Acute pancreatitis due to afferent loop obstruction treated by endoscopic ultrasound-guided transpancreatic afferent limb drainage

Afferent loop obstruction (ALO) is a rare mechanical complication occurring in 0.3–1.0% of patients after gastrectomy [ 1 ]. Elevated intraluminal pressure in the afferent loop can lead to cholangitis or pancreatitis. Recently, endoscopic transluminal stent placement using balloon-assisted endoscopy [ 2 ] or endoscopic ultrasound (EUS [ 3 ]) has been reported as an effective treatment. We describe the first successful case of the endoscopic treatment of ALO complicated with acute pancreatitis by an EUS-guided transpancreatic approach ([ Video 1 ]). Download Video Endoscopic ultrasound-guided transpancreatic afferent limb drainage.Video 1 A 71-year-old woman with a history of gallbladder cancer who had undergone pancreaticoduodenectomy 5 years earlier presented with fever and abdominal pain. Computed tomography revealed dilation of the afferent limb and pancreatic enlargement with dilation of the main pancreatic duct (MPD) to 6 mm, compared with images obtained 3 months earlier ([ Fig. 1 ]). She was diagnosed with acute pancreatitis secondary to ALO. Fig. 1 Computed tomography performed 3 months before admission and at the time of hospitalization: a pancreatic parenchymal atrophy 3 months before admission (yellow arrow); b swelling of the pancreatic parenchyma and dilated main pancreatic duct (yellow arrowhead); c, d dilation of the afferent loop at the blind end. A short-type double ballon endoscope (EI-580BT; Fujifilm, Tokyo, Japan) reached the choledochojejunal anastomosis; however, the dilated blind end where the pancreaticojejunal anastomosis was located could not be accessed due to peritoneal dissemination. Histopathological examination of endoscopic biopsy specimens revealed adenocarcinoma. As a result, decompression of the afferent limb was not achieved, and only biliary stents were placed. Consequently, we planned to perform EUS-guided transpancreatic afferent limb drainage. Under EUS guidance, a 19-gauge needle was inserted into the MPD, and a guidewire was advanced across the pancreaticojejunal anastomosis into the blind end. There was no pancreatic duct stricture. The fistula was dilated using a drill dilator. A plastic stent and a nasodrainage tube were placed into the dilated blind end ([ Fig. 2 ]). Six days after the procedure, the nasodrainage tube was removed because both afferent loop dilation and pancreatitis improved promptly ([ Fig. 3 ]). No recurrence of pancreatitis was observed without removing the stent until the patientʼs death. Fig. 2 a–d Placement of a plastic stent and a nasodrainage tube into the dilated afferent loop at the blind end via the main pancreatic duct using endoscopic ultrasound-guided transpancreatic afferent limb drainage. a Under EUS guidance (UCT260; Olympus Co., Ltd, Tokyo, Japan), a 19-gauge needle (SonoTip Pro Control; Medico’s Hirata Inc., Osaka, Japan) was inserted into the dilated main pancreatic duct. b A 0.025-inch guidewire (Visiglide2; Olympus) and an MTW catheter (ABIS, Tokyo, Japan) were advanced across the pancreaticojejunal anastomosis into the blind end. c The fistula was dilated using a drill dilator (Tornus ES; Asahi Intecc, Aichi, Japan). d A plastic stent (6-Fr 7-cm, pigtail type, Zimmon; COOK Medical, Bloomington, IN, USA) and a nasodrainage tube (5Fr; Create Medic) were placed into the dilated blind end. EUS, endoscopic ultrasound. Fig. 3 Schematic illustration of EUS-guided afferent limb drainage via the main pancreatic duct. EUS, endoscopic ultrasound. EUS-guided transpancreatic afferent limb drainage may represent a feasible and effective endoscopic treatment for ALO associated with acute pancreatitis. Endoscopy_UCTN_Code_CCL_1AC_2AH Endoscopy_UCTN_Code_TTT_1AS_2AK Endoscopy_UCTN_Code_TTT_1AS_2AI Publication History Article published online: 16 March 2026 © 2026. The Author(s). This is an open access article published by Thieme under the terms of the Creative Commons Attribution License, permitting unrestricted use, distribution, and reproduction so long as the original work is properly cited. (https://creativecommons.org/licenses/by/4.0/). Georg Thieme Verlag KG Oswald-Hesse-Straße 50, 70469 Stuttgart, Germany