Endoscopic Management of Malignant Afferent Loop Syndrome after Pancreaticoduodenectomy Using Ultrathin Endoscopy and Double-Pigtail Stents: A Feasible and Minimally Invasive Approach

We describe the case of a 72-year-old woman with a history of pancreaticoduodenectomy with single-loop reconstruction for pancreatic adenocarcinoma (pT2N1) performed 2 years earlier. Due to localized recurrence, she underwent chemotherapy and radiotherapy. She was admitted with jaundice. Laboratory tests showed elevated bilirubin levels and cholestatic enzymes. Magnetic resonance imaging demonstrated infiltrative tissue involving the celiac trunk and superior mesenteric artery, along with moderate biliary dilation secondary to narrowing of the biliary-enteric anastomosis. Upper endoscopy revealed a pinpoint malignant stenosis of gastrojejunal anastomosis at the level of the afferent/biliopancreatic loop, and endoscopic drainage was indicated ([ Fig. 1 ]). The intervention was performed under general anesthesia. A 0.035-inch guidewire was carefully advanced across the pinpoint gastrojejunal stenosis under direct endoscopic visualization and fluoroscopic guidance ([ Fig. 2 ]). Contrast injection confirmed correct access to the afferent loop, demonstrating opacification of the dilated afferent limb. Fig. 1 Endoscopic view of the gastrojejunal anastomosis showing edematous and infiltrative mucosa. The red arrow highlights the pinpoint malignant stenosis of the afferent limb, the blue arrow identifies the efferent limb, and the yellow stars delineate the gastrojejunal anastomosis. Fig. 2 ( A ) Endoscopic view showing guidewire passage across the pinpoint malignant stenosis of the afferent limb ( red arrow ). ( B ) Fluoroscopic image confirming successful guidewire access into the afferent loop with contrast opacification of the dilated afferent limb ( yellow arrow ). An ultrathin 4.9-mm gastroscope was then advanced across the stricture, demonstrating an intact biliary-enteric anastomosis with abundant bile flow ([ Fig. 3 ]). Following confirmation of the obstruction site, two 7 Fr × 7 cm double-pigtail plastic stents were deployed across the gastrojejunal stenosis under combined endoscopic and fluoroscopic guidance, achieving effective luminal decompression ([ Fig. 4 ]). At 7-day follow-up, the patient showed marked clinical and biochemical improvement, with total bilirubin decreasing from 11.5 to 4.8 mg/dL, direct bilirubin from 7.8 to 4.45 mg/dL, alkaline phosphatase from 711 to 543 U/L, and gamma-glutamyl transferase from 410 to 303 U/L. During the subsequent 2-month follow-up period, no recurrent jaundice, cholangitis, or symptoms of afferent loop obstruction were observed, and no repeat intervention was required. The patient subsequently died due to progression of the underlying recurrent malignancy. Fig. 3 ( A ) Ultrathin endoscopic view of the afferent limb beyond the stenosis. ( B ) Direct visualization of a patent biliary-enteric anastomosis. Fig. 4 Deployment of two double-pigtail plastic stents across the gastrojejunal stenosis. ( A ) Endoscopic view after stent placement. ( B ) Fluoroscopic view confirming correct stent positioning. Authors' Contributions M.M.M.G. studied concept, endoscopic procedure, and drafted manuscript. L.L. performed the endoscopic procedure and did the critical revision. F.M.F. performed the endoscopic procedure, supervised, and critically revised the manuscript. Publication History Article published online: 01 August 2026 © 2026. The Author(s). This is an open access article published by Thieme under the terms of the Creative Commons Attribution License, permitting unrestricted use, distribution, and reproduction so long as the original work is properly cited. (https://creativecommons.org/licenses/by/4.0/) Thieme Medical and Scientific Publishers Private Limited A-13A, Graphix Tower 1, 6th floor, Sector 62, Noida 201309, Uttar Pradesh, India