A 75-year-old man with previous Billroth II reconstruction was admitted in April 2025 with jaundice and elevated cytolytic and cholestatic markers. Ultrasound revealed common hepatic duct lithiasis with intrahepatic duct dilation. After failure of entero-ERCP, a lateral-viewing duodenoscope was used. During intubation of the afferent limb, a 2-cm jejunal wall defect was identified at a sharp angulation. Due to immediate recognition of the perforation and the patient’s comorbidities, endoscopic closure was performed using the X-Tack™. The patient resumed enteral feeding after 48 hours without symptoms.However, worsening cholestatic indices required a repeat ERCP. After unsuccessful attempts at biliary cannulation, a precut fistulotomy allowed access to the major papilla and placement of a biliary stent.