Acute ALS requires immediate diagnosis and corrective surgery. Indeed, the major pitfall associated with ALS is a delay in diagnosis due to risk of intestinal perforation and sepsis [33]. Patients with chronic ALS may develop malnutrition or anemia [22, 34], and may derive benefit from nutritional therapy or transfusion prior to surgery.

Although surgical conversions have been the treatment of choice, percutaneous tube drainage or stent placement has been performed as a palliative treatment for patients who cannot tolerate a surgical procedure. Metallic stents have been used for the relief of afferent loop syndrome due to number of etiologies [35–37]. In a 77-year-old patient with afferent loop obstruction due to recurrent cancer, a double-pigtail catheter placed beyond the ampulla of Vater resolved symptoms [36]. Two cases of refractory ALS were successfully treated by transhepatic biliary catheterization coupled with transcholecystic cholangiography, both showed clinical improvement with no complications [37]. More recently, Lee et al. described the successful endoscopic treatment of near-complete obstruction of the efferent loop with insertion of a double-pigtail stent (Fig. 14.2a–e) [38]. A study by Morita and colleagues indicated that percutaneous transhepatic catheter drainage for obstructed afferent loop may be risky due to the development of septic shock [39]. In such cases, the authors suggested an additional drainage catheter of the bile duct might be needed when biliary stasis is present.

Han retrospectively analyzed the clinical effectiveness of placement of dual stents in 13 consecutive patients who underwent operations for gastric cancer, cholangiocarcioma, or pancreatic adenocarcinoma and subsequently developed afferent loop syndrome due to disease progression. Twelve of the 13 patients experienced normalization of their abnormal biliary laboratory findings and decompression of the dilated bowel loop following dual stent placement [40].

Kim et al. found that percutaneous tube enterostomy is an effective palliative treatment in ALS presenting as obstructive jaundice [41]. Radiographically guided interventional techniques with metallic stents have been used to effectively palliate ALS caused by a number of different etiologies. Successful palliation of biliary obstruction was achieved using transhepatic metallic stents across duodenal and biliary strictures for the treatment of malignant ALS caused by inoperable carcinoma of the head of the pancreas [35]. Percutaneous transhepatic metallic stent insertion for malignant afferent loop obstruction following pancreaticoduodenectomy for carcinoma of the ampulla of Vater is an option [42]. Percutaneous transhepatic insertion of metal stents was also successfully used to treat ALS due to distal gastrectomy [36]. A study by Song et al. looked at the use of metallic stents in 39 patients with recurrent cancer after gastrojejunostomy and found that placement of expandable metallic stents was successful in 90 % of patients, but did require accurate knowledge of surgical procedure and tumor recurrence pattern for effective stent placement [43].