A 72-year-old woman with pancreatic adenocarcinoma (pT2N1) treated by pancreaticoduodenectomy with single-loop reconstruction two years earlier developed local recurrence and received chemoradiotherapy. She presented with jaundice, acholic stools, and dark urine. Laboratory tests showed total bilirubin 11.5 mg/dL, direct bilirubin 7.8 mg/dL, and alkaline phosphatase 711 U/L. Magnetic resonance imaging revealed infiltrative recurrence encasing the coeliac trunk and superior mesenteric artery with moderate biliary dilatation secondary to narrowing of the hepaticojejunostomy.

Upper endoscopy identified severe malignant stenosis at the gastrojejunal anastomosis with oedematous, infiltrative mucosa. Under fluoroscopic guidance, a 0.035-inch guidewire was negotiated across the pinpoint stenosis. Contrast injection confirmed position in the afferent loop. An ultrathin 4.9-mm gastroscope was advanced through the stenosis, revealing an intact but compressed hepaticojejunostomy with abundant biliary drainage and no intraductal tumour. Two 7-Fr × 7-cm double-pigtail plastic stents were successfully deployed side-by-side across the gastrojejunal stenosis. No biliary stent was placed.

At 7-day follow-up the patient was asymptomatic, bilirubin had fallen to 2.1 mg/dL, and liver enzymes normalised. She was discharged home.

This case demonstrates that endoscopic transmural drainage of malignant afferent loop syndrome using double-pigtail stents across the gastrojejunal anastomosis is feasible, safe, and rapidly effective. The ultrathin gastroscope was key to confirming hepaticojejunostomy patency and avoiding unnecessary biliary intervention.