Ultrasound-guided percutaneous transhepatic duct drainage for decompression in management of afferent loop obstruction caused by anastomotic ulcer following pancreaticoduodenectomy: a case description

Introduction

Pancreaticoduodenectomy (PD), known colloquially as the Whipple procedure, is a highly intricate abdominal surgery routinely performed to treat both benign and malignant conditions of the pancreas and duodenum. Thus, surgical intervention significantly alters anatomical structures, thereby predisposing patients to a range of potential complications. Among these, afferent loop obstruction, residual gastric cancer, and anastomotic ulceration (AU) stand out as significant concerns. These complications not only pose a challenge to the patient’s recovery but also require vigilant monitoring and prompt management to ensure optimal outcomes.

Afferent loop obstruction, a relatively rare complication associated with gastrectomy combined with Billroth II or Roux-en-Y reconstruction, as well as PD with conventional annular or Roux-en-Y reconstruction, has a variety of causes. Specifically, its etiology includes: (I) compression, oppression, and distortion due to postoperative tissue adhesions; (II) internal hernia, intestinal torsion, and intussusception; (III) stenosis caused by ulceration at the gastrojejunostomy site, along with potential radiation enteritis affecting the afferent loop; (IV) recurrence of cancer; or (V) the presence of intestinal stones, jujube-like objects, or other foreign bodies (1). Additionally, in the longer term after surgery, scar obstruction caused by ulceration at the gastrointestinal anastomosis site is very rare.

This report describes a case of afferent loop obstruction induced by perforation of a gastrointestinal anastomotic ulcer. Taking into account the complexity of the patient’s condition and aiming to optimize surgical readiness and improve prognosis, we decisively employed ultrasound-guided percutaneous transhepatic duct drainage (PTDD) for precise decompression of the affected intestinal segment. As there are relatively few case reports on the use of PTDD in the treatment of afferent loop obstruction caused by AU, this paper discusses the significance of PTDD in terms of patient treatment and prognosis.

Case presentation

All procedures performed in this study were in accordance with the Declaration of Helsinki and its subsequent amendments. The study was approved by the institutional ethics board of The First Affiliated Hospital of Nanchang University (No. ISL2024868). Written informed consent was obtained from the patient for publication of this article and accompanying images. A copy of the written consent is available for review by the editorial office of this journal.

A 64-year-old female patient presented with recurrent chills, high fever (up to 40 ℃), abdominal pain, jaundice, and a blood pressure of 99/52 mmHg, without an obvious trigger 8 days prior to hospital visit. She had undergone PD for moderately differentiated pancreatic ductal adenocarcinoma 16 months prior, which was followed by 6 months of chemotherapy. Her fever temporarily subsided after antibiotic treatment but was ineffective in the long term, leading to referral for further management at The First Affiliated Hospital of Nanchang University.

The laboratory findings (Table 1) were as follows: white blood cell count, 12.12×10⁹/L; erythrocyte count, 2.18×10¹²/L; hemoglobin level, 51 g/L; neutrophil percentage, 93.2%; C-reactive protein level, 64.81 mg/L; alanine aminotransferase level, 122.4 U/L; aspartate aminotransferase level, 260.5 U/L; total bilirubin level, 22.7 mmol/L; direct bilirubin level, 12.4 mmol/L; and alkaline phosphatase level, 563.3 U/L.

The computed tomography (CT) findings were as follows (Figure 1): an indistinct common bile duct, dilated intrahepatic bile ducts, thickening of the wall of the upper abdomen, and enlarged lymph nodes adjacent to the esophagus. Endoscopy (Figure 2) revealed a 2.0 cm × 2.5 cm ulcer in the esophageal cardia with yellow-white plaque at the base, surrounded by edematous mucosa causing mild luminal narrowing. Barium meal examination (Figure 3) indicated no stricture or leakage at the gastrojejunostomy but poor filling of the afferent loop. Ultrasound (Figure 4A,4B) revealed significant dilatation of the afferent loop, marked thickening at the gastrojejunostomy, and marked luminal narrowing (d=1.5 mm) at the distal end of the afferent loop.

