EUS-guided hepaticogastrostomy in patients with obstructive jaundice after failed or impossible endoscopic retrograde drainage: A multicenter, randomized phase II Study

Endoscopic ultrasound-guided choledochoduodenostomy results in fewer complications than percutaneous drainage following failed ERCP in malignant distal biliary obstruction

Percutaneous transhepatic biliary drainage (PTBD) and endoscopic ultrasound-guided biliary drainage (EUS-BD), including choledochoduodenostomy (EUS-CDS), are alternative methods for biliary drainage in patients with distal malignant biliary obstruction (MBO) after failed endoscopic retrograde cholangiopancreatography (ERCP). Data on long-term outcomes, adverse events (AEs), and quality of life (QoL) after EUS-CDS and PTBD are limited. Therefore, we created a registry to evaluate the outcomes of both drainage procedures.Patients with distal MBO who underwent EUS-CDS or PTBD after unsuccessful ERCP were included in this multicenter investigator-initiated prospective registry over an 18-month inclusion period. Primary end points were procedure-related AEs and mortality within 90 days post-procedure. Secondary end points included technical and clinical success, reinterventions, hospital stay, and QoL.55 patients were included, with 12 patients undergoing PTBD (technical success 100%) and 43 patients EUS-CDS (technical success 97.7%). Prior to ERCP, 7/12 patients in the PTBD group and 12/43 patients in the EUS-CDS group opted for best supportive care. The 90-day mortality rate was 66.7% in the PTBD group and 20.9% in the EUS-CDS group (P = 0.005). Furthermore, 11/12 patients (91.7%) in the PTBD group and 19/43 (44.2%) in the EUS-CDS group developed one or more AEs (P = 0.004). The median post-procedural hospital stay was 4 days (interquartile range [IQR] 2-6) in the PTBD group vs. 1 day (IQR 1-2) in the EUS-CDS group (P = 0.001).When both modalities were available and technically feasible, gastroenterologists preferred EUS-CDS over PTBD. EUS-CDS seems to be associated with lower mortality and AE rates, shorter hospital admission, and fewer reinterventions, but a randomized controlled trial should confirm these observations.

Clinical effect of percutaneous hepatic puncture biliary drainage combined with metal stent implantation in the treatment of malignant obstructive jaundice

OBJECTIVE

To evaluate the clinical efficacy of percutaneous hepatic puncture biliary drainage combined with metal stent implantation in the treatment of malignant obstructive jaundice, focusing on improvements in liver function, bile duct patency time, and reduction of postoperative complications.

METHODS

181 patients with malignant obstructive jaundice were retrospectively selected from a hospital in Ganzhou City, Jiangxi Province, from April 2021 to May 2024, of which 132 underwent routine percutaneous liver puncture biliary drainage and 49 underwent percutaneous liver puncture biliary drainage combined with metal stent implantation as the observation group.

RESULTS

The clinical efficacy of the observation group was higher (P < 0.05), and the bile duct patency time was longer (P < 0.05). The AST, ALT, DBIL and TBIL levels were decreased 1 week and 1 month after surgery, and the decrease was more significant in the observation group (P < 0.05). In addition, the incidence of postoperative complications (bile duct infection and electrolyte disturbance) in the observation group was lower (P < 0.05).

CONCLUSION

Percutaneous hepatic puncture biliary drainage combined with metal stent implantation has significant clinical efficacy, which can effectively improve the clinical symptoms of patients, prolong the biliary patency time, reduce the level of bilirubin, promote the improvement of liver function, and lower the incidence of postoperative complications.

CLINICAL TRIAL NUMBER

not applicable.

Updates on therapeutic endoscopic ultrasound

PURPOSE OF REVIEW

Multiple endoscopic ultrasound (EUS) guided therapeutic interventions have been developed for the management of benign and malignant pancreaticobiliary and gastrointestinal luminal pathology. Recent high-quality evidence is increasingly validating these interventions and positioning them within evidence-based therapeutic algorithms.

RECENT FINDINGS

Here we review therapeutic EUS-guided interventions including pancreatic fluid collection drainage, gastroenterostomy, biliary drainage, pancreatic duct drainage and gallbladder drainage. The most up-to-date high-quality evidence supporting these interventions is presented including comparative data with other conventional treatment options. Newer emerging interventions such as tumor ablation are also reviewed. Current controversies and future avenues for research are discussed. The key role of EUS-guided interventions in managing pancreaticobiliary pathology in patients with a surgically altered anatomy is highlighted.

