Enteroscopic direct drainage for submucosal intestinal juice leakage due to afferent loop syndrome in Roux-en-Y anatomy

We report a case of intestinal fluid accumulation secondary to afferent loop syndrome, successfully treated via enteroscopic submucosal drainage.

A 66-year-old man with a history of gastric resection and Roux-en-Y reconstruction for gastric cancer 6 years earlier presented with fever. Computed tomography (CT) revealed liver metastasis invading the bile duct near the duodenal end loop ( Fig. 1 ). Enteroscopy confirmed tumor invasion near the end loop of the duodenum, with no additional intestinal abnormalities. Suspecting cholangitis, bilateral biliary plastic stent (PS) drainage was performed using an enteroscope (EI-580BT; Fujifilm, Tokyo, Japan), and the patient was discharged after clinical improvement.

Fig. 1.

a Computed tomography reveals a liver metastasis (arrow) with invasion to the bile duct (arrowhead) in a patient with Roux-en-Y reconstruction. Enteroscopy shows tumor invasion near the duodenal end loop (green arrow) without other intestinal abnormalities. b Bilateral biliary plastic stent drainage (yellow arrow) was performed under enteroscopic guidance.

Three weeks later, he developed abdominal pain. CT revealed a distended end loop and submucosal expansion in the horizontal part of the duodenum ( Fig. 2 ), suggesting leakage of accumulated intestinal fluid from the end-loop cavity into the duodenal submucosal space. Endoscopic ultrasound failed to access the site. Therefore, an enteroscope was used, and the tensed mucosa was punctured with a precut needle knife, with the elasticity of the mucosal surface assessed prior to entry. A 6-mm dilation balloon was used to expand the puncture tract, and both 7-Fr PS and 6-Fr drainage tubes were placed in the fluid collection cavity. One week later, fluoroscopy confirmed collapse of the fluid collection, and the 6-Fr tube was removed ( Video 1 ).

Fig. 2.

Computed tomography shows a tensed end loop (arrow) and expansion of the submucosal space in the horizontal part of the duodenum (arrowhead).

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Massive submucosal fluid collection in the duodenum was drained using a precut needle knife under enteroscopy in a case of afferent loop syndrome with Roux-en-Y anatomy.

Video 1

Although endoscopic ultrasound-guided gastroenterostomy is a safe option for afferent loop syndrome, as it allows the evaluation of blood vessels and needle access to the afferent limb ^{1 2 3} , access was limited in this case due to Roux-en-Y anatomy. Direct enteroscopic puncture poses a perforation risk but was safely performed with mucosal elasticity assessment. Fluid accumulated after drainage tube removal, though the patient remained asymptomatic, with partial drainage via the remaining 7-Fr PS ( Fig. 3 ).

Fig. 3.

a PTGBD (arrow) is performed. No communication was observed between the gallbladder and the duodenal submucosal cavity. b Fluoroscopy and computed tomography demonstrate collapse of the fluid collection. After which, the 6-Fr drainage tube (yellow arrow) was removed. c Following drainage tube removal, fluid retention reappeared (arrowhead), although the patient remained asymptomatic. It was considered that intestinal juice continued to drain partially through the remaining 7-Fr plastic stent (green arrow). PTGBD: percutaneous transhepatic gallbladder drainage.

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