename: Jiaxin
authors.initials: J
authors.lastname: Huang
authors.affiliation: Department of Pancreatic Surgery, Huashan Hospital, Fudan University, Shanghai, China.
authors.forename: Sijie
authors.initials: S
authors.lastname: Hao
authors.affiliation: Department of Pancreatic Surgery, Huashan Hospital, Fudan University, Shanghai, China.
authors.forename: Feng
authors.initials: F
authors.lastname: Yang
authors.affiliation: Department of Pancreatic Surgery, Huashan Hospital, Fudan University, Shanghai, China.
authors.forename: Yang
authors.initials: Y
authors.lastname: Di
authors.affiliation: Department of Pancreatic Surgery, Huashan Hospital, Fudan University, Shanghai, China.
authors.forename: Lie
authors.initials: L
authors.lastname: Yao
authors.affiliation: Department of Pancreatic Surgery, Huashan Hospital, Fudan University, Shanghai, China.
authors.forename: Ji
authors.initials: J
authors.lastname: Li
authors.affiliation: Department of Pancreatic Surgery, Huashan Hospital, Fudan University, Shanghai, China.
authors.forename: Yongjian
authors.initials: Y
authors.lastname: Jiang
authors.affiliation: Department of Gastroenterology, Huashan Hospital, Fudan University, Shanghai, China.
authors.forename: Liang
authors.initials: L
authors.lastname: Zhong
authors.affiliation: Department of Pancreatic Surgery, Huashan Hospital, Fudan University, Shanghai, China.
authors.forename: Deliang
authors.initials: D
authors.lastname: Fu
authors.affiliation: Department of Pancreatic Surgery, Huashan Hospital, Fudan University, Shanghai, China.
authors.forename: Chen
authors.initials: C
authors.lastname: Jin
keywords: afferent loop syndrome; endoscopic treatment; metal enteral stent; pancreaticoduodenectomy