Afferent loop syndrome is a known complication of gastric surgery specifically after Billroth II and

to a lesser extent a Roux–en–Y reconstruction. However, the incidence decreased over the years

proportionally with the decrease in the number of gastric surgery.

Afferent loop syndrome can be either acute or chronic with different presentation and treatment

options. The acute type can occur early post operatively or it could be delayed presentation. Acute

ALS is associated with complete closed-loop obstruction and is considered a surgical emergency,

Afferent loop obstruction (ALO), is a mechanical complication that infrequently occurs following

a gastrojejunostomy. Classically described with a Billroth II gastrojejunostomy, less frequently

occurring with other procedures such as a Roux-en-Y gastrojejunostomy, Roux-en-Y oesophago-

jejunostomy. Recently with the emergence of OAGB as a common bariatric procedure it should

form of Billroth II reconstruction with a very long biliopancreatic afferent limb.

Afferent loop obstruction is less frequently seen now as the frequency of distal gastrectomy being

performed has decreased. Yet, with the one anastomosis gastric bypass (OAGB) becoming more

with a twelve-hour history severe and progressive upper abdominal pain, associated with vomiting

and poor oral intake.

He had OAGB for obesity 2 years previously, performed at another Trust, with endoscopic

dilatation of the anastomosis performed twice following the index surgery.

On examination, the patient was tachycardic and mildly jaundiced. Abdominal exam revealed

abdominal distention, significant tenderness and guarding in the epigastrium and left upper

surgical history, an urgent portal venous CT scan through the abdomen and pelvis was performed.

This showed small bowel obstruction with a transition point at the gastrojejunostomy. This resulted

fication of anatomy was impossible, hence the operation was converted to an open procedure.

Conversion to open laparotomy enabled better identification of the anastomosis and post-surgical

anatomy.

The entire anastomosis was resected as depicted in Figure 1 using an Endo GIA stapler (Medtronic).

Continuity was restored with a Roux-en -Y Gastric bypass reconstruction, performed with an

Antecolic Roux limb using the Endo GIA stapler (Medtronic). The mesenteric defect and Petersen’s

of conversion has been described in the literature (1; 2).

common channel of 230 cm. (Graph 1)

postoperative complications and has achieved the weight loss goals equalling or outperforming

adjustable bands and RYGB (

3

;

4

;

5

). The known drawbacks of this procedure include a risk of

biliary reflux and anastomotic ulcers or stenosis, and a risk of malnutrition if the common limb is

shorter than 2m (

6

). We present rare complications following OAGB and it should be considered

in the differential diagnosis of abdominal pain post OAGB.

Afferent loop syndrome or obstruction was first described in 1950 by Roux, Pedoussaut, and

Marchal in post-gastrectomy patients with bilious vomiting (

7

). ALO can be either acute or chronic,

early or late post operatively, and result in complete or partial obstruction.

Chronic ALO following OAGB has been described in the literature (

1

reported case of acute ALO post OAGB, to the authors’ knowledge. The reason for the obstruction

requires a jejunal aspirate performed during endoscopy with jejunal intubation. If the microbial

load is more than 106 organisms per millilitre of aspirate it will be considered pathological (

Imaging is the cornerstone of diagnosis in ALO with contrast-enhanced CT being the gold standard,

especially in the acute setting (8).

A few studies are looking at the aetiology for conversion of OAGB to RYGB, none reported acute

ALO as a reason for conversion. Jedamzik et al who looked at 1025 patients with OAGB over an

for conversion as biliary reflux, a marginal ulcer, malnutrition, weight regain, or anastomotic

stenosis (2). This series showed that ALO is not of concern in this operation.

In their series of 16 patients converted from OAGB to RYGB, Landreneau JP reported the primary

(2%) presented with a late complication. There were two deaths due to major cardiovascular

complications (10).

Different techniques have been described in the literature to convert OAGB to RYGBP, the

technique is adjusted according to the indication for conversion and the urgency of the operation.

The conversion rate from laparoscopic to open is reported to be up to 25% with this type of

9

case, it was deemed unsafe to proceed laparoscopically, and early conversion was the best option

unclear.

Treatment of acute ALO post-OAGB is surgical and best performed by a bariatric surgeon in

bariatric units, the best surgical strategy is to convert to RYGB, and in acute ALO this should

be done urgently to prevent catastrophic complications. However, morbidity related to the