SUMMARY

Multiple EUS therapeutic interventions have evolved from experimental or rescue options to now well established first- and second-line interventions over other endoscopic, percutaneous and surgical alternatives with the support of high-quality data. Further research is needed to better optimize patient selection and guide long term postintervention follow-up.

EUS-guided hepaticojejunostomy in patients with history of total gastrectomy: a multicenter retrospective feasibility study (with video)

BACKGROUND AND AIMS

EUS-guided hepaticogastrostomy (EUS-HGS) is an effective biliary drainage technique for patients with altered anatomy or duodenal strictures. EUS-guided hepaticojejunostomy (EUS-HJS) can be used to create a fistula between the left hepatic duct and the jejunum in patients with a history of total gastrectomy. No specific data on this technique have been published. The aim of this study was to assess the feasibility and safety of EUS-HJS in patients with a history of total gastrectomy.

METHODS

This retrospective multicenter study included all adult patients who underwent EUS-HJS at 3 tertiary French centers and 1 tertiary Swiss center between May 2011 and February 2023. The primary outcome was clinical success, which was defined as the disappearance of pruritus, jaundice, and/or cholangitis. An improvement in bilirubin >30% within the first week and/or bilirubin normalization within 1 month after the procedure were also considered indicators of clinical success. Secondary outcomes were technical success, rate of adverse events, need for endoscopic revision, possibility of resuming anticancer treatment, median survival, and technical differences compared with EUS-HGS.

RESULTS

Twenty-one patients with history of complete gastrectomy who underwent EUS-HJS were included. Technical success was achieved in 100% of patients (95% confidence interval [CI], 85-100). Clinical success was achieved in 80% of patients (95% CI, 58-92). The incidence of recorded adverse events was 33% (95% CI, 17-55), with cholangitis being the most frequent adverse event. Seven patients (39%) were able to benefit from anticancer treatment after the procedure. Median survival time was 6 months (interquartile range, 1.5-12).

CONCLUSIONS

EUS-HJS is an effective and feasible procedure for patients whose anatomy has been altered by total gastrectomy.

The past, present, and future of endoscopic management for biliary strictures: technological innovations and stent advancements

Biliary stricture can be induced by intrinsic narrowing and extrinsic compression, with the majority of cases being malignant. Clinically, distinguishing between benign and malignant biliary strictures remains a considerable challenge, and the ongoing disagreement over the optimal choice of biliary stents significantly influences treatment strategies and impacts patients' survival and prognosis. The utilization and advancement of endoscopic techniques have heightened the diagnostic sensitivity for biliary strictures. Concurrently, innovative technologies such as endoscopic ultrasound and magnetic compression anastomosis emerge as viable alternatives when endoscopic retrograde cholangiopancreatography (ERCP) is not an option, providing fresh insights for the clinical management of these patients. Traditional plastic and metal stents, characterized by their complex application and limited scope, have been unable to fully satisfy clinical needs. The introduction of novel stent varieties has notably improved this scenario, marking a considerable progression towards precision medicine. However, the clinical validation of the diverse stent materials available is incomplete. Hence, a thorough discussion on the present state and evolving trends of biliary stents is warranted.

Endoscopic ultrasound-guided biliary drainage vs percutaneous transhepatic biliary drainage for malignant biliary obstruction after endoscopic retrograde cholangiopancreatography failure

In a recent issue of the World Journal of Gastrointestinal Surgery, a meta-analysis investigated the safety and efficacy of electrocautery-enhanced lumen-apposing metal stent (ECE-LAMS) implantation for managing malignant biliary obstruction following failed endoscopic retrograde cholangiopancreatography. This manuscript endeavors to offer a comprehensive look at the progression of endoscopic ultrasound-guided biliary drainage (EUS-BD) technologies, weighing their merits and drawbacks against traditional percutaneous methods. Several meta-analyses and randomized controlled trials have compared the performance of EUS-BD and percutaneous transhepatic cholangiodrainage (PTCD). These studies revealed that the technical success rate, clinical success rate, and adverse events were similar between EUS-BD and PTCD. Nevertheless, given that most of these studies predate 2015, the safety and effectiveness of novel EUS-BD techniques, including ECE-LAMS, compared with those of percutaneous biliary drainage remain elusive. Further investigation is imperative to ascertain whether these novel EUS-BD techniques can safely and efficaciously replace conventional percutaneous therapeutic approaches.

