A Case of Acute Afferent Loop Obstruction after Total Gastrectomy with Roux-en-Y Reconstruction

Abstract

A 64-year-old man presented with abdominal pain and vomiting following total gastrectomy with Roux-en-Y reconstruction for remnant gastric cancer. An abdominal computed tomography (CT) revealed a markedly inflated afferent loop, and we performed emergency laparotomy under the diagnosis of acute afferent loop obstruction. The anastomotic site of the afferent loop was twisted, and a markedly inflated dark-red afferent loop and duodenum were observed. As his condition was unstable and shock vital signs persisted during surgery, we inserted a tube into the afferent loop for pressure reduction instead of resecting the intestine. Contrast-enhanced CT scanning on the 8th and 14th hospital days demonstrated blood flow in the afferent loop and improved inflation ; therefore, we performed the second operation on the 22nd hospital day. He was discharged 43 days after the primary operation.

At the emergent operation, the torsion had occurred around the jejuno-jejunostomy site of Roux- en-Y loop. From the preoperative CT findings, it was inferred that the Roux limb might have invaginated into the enteroenterostomy site defect that might have caused the torsion. Since obstructive enteritis was probably the main cause of intestinal ischemia, decompression surgery might contribute to save his life. For patients with unstable general condition like shock, performing two-stage surgery preceded by decompression surgery should be considered.