This is the case of a 78-year-old patient with previous Whipple's pancreaticoduodenectomy for a poorly differentiated adenocarcinoma.  14 months later there is evidence of disease recurrence, and the patient develops biliary obstruction secondary to afferent (biliary) limb obstruction. After discussion at the HPB MDT endoscopic palliative management was decided.  Initial attempts at endoscopic luminal stent insertion were limited by anatomic access.  An EUS approach was then attempted. The dilated obstructed small bowel limb was easily identified. We punctured with a 19A needle and aspirated dark bile. Contrast injected confirmed a very dilated small bowel with reflux into a dilated biliary tree. With the wire kept in place, a HOT SPAXUS LAMS 20x16mm stent was deployed creating a gastrojejunostomy with the obstructed jejunum loop. Large amount of bile was drained into the stomach. Contrast study confirmed correct placement. 4 weeks later the LAMS was replaced by two double pig tails 7fr x 15cm. Patient symptoms (jaundice, pruritus) and abnormal LFTs resolved gradually. Afferent loop syndrome can affect patients with recurrence. It is defined by distal obstruction and accumulation of bile, pancreatic and enteric fluid, causing distension of the afferent loop and recurrent cholangitis. EUS-guided gastroenterostomy is a novel technique that bypasses an area of obstruction by creating a lumen-to-lumen direct anastomosis using a fully covered lumen-apposing metal stent. EUS-guided gastroenterostomy is a minimal -invasive approach, especially compared to surgical gastroenterostomy, that could be favoured over enteral stent placement, because of difficult anatomical access and durable effect.