Endoscopic Ultrasound-Guided Hepaticogastrostomy in Malignant Biliary Obstruction: A Comprehensive Review on Technical Tips and Clinical Outcomes

Endoscopic ultrasound-guided biliary drainage (EUS-BD) has dramatically spread and improved in the last two decades and is changing the paradigm of drainage in case of malignant biliary obstruction (MBO). EUS-BD can be achieved from different routes, including the common bile duct (choledochoduodenostomy), intrahepatic bile ducts (hepaticogastrostomy), and gallbladder as a rescue (cholecystogastrostomy/cholecystoduodenostomy). EUS-guided hepaticogastrostomy (EUS-HGS) is a valuable option for biliary drainage in MBO when ERCP fails or is not feasible. EUS-HGS has demonstrated high efficacy with a good rate of technical and clinical success. The safety profile is also overall favorable, although severe adverse events may occur in a significant proportion of patients. From a technical perspective, EUS-HGS is considered one of the most demanding procedures in biliopancreatic endoscopy, requiring multiple steps and high technical skills and experience. In this comprehensive review, technical tips and clinical outcomes of EUS-HGS are reviewed according to the latest evidence in the literature.

Efficacy and safety of endoscopic ultrasonography (EUS) hepaticogastrostomy (HGS) versus choledochoduodenostomy (CDS) in ERCP-failed malignant biliary obstruction: A systematic review and META-analysis

Endoscopic retrograde cholangiopancreatography (ERCP) is the gold standard in managing malignant biliary obstruction. The success of ERCP has limitations, whereas surgical biliary bypass and percutaneous transhepatic approaches, as alternative modalities, come with significant costs, longer durations, and higher levels of mortality and morbidity. Endoscopic ultrasonography (EUS)-guided biliary drainage with two approaches, hepaticogastrostomy (EUS-HGS) and choledochoduodenostomy (EUS-CDS), is a favored and evolving alternative modality. This study aims to compare the efficacy and safety of EUS-HGS and EUS-CDS. We conducted a systematic review and meta-analysis by searching PubMed, ScienceDirect, Cochrane Library, and Scholar databases up to August 2023, based on the 2020 PRISMA guidelines. We identified randomized and nonrandomized studies comparing the efficacy and safety of EUS-HGS and EUS-CDS. Outcome measures included technical and clinical success, side effects, and mean procedure time. Nine nonrandomized studies and two randomized controlled trials involving 537 patients (225 EUS-HGS, 312 EUS-CDS) were analyzed. No difference was found in technical success (OR, 0.83; 95% CI, 0.41-1.68; I 2 = 0%) and clinical success between the two procedures (OR, 0.96; 95% CI, 0.51-1.81; I 2 = 9.94%). Side effects were significantly higher in EUS-HGS (OR, 2.01, 95% CI, 1.14-3.59; I 2 = 0%). No significant difference in mean procedure time was observed between the two procedures (0.13; 95% CI, -0.15-0.41; I 2 = 34.89%). There are differences in efficacy and safety between EUS-HGS and EUS-CDS. EUS-CDS has a faster procedure time, lower risk of side effects, and ease of puncture during the procedure.

Is Endoscopic Ultrasound-Guided Hepaticogastrostomy Safe and Effective after Failed Endoscopic Retrograde Cholangiopancreatography?-A Systematic Review and Meta-Analysis

Background/Objectives: Endoscopic ultrasound-guided hepaticogastrostomy (EUS-HGS) has emerged as an alternative option for biliary drainage in cases of failed endoscopic retrograde cholangiopancreatography (ERCP). Limited data exist on the safety and efficacy of EUS-HGS. In this comprehensive meta-analysis, we aim to study the safety and efficacy of EUS-HGS in cases of failed conventional ERCP. Methods: Embase, PubMed, and Web of Science databases were searched to include all studies that evaluated the efficacy and safety of EUS-HGS. Using the random effect model, the pooled weight-adjusted event rate estimate for clinical outcomes in each group were calculated with 95% confidence intervals (CIs). The primary outcomes were technical and clinical success rates. Secondary outcomes included overall adverse events (AEs), rates of recurrent biliary obstruction (RBO), and rates or re-intervention. Results: Our analysis included 70 studies, with a total of 3527 patients. The pooled technical and clinical success rates for EUS-HGS were 98.1% ([95% CI, 97.5-98.7]; I2 = 40%) and 98.1% ([95% CI, 97.5-98.7]; I2 = 40%), respectively. The pooled incidence rate of AEs with EUS-HGS was 14.9% (95% CI, 12.7-17.1), with bile leakage being the most common (2.4% [95% CI, 1.7-3.2]). The pooled incidence of RBO was 15.8% [95% CI, 12.2-19.4], with a high success rate for re-intervention (97.5% [95% CI, 94.7-100]). Conclusions: Our analysis showed high technical and clinical success rates of EUS-HGS, making it a feasible and effective alternative to ERCP. The ongoing development of dedicated devices and techniques is expected to make EUS-HGS more accessible and safer for patients in need of biliary drainage.

