In selected patients with altered surgical anatomy, inadequate biliary drainage of the left hepatic duct, or duodenal obstruction, Endoscopic Ultrasound Guided Hepaticogastrostomy (EUS-HGS) offers the possibility to acquire internal biliary drainage via the stomach. This approach may reduce bile salt loss and improve quality of life compared to percutaneous transhepatic biliary drainage. However, outcomes of EUS-HGS outside highly selected study cohorts remain unclear and are likely overestimated in the literature due to selective reporting and bias. We aimed to evaluate the real-world outcomes of this technically demanding procedure in a nationwide cohort. 

In this multicenter, retrospective cohort study, all consecutive patients who underwent an attempted EUS-HGS between 2009 and 2025 among nine Dutch hospitals were included. The primary outcome was technical success, defined as adequate stent positioning confirmed by endoscopy and fluoroscopy. Secondary outcomes included clinical success, defined as the absence of further biliary drainage interventions during follow-up; procedural and post-procedural complications, classified according to the AGREE criteria; and time to recurrent biliary obstruction (RBO), defined as the occurrence of symptoms and/or interventions related to biliary obstruction. Predictors of RBO were analyzed using competing risk regression, and overall survival was estimated by the Kaplan–Meier method.

A total of 107 procedures among 105 patients were included. Median age was 68 years [IQR 59–76], and 55% were male. Overall technical success was 77% (81/105). Bile duct puncture was performed in 98/105 patients (93%) and was successful in 95/98 (97%). Deep guidewire insertion was achieved in 92/95 patients (97), with tract dilation in 88/92 (96%). Stent placement was performed in 85/88 patients (97%) and was technically successful in 81/85 (95%). The majority (62%) received a dedicated partially covered SEMS, while 36% received a combination of two stents: one long uncovered SEMS to avoid migration and one shorter covered SEMS to avoid bile leakage. Procedural and post-procedural complications occurred in 15% and 17% of patients, respectively, including one procedure-related death. Among patients with technically successful EUS-HGS, clinical success was achieved in 63 of 81 (78%), corresponding to an overall clinical success rate of 60% (63/105) when analyzed by intention to treat. RBO was observed in 23/81 patients (28%) during a median follow-up of 61 days [IQR: 23 – 131], with no significant risk factors identified. Median overall survival was 91 days [IQR: 66–155]. Survival did not differ between stent types (p=0.81).

EUS-HGS was technically feasible in almost 4 out of 5 patients while adequate bile drainage was achieved in more than three-quart in this group. This is relatively low compared to the literature with technical success rates around 95% and clinical success rates of around 88% (1), and therefore prospective studies are warranted to optimize patient selection, standardize stent choice, and minimize complications.