Endoscopic treatment of acute ascending cholangitis in a patient with Roux-en-Y limb obstruction after a Whipple operation.

with pancreatic head adenocarcinoma. He underwent pancreaticoduodenectomy (Whipple procedure). Four months later he developed obstructive jaundice, high fever, and chills. His total bilirubin level was 2.0mg/dL (range 0.3–1.2mg/dL) and alkaline phosphatase was 270 U/L (range 39–117 U/L). Computed tomography (CT) of the abdomen showedmarked dilatation of the afferent limb and a suspected recurrent tumor in the pancreatic area (●" Fig. 1). The patient underwent an emergency endoscopy and a guidewire could be passed beyond the obstruction into the proximal part of the afferent limb (●" Fig. 2). Endoscopic placement of a self-expandable metallic stent (enteral stent, 80mm; Boston Scientific, Massachusetts, USA) was performed using a therapeutic gastroscope (1TGIF; Olympus Corp., Tokyo, Japan) (●" Fig. 3). After the procedure, the patient’s bilirubin normalized and the fever resolved. Plain film of the abdomen revealed a good deployment of the stent (●" Fig. 4). The patient was discharged 1 week later. He received adjunctive radiotherapy and at the 6-month follow-up remained asymptomatic. Afferent loop obstruction is a rare complication after theWhipple procedure. In the rare case of complete obstruction, there is a high risk of developing necrosis and perforation. This condition requires immediate intervention. Percutaneous transhepatic drainage [1,2] and surgical drainage [3,4] are alternative management strategies with very high risk in some patients. Endoscopic metallic stent placement [5] is a treatment of choice to avoid an unnecessary and high risk operation. Longterm follow-up data are required to establish its clinical efficacy.