Endoscopic Ultrasound-Guided Biliary Drainage (EUS-BD)

Endoscopic ultrasound (EUS)-guided biliary drainage (BD) is a minimally invasive procedure that allows for biliary access when conventional endoscopic retrograde cholangiopancreatography (ERCP) is unsuccessful. The technique can be divided based on biliary access route: intrahepatic or extrahepatic, as well as on stenting approach: rendezvous approach (EUS-RV), antegrade placement, or transluminal (intra or extra hepatic) placement. There is no clear consensus on which approach is superior. Compared to percutaneous transhepatic biliary drainage, EUS-BD offers lower rates of adverse events without the need for an external drain. Compared to conventional ERCP, EUS-BD shows comparable, and in some cases superior, outcomes related to technical success, clinical success, and adverse events.

Controversies in Endoscopic Ultrasound-Guided Biliary Drainage

In this 14th document in a series of papers entitled "Controversies in Endoscopic Ultrasound" we discuss various aspects of EUS-guided biliary drainage that are debated in the literature and in practice. Endoscopic retrograde cholangiography is still the reference technique for therapeutic biliary access, but EUS-guided techniques for biliary access and drainage have developed into safe and highly effective alternative options. However, EUS-guided biliary drainage techniques are technically demanding procedures for which few training models are currently available. Different access routes require modifications to the basic technique and specific instruments. In experienced hands, percutaneous transhepatic cholangiodrainage is also a good alternative. Therefore, in this paper, we compare arguments for different options of biliary drainage and different technical modifications.

EUS-BD for calibration of benign stenosis of the bile duct in patients with altered anatomy or inaccessible papilla

Background and study aims In cases of inaccessible papilla, EUS-guided biliary drainage (EUS-BD) has been described as an alternative to calibrate benign biliary stenosis. However, few studies are available. Patients and methods This tw-center, retrospective study was designed to evaluate technical success and clinical success at 1 year. All patients who underswent EUS-BD without the rendezvous technique used for calibration of benign biliary stenosis were included from 2016 to 2022. Patients underwent EUS-hepaticogastrostomy (EUS-HGS) during the first session. Then, HGS was used to access the bile duct, allowing calibration of the stenosis: Dilation of the biliary stenosis and placement of double pigtail stents through the stenosis for 1 year. Results Thirty-six patients were included. Technical success was 89% (32/36), with four failures to cross the stenosis but EUS-HGS was performed in 100% of the cases. Nine patients were excluded during calibration because of oncological relapse in six and complex stenosis in three. Three patients had not yet reached 1 year of follow-up. Twenty patients had a calibration for at least 1 year. Clinical success after stent placement was considered in all cases after 1 year of follow-up. Thirteen patients underwent stent removal and no relapse occurred after 435 days of follow-up (SD=568). Global morbidity was 41.7% (15/36) with only one serious complication (needing intensive care), including seven cases of cholangitis due to intrabiliary duct obstruction and five stent migrations. No deaths were reported. Conclusions EUS-BD for calibration in case of benign biliary stenosis is an option. Dedicated materials are needed to decrease morbidity.

