Abstract A036: Afferent loop syndrome in a young patient with extrahepatic cholangiocarcinoma: A challenging postoperative anatomy after complex hepatobiliary surgery

Abstract Extrahepatic cholangiocarcinoma (EC) represents a challenging malignancy, usually requiring extensive surgical resection as concurrent treatment with chemotherapy. Right hepatectomy with ductoplasty and hepaticojejunostomy is an often-used procedure to achieve negative margins. Nonetheless, extensive reconstruction of the gastrointestinal anatomy predisposes to postoperative complications, such as afferent loop syndrome (ALS). ALS occurs when the afferent limb created for biliary drainage becomes obstructed, causing accumulation of bilious material. This report presents a young patient with EC who developed ALS following complex hepatobiliary reconstruction. A 35-year-old woman with EC arising within a choledochal cyst, who underwent right lobe hepatectomy and Roux-en-Y hepaticojejunostomy, was referred to the emergency department due to elevated bilirubin levels (total 8.3, direct 6.7, indirect 1.6, all mg/dL) and generalized jaundice that began two weeks before presentation. Additionally, the patient had increasing abdominal fullness accompanied by fevers, nausea, non-bilious vomiting, and decreased oral intake. Of note, she had received only one cycle of gemcitabine, cisplatin, and durvalumab without adverse events one month prior. CT abdomen and pelvis performed on admission demonstrated extensive intrahepatic biliary ductal dilation with pneumobilia, with markedly dilated proximal loops of small bowel causing short segment bowel obstruction, likely due to tumor infiltration and adhesions. Broad-spectrum intravenous antibiotics were initiated, and a nasogastric tube (NGT) was placed for assistance with decompression. Upon an initial gastroenterology (GI) consult, there was no role for endoscopic retrograde cholangiopancreatography (ERCP) given the extensive pneumobilia; surgical oncology also indicated no intervention due to diffuse biliary dilation and multifocal obstruction sites. Additionally, interventional radiology determined that urgent percutaneous biliary drainage was not indicated, supporting the impression that the clinical picture was most consistent with ALS. Nonetheless, GI performed an upper endoscopic ultrasound which visualized the multiple dilated loops of small bowel, corresponding to the obstructed afferent (biliopancreatic) limb. A 15x10mm metal gastro-jejunal stent was successfully placed from the anterior wall of the gastric body to the target loop of small bowel, with subsequent large amounts of dark bile and sludge seen flowing through the stent. The previously placed NGT was removed, and there were no post-procedure complications. After stent placement, bilirubin levels steadily declined (total 1.3, direct 0.8, indirect 0.5, all mg/dL) and the patient experienced improved oral intake. This case highlights ALS as an inherent risk of extensive hepatobiliary surgery performed for EC, in which an altered anatomy predisposes to a condition that may not be immediately apparent. Anticipating ALS as a possible complication and implementing timely intervention are key to protect long-term biliary function. Citation Format: Humberto R. Nieves-Jiménez, Mohamad Ali Ibrahim, Chase V. West, Mitchell C. Boshkos, Sergio U. Villegas-De León, Daniel J. Leal-Alviárez. Afferent loop syndrome in a young patient with extrahepatic cholangiocarcinoma: A challenging postoperative anatomy after complex hepatobiliary surgery [abstract]. In: Proceedings of the AACR Special Conference in Cancer Research: The Rise in Early-Onset Cancers—Knowledge Gaps and Research Opportunities; 2025 Dec 10-13; Montreal, QC, Canada. Philadelphia (PA): AACR; Clin Cancer Res 2025;31(23_Suppl):Abstract nr A036.

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