Afferent loop syndrome (ALS) after Roux-en-Y hepaticojejunostomy is an uncommon but clinically significant complication, particularly when secondary to malignant recurrence. We report the successful endoscopic management of malignant ALS using a sequential approach combining EUS-guided duodenojejunostomy with a lumen-apposing metal stent (LAMS) and trans-LAMS stenting of the distal afferent limb.

A 62-year-old man with extrahepatic cholangiocarcinoma had previously undergone Roux-en-Y hepaticojejunostomy and was receiving concurrent chemoradiotherapy for tumor recurrence. He presented with progressive abdominal pain and vomiting of one week’s duration. Physical examination revealed abdominal distension without peritoneal signs. Laboratory tests demonstrated mild anemia (hemoglobin 11.1 g/dL), normal liver biochemistry, and markedly elevated CA 19-9 (>12,000 U/mL). Computed tomography (CT) revealed recurrent tumor infiltration at the jejunojejunal anastomosis with pronounced dilatation of both the Roux limb and the afferent limb, confirming malignant ALS.

Endoscopic decompression of the Roux limb was initially attempted by deploying an uncovered self-expandable metal stent (SEMS, 20 × 100 mm) across the jejunojejunal obstruction using a colonoscope. Although the Roux limb improved radiologically, follow-up CT demonstrated persistent and progressive dilation of the afferent limb, indicating continued obstruction.

Subsequently, linear EUS was advanced to the duodenal bulb, where the markedly dilated afferent limb was identified. The limb was punctured with a 19-gauge FNA needle, and bile aspiration confirmed correct intraluminal entry. A guidewire was advanced, and a 10 × 20 mm Hot Spaxus LAMS was deployed, establishing a duodenojejunostomy. While interval CT showed partial decompression, a distal afferent limb stricture consistent with malignant involvement remained.

Using the newly created LAMS tract as an access route, a colonoscope was advanced, and a 0.025-inch guidewire was successfully negotiated across the distal stricture. A second uncovered SEMS (20 × 100 mm) was then deployed, achieving complete drainage of the afferent limb. Final CT confirmed full decompression of both limbs with all stents appropriately positioned.

The patient experienced rapid clinical improvement, resumed oral intake, and was discharged in stable condition. This case demonstrates that EUS-guided duodenojejunostomy with LAMS followed by trans-LAMS enteral stenting is a feasible and effective minimally invasive strategy for malignant ALS in patients with surgically altered anatomy. This approach may serve as a valuable alternative to surgical or percutaneous interventions in selected cases.