Retrograde filling of the afferent limb as a cause of chronic nausea after single anastomosis loop duodenal switch Amit Surve, M.D., Hinali Zaveri, M.D.,

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Retrograde filling of the afferent limb as a cause of chronic nausea after single anastomosis loop duodenal switch Amit Surve, M.D., Hinali Zaveri, M.D., Daniel Cottam, M.D. Surgery for Obesity and Related Diseases Volume 12, Issue 4, Pages e39-e42 (May 2016) DOI: 10.1016/j.soard.2016.01.018 Copyright © 2016 American Society for Bariatric Surgery Terms and Conditions

Fig. 1 (a) Image a few minutes after the ingestion of barium contrast shows a dilated afferent limb and very little contrast entering the efferent limb. (b) Image after 30 minutes of the contrast ingestion showing presence of little barium in the distal efferent limb and dilated afferent limb. Surgery for Obesity and Related Diseases 2016 12, e39-e42DOI: (10.1016/j.soard.2016.01.018) Copyright © 2016 American Society for Bariatric Surgery Terms and Conditions

Fig. 2 Highlights preferential filling of the dilated afferent limb with the contrast. Also the efferent limb is much more narrow and filled with little contrast. Surgery for Obesity and Related Diseases 2016 12, e39-e42DOI: (10.1016/j.soard.2016.01.018) Copyright © 2016 American Society for Bariatric Surgery Terms and Conditions

Fig. 3 Schematic representation of Case 1 and 2, before and after surgery. (A) Shows gravity-pulling secretions and foodstuffs downhill into the afferent loop. (B) Is post-adhesiolysis with the afferent limb tacked superiorly to the sleeve to allow gravity to pull the food and secretion into the efferent limb and away from the duodenoileostomy. Only bile is traveling through the afferent limb now. Surgery for Obesity and Related Diseases 2016 12, e39-e42DOI: (10.1016/j.soard.2016.01.018) Copyright © 2016 American Society for Bariatric Surgery Terms and Conditions

Fig. 4 (Case 1a, Case 2b) Follow-up UGI series at 1 month shows the flow of contrast into the efferent limb, without entering afferent limb. Surgery for Obesity and Related Diseases 2016 12, e39-e42DOI: (10.1016/j.soard.2016.01.018) Copyright © 2016 American Society for Bariatric Surgery Terms and Conditions