Endoscopic salvage for afferent loop syndrome: the antegrade lumen-apposing metal stent technique

Background and Aims: Afferent loop syndrome (ALS) is a rare postgastrectomy condition with biliopancreatic limb obstruction. Revision surgery carries high morbidity in patients with hostile anatomy. We aimed to demonstrate the feasibility of a double-scope, antegrade EUS-guided lumen-apposing metal stent (LAMS) enteroenterostomy as an endoscopic alternative in the management of complex ALS. Methods: A patient with extensive prior gastric surgery presented with ALS. With a double-scope antegrade technique, a pediatric gastroscope (GIF-XP190 N; Olympus, Tokyo, Japan) was used to cannulate the afferent limb to place a guidewire, and a linear echoendoscope (GF-UCT180; Fujifilm, Tokyo, Japan) was advanced into the blind loop. The pediatric gastroscope was reintroduced into the efferent limb, which was water-distended to approximately 3 cm in diameter to achieve sonographic apposition. Under combined EUS and fluoroscopic guidance, a 15- × 15-mm electrocautery-enhanced LAMS (Boston Scientific, Marlborough, Mass, USA) was deployed to create an enteroenterostomy. Results: Postdeployment contrast confirmed optimal position and immediate patency without leak. Symptoms resolved rapidly; the patient resumed a diet within days and gained weight. Abdominal radiography showed progressive LAMS expansion without adverse events. Conclusions: Double-scope antegrade EUS-guided LAMS placement safely decompressed the afferent limb in our patient, restoring enteral flow and avoiding high-morbidity reoperation. This technique merits consideration within multidisciplinary care and warrants larger comparative studies to define long-term outcomes.