EUS-guided hepaticogastrostomy (EUS-HGS) is one of the preferred rescue techniques for biliary drainage when ERCP fails or when the papilla is inaccessible due to altered anatomy or neoplastic invasion. Despite its proven technical feasibility and clinical effectiveness, several safety concerns have limited its widespread adoption even among expert centers. The primary fear relates to the potentially catastrophic consequences of stent misdeployment or migration, events that are often challenging to manage with either endoscopic or surgical interventions. To mitigate these risks, several dedicated stent designs incorporating anti-migratory features have been developed. However, evidence on their performance has so far been limited to individual studies.

We conducted a comprehensive search of multiple electronic databases (PubMed/MEDLINE, Scopus, and EMBASE) and major conference proceedings from inception through July 2025. Technical outcomes included pooled rates of technical success and procedural time. Clinical outcomes included pooled clinical success, stent dysfunction, and adverse event rates, with particular focus on stent misdeployment and migration. Meta-analyses were performed using a random-effects model, and heterogeneity was assessed using the I² statistic.

We analyzed 18 studies (including 7 multicenter studies), 13 of which were conducted in Eastern countries, comprising a total of 595 patients who underwent EUS-guided HGS. The most frequently used dedicated stents were the Giobor stent (reported in 6 studies) and the Spring Stopper Stent (reported in 3 studies). The pooled technical success rate of EUS-HGS was 99.1% (95% confidence interval [CI], 98.4–99.8%; I² = 0%), with a mean procedural time ranging from 16 to 50 minutes. The pooled clinical success rate was 94.8% (95% CI, 92.1–97.4%; I² = 55.3%). Among patients achieving clinical success, the 23.0% (95% CI, 15.4–30.7%; I² = 78.6%) experienced stent dysfunction. The pooled rate of adverse events following EUS-HGS was 9.9% (95% CI, 6.9–13.0%; I² = 32.5%), with the 1.1% (95% CI, 0.2–1.9%; I² = 0%) of them being severe. Most complications were infection-related, including cholangitis and intra-abdominal abscesses (3.4%, 95% CI 1.8–5.0%; I² = 10.7%). The pooled risk of stent misdeployment or migration was 0.8% (95% CI, 0.1–1.6%; I² = 0%).

Performing EUS-HGS with dedicated stents is an effective option for these difficult-to-treat patients. Although the risk of adverse events remains clinically relevant and should be thoroughly discussed with patients before the procedure, the risk of the most feared complications—stent misdeployment and migration—appears to be substantially minimized with dedicated devices, translating into a lower likelihood of severe adverse events.