EUS-guided hepaticogastrostomy versus percutaneous transhepatic biliary drainage after failed ERCP: A propensity score-matched analysis

Background and study aims Percutaneous transhepatic biliary drainage (PTBD) is the traditional second-line option after unsuccessful endoscopic retrograde cholangiopancreatography (ERCP). Endoscopic ultrasound-guided hepaticogastrostomy (EUS-HG) is a viable alternative to PTBD. Our study aimed to compare outcomes of EUS-HG and PTBD for benign and malignant biliary diseases following failed ERCP. Patients and methods This single-center study retrospectively analyzed patients undergoing EUS-HG and PTBD for benign and malignant biliary disorders. A propensity score-matched analysis was performed using age, sex, and Charlson Comorbidity Index. The primary outcome was clinical success, which we defined as a decrease in total bilirubin by ≥ 50% at 2 weeks for malignant disease and resolution of the biliary disorder for benign disease. Results In total, 41 patients underwent EUS-HG and 138 patients underwent PTBD. After propensity score matching in a 1:2 ratio, 32 EUS-HG patients were matched with 64 PTBD. Technical success was achieved in 29 of 32 (91%) for EUS-HG and 63 of 64 (98%) for PTBD ( P =0.11). Clinical success was 100% for EUS-HG and 75% for PTBD ( P =0.0021). EUS-HG was associated with a lower adverse event rate (EUS-HG 13% vs. PTBD 58%, P <0.0001), shorter procedure duration (median 60 vs. 115 minutes, P <0.0001), shorter post-procedure length of stay (median 2 vs. 4 days, P <0.0001), and fewer reinterventions (median 1 vs. 3, P <0.0001). Conclusions Our results suggest that EUS-HG is superior to PTBD in the treatment of benign and malignant biliary disorders after failed ERCP.

Adverse events with EUS-guided biliary drainage: a systematic review and meta-analysis

BACKGROUND AND AIMS

Multiple meta-analyses have evaluated the technical and clinical success of EUS-guided biliary drainage (BD), but meta-analyses concerning adverse events (AEs) are limited. The present meta-analysis analyzed AEs associated with various types of EUS-BD.

METHODS

A literature search of MEDLINE, Embase, and Scopus was conducted from 2005 to September 2022 for studies analyzing the outcome of EUS-BD. The primary outcomes were incidence of overall AEs, major AEs, procedure-related mortality, and reintervention. The event rates were pooled using a random-effects model.

RESULTS

One hundred fifty-five studies (7887 patients) were included in the final analysis. The pooled clinical success rates and incidence of AEs with EUS-BD were 95% (95% confidence interval [CI], 94.1-95.9) and 13.7% (95% CI, 12.3-15.0), respectively. Among early AEs, bile leak was the most common followed by cholangitis with pooled incidences of 2.2% (95% CI, 1.8-2.7) and 1.0% (95% CI, .8-1.3), respectively. The pooled incidences of major AEs and procedure-related mortality with EUS-BD were .6% (95% CI, .3-.9) and .1% (95% CI, .0-.4), respectively. The pooled incidences of delayed migration and stent occlusion were 1.7% (95% CI, 1.1-2.3) and 11.0% (95% CI, 9.3-12.8), respectively. The pooled event rate for reintervention (for stent migration or occlusion) after EUS-BD was 16.2% (95% CI, 14.0-18.3; I2 = 77.5%).

CONCLUSIONS

Despite a high clinical success rate, EUS-BD may be associated with AEs in one-seventh of the cases. However, major AEs and mortality incidence remain less than 1%, which is reassuring.

Utility of interventional endoscopic ultrasound in pancreatic cancer

Endoscopic ultrasound (EUS) has an important role in the management algorithm of patients with pancreatic ductal adenocarcinoma (PDAC), typically for its diagnostic utilities. The past two decades have seen a rapid expansion of the therapeutic capabilities of EUS. Interventional EUS is now one of the more exciting developments within the field of endoscopy. The local effects of PDAC tend to be in anatomical areas which are difficult to target and endoscopy has cemented itself as a key role in managing the clinical sequelae of PDAC. Interventional EUS is increasingly utilized in situations whereby conventional endoscopy is either impossible to perform or unsuccessful. It also adds a different dimension to the host of oncological and surgical treatments for patients with PDAC. In this review, we aim to summarize the various ways in which interventional EUS could benefit patients with PDAC and aim to provide a balanced commentary on the current evidence of interventional EUS in the literature.

Endoscopic Ultrasound-guided Versus Percutaneous Transhepatic Biliary Drainage After Failed ERCP: A Systematic Review and Meta-analysis

BACKGROUND

Endoscopic retrograde cholangiopancreatography (ERCP) may fail to achieve biliary drainage in 5% to 10% of cases. Endoscopic ultrasound-guided biliary drainage (EUS-BD) and percutaneous transhepatic biliary drainage (PTBD) are alternative therapeutic options in such cases. The present meta-analysis aimed to compare the efficacy and safety of EUS-BD and PTBD for biliary decompression after failed ERCP.

