Naturally, a more aggressive moreover approach is also necessary if BCCs are suspected. Then, depending from the site of the lesion and the kind of surgery, reconstruction can be performed (19�C22). Sometimes alloplastic materials can be used for the maxillofacial reconstruction (23). In general, patients with NBCCS require long-term integrated multi-specialty follow-up, aiming particularly at the early diagnosis of any life-threatening lesions.
A 80-yr-old man was admitted to a hospital for severe upper abdominal pain associated with nausea and fever. Physical examination revealed a distended abdomen with right upper quadrant tenderness and jaundice. The patient had undergone a Billroth II partial gastrectomy for benign ulcer 27 years before.

Laboratory tests showed an elevated white blood cell count of 15,000/mm3, biliary stasis and pancreatitis (bilirubin 4.8 mg/dL – direct 3,5 mg/dL; GGT 213 mU/mL; alkaline phosphatase 521 mU/mL; amylase 1,512 U/L). The preliminary diagnosis was pancreatitis and acute cholangitis. An appropriate therapy was started. In the following few hours, no symptom relief was observed and the patient��s condition made worse. Abdominal computed tomography (CT) showed dilatation of both the main pancreatic duct and the biliary duct (Fig. 1), and a huge stone in the dilated duodenal afferent loop (Fig. 2). The pancreas was normal and no gallstones were found in the gallbladder. The diagnosis of acute afferent loop obstruction by enterolith was made. Urgent laparotomy was planned. Fig. 1 Abdominal CT – Dilated common bile duct (black arrow) and main pancreatic duct (white arrow).

Fig. 2 Abdominal CT – A large incarcerated enterolith in the dilated afferent loop. Abdominal exploration revealed dilatation of the duodenum without signs of ischemia and an entrapment of the afferent loop by extensive adhesions, causing kinks, particulary at the anastomosis site. Adhesiolysis was carried out and a greenish stone measuring 5 �� 6 cm was removed through a longitudinal cut in the second portion of duodenum. The enterolith was ovoid in shape and composed mainly of cholesterol and bile salts. The postoperative course was uneventful and the patient was discharged home 9 days after surgery. Discussion Afferent loop syndrome is a relatively uncommon complication encountered after gastrectomy and Billroth II reconstruction (3).

The incidence reported in literature ranges between 0,2% and 20% (4); with modern surgical techniques it has been reduced to 0,3% (5,6). The afferent loop syndrome has been attributed to the stasis of biliary, pancreatic and intestinal secretions in the afferent Dacomitinib loop. When the pressure within the afferent loop exceeds the resistant threshold of the obstruction, its content is then propelled into the stomach to cause sudden bilious vomiting and so pain is relieved.