Post written by Dayyan Adoor, MD, and Zachary L. Smith, DO, from the Department of Internal Medicine and the Division of Gastroenterology and Liver Disease, University Hospitals Cleveland Medical Center, Cleveland, Ohio.

A 66-year-old woman with poorly-differentiated pancreatic adenocarcinoma underwent a Whipple that was complicated by a biliary leak requiring placement of an internal external biliary drain. Several months post-operatively, she presented with severe abdominal pain. Cross-sectional imaging demonstrated an obstructed afferent limb, likely due to disease progression. She subsequently had an upper endoscopy, which demonstrated a near-complete obstruction of the afferent limb that was not traversed with an upper endoscope. To decompress the obstructed limb, we performed an EUS-guided gastroenterostomy. Unique to this case, the patient had a percutaneous internal/external biliary drain, and we used this drain to inject a contrast/methylene blue mixture to distend the limb and augment technical success. The successful gastroenterostomy ultimately allowed the patient to be liberated from the percutaneous drain, which was desirable from a quality-of-life standpoint.

Malignant afferent limb syndrome (ALS) is a rare adverse event of a Whipple operation for pancreatic cancer. The syndrome requires urgent intervention to decompress the obstructed closed limb and treat other related adverse events such as cholangitis. Although surgery can sometimes serve as definitive therapy in benign obstructions, in malignant-associated obstructions, endoscopic interventions offer a less-invasive, safer, and palliative approach. Various endoscopic management strategies have become increasingly popular in management of afferent limb syndrome, including enteral stent placement, balloon dilatation, and EUS-guided gastroenterostomy.

Our case demonstrates a unique therapeutic strategy in a specific subset of patients presenting with malignant ALS. We demonstrate that, when present, the use of a percutaneous biliary drain offers easy distention and targeting of the afferent limb, and this results in a more straightforward creation of the gastroenterostomy.

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