Management of afferent loop syndrome after Roux-en-Y subtotal gastrectomy and choledocolithiasis with recurrent cholangitis

Abstract

Afferent loop syndrome is a rare complication after gastrectomy with Billroth II or Roux-en-Y reconstruction, caused by an obstruction in the proximal loop. The biliary stasis and bacterial overgrowth secondary to this obstruction can lead to repeated episodes of acute cholangitis. We present the case of a male patient who had previously undergone gastrectomy with Roux-en-Y reconstruction and later experienced multiple episodes of acute cholangitis secondary to choledocolithiasis. He underwent an open exploration of the bile ducts with choledocolitotomy, but the events of cholangitis persisted. Further investigation permitted to identify a dilation of the biliary loop of the Roux-en-Y anastomosis, suggesting enterobiliary reflux as the cause of recurrent acute cholangitis. Therefore, a bowel enterectomy and new jejunojejunostomy were undertaken, and normal biliary flow was re-established. The surgical treatment is mandatory in benign causes, leading to the resolution of the obstruction and subsequent normalisation of bile flow.