Figure 1 Preoperative CT images of the afferent loop following PTDD treatment. The red arrow indicates the location of the afferent loop, while the white arrow indicates the anastomotic site. CT, computed tomography; PTDD, percutaneous transhepatic duct drainage.

Figure 2 Endoscopy demonstrated an ulcer in the esophageal cardia with yellow-white plaque at the base, surrounded by edematous mucosa causing mild luminal narrowing.

Figure 3 Radiological findings from the barium meal examination demonstrated adequate opacification of the anastomotic site and efferent loop but inadequate filling of the afferent loop.

Figure 4 Ultrasound images obtained before and during the PTDD procedure. (A) In the preoperative assessment, ultrasound revealed a dilated bowel loop anterior to the right kidney, suggestive of obstruction. (B) Tracking the bowel loop, ultrasound showed evidence of bowel wall thickening and luminal narrowing proximal to the anastomotic stoma. The spacing between the two cursors is the effective diameter of the lumen. (C) Successful placement of an 8-F pigtail drainage catheter into the intestinal loop under ultrasound guidance. The red arrow indicates the needle entering the intestinal loop. PTDD, percutaneous transhepatic duct drainage.

As the patient’s medical history included grade I hypertension, diabetes mellitus, liver function abnormalities, and abnormal blood parameters, she was deemed unsuitable for immediate repeat surgery. Failure to promptly relieve the obstruction could increase intestinal pressure, compromise blood supply, and elevate the risks of intestinal perforation and infection. Following multidisciplinary assessment, the patient underwent PTDD under ultrasound guidance for decompression therapy.

Operation procedure

Ultrasound-guided PTDD was performed as follows. The patient was positioned in a supine position, with the upper abdomen being adequately exposed. Routine ultrasound scanning of the left liver and dilated intestinal loops was performed, with color Doppler ultrasound being employed to visualize the intravascular structures and determine the puncture pathway. Standard disinfection of the abdominal wall was carried out, sterile drapes were placed, and local infiltration anesthesia with 5 mL of 2% lidocaine was implemented; care was taken to ensure that the anesthetic reached the liver capsule. Subsequently, a surgical blade was used to incise the skin at the puncture site. Under ultrasound guidance, the target intestinal loop was punctured directly with an 8-F pigtail drainage catheter with an inner cannula, and the catheter was advanced into the intestinal loop. Subsequently, the inner cannula was removed, and a syringe was used for aspiration until the intestinal drainage was visible. The inner cannula was secured, and the drainage catheter was pushed forward under real-time ultrasound guidance until the catheter tip reached the target location (Figure 4C), after which the inner cannula was removed. The pigtail catheter was secured in the desired shape by pulling the pigtail wire, then the excess wire was coiled and fastened with a clamp, and the handle was rotated off. The catheter was then secured to the body surface, and the drainage control tubing and drainage bag were connected. The entire procedure progressed smoothly. Enteral nutrition and antimicrobial therapy were provided for the patient postoperatively.

The drainage bag contained slightly viscous, dark green fluid. On the first postoperative day, the patient’s laboratory results showed significant improvement (Table 1). The patient was scheduled to be discharged for rehabilitation, and a date for surgical resection of the ulcer at the anastomotic site was arranged.

Twenty days later, the patient was admitted and evaluated before undergoing surgical intervention, and CT scan revealed the resolution of the obstruction and restoration of the normal luminal diameter of the afferent loop (Figure 5). Intraoperatively, we observed significant thickening and hardening of the posterior wall of the gastroenteric anastomosis, with adhesions between the posterior wall of the gastroenteric anastomosis and the jejunum. Upon separation of the adhesions, a massive ulcer measuring approximately 4.0 cm × 4.0 cm with perforation was discovered on the posterior wall of the gastroenteric anastomosis, with the fistula being covered by the distal jejunum. Proximal to the gastroenteric anastomosis, there was scar tissue proliferation obstructing the intestinal lumen, while the distal portion remained patent (Figure 6A). The surgical team performed abdominal adhesiolysis and partial resection of the perforated ulcer within the gastric body and the stenotic afferent loop of the intestinal tract, followed by a gastrojejunostomy and jejunojejunostomy on the distal end. Postoperative frozen pathology examination (Figure 6B) revealed partial absence of the gastric mucosa, which had been replaced by necrotic and inflammatory granulation tissue. Interstitial fibrous tissue proliferation and collagen changes were observed, along with scattered inflammatory cell infiltration indicative of chronic ulcerative changes. The surrounding mucosal glands displayed relatively regular morphology, with some epithelial reactive hyperplasia and numerous multinucleated giant cells.