METHODS

A comprehensive search of literature from inception to September 2022 was done of 3 databases for studies comparing EUS-BD and PTBD for biliary drainage after failed ERCP. Odds ratios (ORs) with 95% CIs were calculated for all the dichotomous outcomes. Continuous variables were analyzed using mean difference (MD).

RESULTS

A total of 24 studies were included in the final analysis. Technical success was comparable between EUS-BD and PTBD (OR=1.12, 0.67-1.88). EUS-BD was associated with a higher clinical success rate (OR=2.55, 1.63-4.56) and lower odds of adverse events (OR=0.41, 0.29-0.59) compared with PTBD. The incidence of major adverse events (OR=0.66, 0.31-1.42) and procedure-related mortality (OR=0.43, 0.17-1.11) were similar between the groups. EUS-BD was associated with lower odds of reintervention with an OR of 0.20 (0.10-0.38). The duration of hospitalization (MD: -4.89, -7.73 to -2.05) and total treatment cost (MD: -1355.46, -2029.75 to -681.17) were significantly lower with EUS-BD.

CONCLUSIONS

EUS-BD may be preferred over PTBD in patients with biliary obstruction after failed ERCP where appropriate expertise is available. Further trials are required to validate the findings of the study.

Duodenojejunostomy for endoscopic management of biliary enteric anastomotic stricture inaccessible via balloon-assisted endoscopy: a case report

BACKGROUND

Stricture formation is a long-term complication of biliary enteric anastomosis (BEA). BEA stricture often causes recurrent cholangitis and lithiasis, can significantly affect quality of life, and promote the development of life-threatening complications. In this report, duodenojejunostomy and subsequent endoscopic management as an alternative surgical technique for strictures of the BEA is described.

CASE PRESENTATION

Case 1: An 84-year-old man who underwent left hepatic trisectionectomy for hilar cholangiocarcinoma 6 years prior presented with fever and jaundice. Computed tomography (CT) revealed intrahepatic lithiasis. The patient was diagnosed with postoperative cholangitis secondary to intrahepatic lithiasis. Balloon-assisted endoscopy could not reach the anastomotic site, and stent insertion failed. A biliary access route was hence created via duodenojejunostomy. After the jejunal limb and duodenal bulb were identified, duodenojejunostomy was performed using a side-to-side continuous layer-to-layer suture. The patient was discharged without serious complications. Endoscopic management through duodenojejunostomy was successfully performed, and intrahepatic stones were completely removed. Case 2: A 75-year-old man who underwent bile duct resection for hilar cholangiocarcinoma 6 years prior was diagnosed with postoperative cholangitis due to intrahepatic lithiasis. Removal of the intrahepatic stones was attempted using balloon-assisted endoscopy; however, the endoscope could not reach the anastomotic site. The patient underwent duodenojejunostomy and subsequent endoscopic management. The patient was discharged without complications. Two weeks after the operation, the patient underwent endoscopic retrograde cholangiography through the duodenojejunostomy and the intrahepatic lithiasis was removed.

CONCLUSIONS

Duodenojejunostomy allows easy endoscopic access to a BEA. Duodenojejunostomy and subsequent endoscopic management may be an alternative treatment option in patients with BEA strictures that are inaccessible via balloon-assisted endoscopy.

Endoscopic Ultrasound-Guided Biliary Drainage

Endoscopic retrograde cholangiopancreatography (ERCP) and percutaneous transhepatic biliary drainage (PTBD) are currently first- and second-line therapeutic options, respectively, for the relief of biliary obstruction. In recent years, however, endoscopic ultrasound-guided biliary drainage (EUS-BD) has become an established alternative therapy for biliary obstruction. There are multiple different techniques for EUS-BD, which can be distinguished based on the access point within the biliary tree (intrahepatic versus extrahepatic) and the location of stent placement (transenteric versus transpapillary). The clinical and technical success rates of biliary drainage for EUS-BD are similar to both ERCP and PTBD, and complication rates are favorable for EUS-BD relative to PTBD. As EUS-BD becomes more widely practiced and endoscopic tools continue to advance, the outcomes will likely improve, and the breadth of indications for EUS-BD will continue to expand.