A 65-year-old woman with pancreatic adenocarcinoma s/p Whipple and Roux-en-Y reconstruction developed locoregional recurrence on palliative chemotherapy. She presented with cholangitis; PTBD improved infection but clamping caused symptom recurrence, suggesting afferent limb syndrome (ALS).

Therapeutic EUS with afferent limb distension (saline/methylene blue/contrast via PTBD) confirmed ALS and revealed an enterolith. Safe access was obtained from the efferent jejunal limb; a 15×10 mm Hot-AXIOS LAMS was placed free-hand with a coaxial double-pigtail stent to prevent obstruction/dislodgment. Cholangiography later showed hepaticojejunal anastomosis stenosis, treated with an uncovered 10×60 mm SEMS. The patient achieved complete clinical and laboratory recovery, and was discharged.