Figure 5 Postoperative CT images of the afferent loop following PTDD treatment. The red arrow indicates the location of the afferent loop, while the white arrow indicates the anastomotic site. CT, computed tomography; PTDD, percutaneous transhepatic duct drainage.

Figure 6 Postoperative pathological specimens. (A) Gross photograph of the resected stenotic bowel segment. (B) Histopathological section of the ulcerated bowel, highlighting the underlying mucosal damage. 10× magnification with HE staining. HE, hematoxylin-eosin.

Discussion

Pancreatic cancer is considered one of the most lethal malignancies, with its incidence, prevalence, and mortality rates having increased by 55%, 63%, and 53%, respectively, over the past 25 years, posing a significant clinical, social, and economic burden (2). PD is a commonly used surgical procedure that is conducive to improving the long-term survival rates of those with pancreatic cancer, with resection involving the pancreatic head, common bile duct at the hepatic hilum, duodenum, partial jejunum, and gastric body (3). Digestive tract reconstruction is also performed. During the operation, lymphadenectomy is performed to ensure the complete removal of potential cancer cells. The study by Malleo et al. (4) demonstrated the significance of lymphadenectomy in enhancing surgical quality and patient prognosis, indicating that thorough lymphadenectomy not only improves long-term survival but also reduces the incidence of postoperative complications. Regarding surgical complications, patients are at a short-term risk of pancreatic fistula, anastomotic leakage, anastomotic bleeding, and delayed gastric emptying, while long-term complications may include residual gastric cancer, dumping syndrome, anastomotic ulcers, and other adverse effects.

According to reports, the average incidence rate of AU post-PD is 2.5% (95% confidence interval: 1.8–3.2%), with an average diagnostic time of 15.5 months (5,6). One study reported that Roux-en-Y reconstruction is the sole significant predictive factor for AUs post-PD (P=0.02) (7). The pathophysiological mechanism underlying these AUs may be related to post-Roux-en-Y gastric emptying disorders, stasis of gastric contents in the stomach, reduced secretion of alkaline buffer solution from Brunner’s glands after duodenal resection, or abnormal gastric acid secretion, resulting in erosive action of highly acidic gastric fluid on the gastrointestinal wall, increased gastric mucosal damage, and ulcer formation (8,9). Postoperative administration of proton pump inhibitors is beneficial to reducing the probability of anastomotic ulcers (6,10).

In this case, the patient presented primarily with recurrent fever, abdominal pain, and jaundice. Imaging studies indicated features consistent with cholangitis, with the main cause attributed to obstruction at the afferent loop. However, the presence of significantly enlarged paraesophageal lymph nodes and minor luminal narrowing suggestive of AU on gastroscopy created diagnostic challenges regarding the etiology of the preoperative afferent loop obstruction. PTDD was performed initially, followed by exploratory laparotomy upon improvement of the patient’s condition. During surgery, the following was observed: the presence of a duodenal ulcer perforation in the duodenal bulb, envelopment of the fistula by the distal jejunum, and mild adhesions. This finding explained the absence of free intraperitoneal gas on CT and the lack of signs of peritoneal irritation on physical examination, preventing severe infectious complications. Subsequent surgical excision of the ulcer perforation in the gastric body and relief of the scar obstruction at the afferent loop were critical to curing the patient’s cholangitis. However, stabilization of vital signs through fasting or conservative treatment was not achievable since failure to promptly relieve the obstruction could lead to an increase in pressure in the proximal narrowed intestine, risking progression to symptoms of acute obstructive suppurative cholangitis with shock and mental status changes. Moreover, there was a further risk of afferent loop rupture, which could result in fatal peritonitis.

