S5252 Advanced Endoscopic Management of Benign Afferent Limb Syndrome and Gastrojejunostomy Strictures: A Case Study

Introduction: Afferent Limb Syndrome (ALS) is a complication after gastrectomy with gastrojejunostomy, occurring in 0.2%-1% of the cases. ALS involved obstruction of the afferent limb leading to abdominal complications. While lumen-apposing metal stents (LAMS) are mainly studied in malignant ALS, evidence suggests they're effective for benign strictures showing high success. We highlight a similar case. Case Description: A 52-year-old woman with a history of gastroparesis, autoimmune dysmotility and peptic ulcer disease complicated by gastric and recurrent duodenal ulcers with duodenal stricture status post-gastrojejunostomy presented with nausea and vomiting. Previously a push enteroscopy was performed for endoscopic decompression of the afferent limb. A subsequent esophagogastroduodenoscopy revealed a dilated stomach with an unidentifiable afferent limb and Grade D esophagitis. On readmission, she was found to have cholestatic liver injury and an elevated lipase of 1500. CT imaging showed evidence of a dilated afferent limb with intra- and extrahepatic biliary dilation and pancreatic inflammation. Her presentation was consistent with afferent limb syndrome, likely exacerbated by a concurrent efferent limb stricture, leading to gastric distension and obstruction. After multidisciplinary discussion, Endoscopic ultrasound (EUS)-guided drainage with lumen-apposing self-expanding metal stent (LA-SEMS) stent placement was elected. During the procedure, a 15 mm circumferential stricture at the GJ anastomosis was identified, likely contributing to obstruction of the afferent limb and pancreaticobiliary drainage. A separate short-segment stricture was also identified in the efferent limb, further complicating gastric emptying. A 20 mm LA-SEMS (AXIOS) stent was placed in the afferent limb, immediately releasing 2 liters of bilious fluid, confirming decompression. A second 20 mm × 10 mm AXIOS stent was placed across the GJ anastomosis to address the efferent limb stricture and improve gastric emptying. Post-procedure, the patient reported significant improvement in her symptoms and was discharged the next day. Discussion: ALS post-gastrojejunostomy remains rare but clinically significant. We report successful treatment of benign ALS using dual EUS-guided 20 mm LAMS, achieving prompt decompression and symptom resolution. EUS-GJ represents a minimally invasive alternative to surgery or PTBD, with emerging data supporting its role in benign disease. This identifies the need for prospective studies to optimize stent management and define long-term outcomes.