Endoscopic long tube, nasogastric tube, and PTDD are commonly employed therapeutic methods considered for acute intestinal obstruction (11-13), and all are capable of immediately aspirating intestinal contents, relieving proximal intestinal dilation, reducing intestinal wall edema, alleviating biliary pressure, and improving intestinal blood supply. Additionally, Aoyama et al. (14) reported that percutaneous transhepatic cholangial drainage (PTCD) is effective in relieving post-PD residual gastric cancer-induced afferent loop obstruction. However, there is currently a lack of large-scale studies evaluating the efficacy of these approaches. Moreover, for fibrotic strictures requiring surgical intervention in intestinal obstruction, endoscopy is hindered by the thickened edematous intestinal wall. In cases reported by Aoyama et al. (14), on the 18^th day of PTCD decompression, inadequate decompression of the afferent loop led to obstructive cholangitis and pancreatitis. However, after replacement of the drain catheter with a larger one, successful decompression was achieved. PTCD is prone to obstruction by bile salts formed during long-term drainage, whereas PTDD can effectively drain and dilate the intestinal loop, offering an alternative solution.

The obstructed afferent loop is in close proximity to the liver, and this anatomical relationship is of significant importance in PTDD. PTDD uses the liver as an acoustic window, which can increase the field of view and thus avoid damage to the critical surrounding structures. Compared with the direct intestinal puncture of the afferent loop, PTDD can avoid direct compression of the high-tension afferent loop, reducing bile leakage. Meanwhile, the liver tissue can enhance the stability of the puncture and fix the drainage tube, thereby reducing the risks of bile leakage and infection. However, compared to that of other solid organs, drainage of the intestine presents relatively greater technical challenges: first, afferent loop obstruction differs from common pyloric obstruction, where gas covering the intestine cannot be purged by oral intake of glucose or saline, and there are limited puncture paths available when compressing the intestine with an ultrasound probe without laparotomy; second, a one-step puncture method is preferred, as despite the two-step method generally being considered safer in cases with complex puncture paths, using the two-step method for afferent loop puncture with percutaneous transhepatic cholangiography (PTC) needle withdrawal may lead to intestinal fluid leakage into the abdominal cavity, causing peritonitis. However, with a one-step puncture, due to the needle passing through the skin, liver anterior and posterior layers of the capsule, and a somewhat elastic intestine, penetrating the needle core into the intestinal lumen is not easily achieved. Once the needle core punctures the intestinal wall, inserting the needle sheath into the intestine also presents difficulties. If the drainage sheath fails to enter the intestinal lumen after intestinal wall puncture, intestinal fluid leakage into the peritoneum may occur, leading to peritonitis. Additionally, due to the decreased intestinal pressure, there may be a missed opportunity for a second puncture. During the procedure, appropriate rotation of the puncture needle can aid in successful puncturing. If the one-step method fails to place the drainage tube, the two-step method can serve as an emergency measure. However, it should be noted that after the guidewire is inserted into the afferent loop, the dilatation tract should be prevented from expanding to the intestine as much as possible to stop the accumulated bile from overflowing into the abdominal cavity. Moreover, the patient’s vital signs should be closely monitored postoperatively.

Conclusions

PTDD may be applied in the rare occurrence of ulceration scar strictures following PD. This approach is minimally invasive, can effectively alleviate intestinal edema and bile duct hypertension, and may enhance the tolerability of the surgery, thus holding a degree of clinical significance.

Acknowledgments

None.

Footnote

Funding: None.

Conflicts of Interest: All authors have completed the ICMJE uniform disclosure form (available at https://qims.amegroups.com/article/view/10.21037/qims-24-2381/coif). The authors have no conflicts of interest to declare.

Ethical Statement: The authors are accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved. All procedures performed in this study were in accordance with the Declaration of Helsinki and its subsequent amendments. The study was approved by the institutional ethics board of The First Affiliated Hospital of Nanchang University (No. ISL2024868). Written informed consent was obtained from the patient for publication of this article and accompanying images. A copy of the written consent is available for review by the editorial office of this journal.

Open Access Statement: This is an Open Access article distributed in accordance with the Creative Commons Attribution-NonCommercial-NoDerivs 4.0 International License (CC BY-NC-ND 4.0), which permits the non-commercial replication and distribution of the article with the strict proviso that no changes or edits are made and the original work is properly cited (including links to both the formal publication through the relevant DOI and the license). See: https://creativecommons.org/licenses/by-nc-nd/4.0/.

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