EUS-guided biliary drainage (EUS-BD) is emerging as a potential alternative to percutaneous transhepatic biliary drainage and ERCP in the management of malignant biliary and pancreatic strictures. This study aimed to analyze and detail the epidemiological, clinical, biological, and radiological profile of patients who underwent EUS-BD for malignant biliary obstructions, after failure retrograde drainage 

This was a retrospective, descriptive, and analytical study including all patients who underwent EUS-guided biliary drainage between 2021 and 2025.All procedures were performed using a therapeutic linear echoendoscope (Olympus). 

Our study involved 16 patients, 8 women and 8 men, with a mean age of 64.3 years (range: 37–78 years). Clinically, all patients presented with jaundice, 6 suffered from hepatic colic, 7 from pancreatic-type pain, and 2 others from diffuse and atypical abdominal pain. Radiologically, all had dilation of the common bile duct (CBD) and intrahepatic bile ducts (IHBD). All patients were in cholangitis. 

The indication for EUS-BD was duodenal tumor invasion related to pancreatic head adenocarcinoma with failed ERCP for 7 patients , duodenal tumors invading the CBD for 2 patients, perihilar cholangiocarcinoma for 3 patients , for an afferent loop syndrome after Whippple surgery, and finally, 3 patient with an antral adenocarcinoma invading the lower common bile duct, who had previously undergone a gastrojejunostomy. 

Regarding the procedure, three drainage approaches were used:

       Choledocho-bulbar drainage in 6 cases,

       Antegrade drainage in 4 cases,

       Hepatico-gastric drainage in 6 cases.

The procedure was technically successful in 87,5% of cases. The targeted bile duct was punctured using a 19-. The creation of the tract was performed with different instruments: a 7 Fr cystotome for 7 cases, a 8.5 Fr cystotome for 3 cases, a Soehendra dilatation bougie for 2 cases, and a needle knife for 4 others. 

Post-operative follow-up showed clinical and biological improvement, with pain resolution and a reduction in total bilirubin (TB) of over 75% after one week of drainage. 

During follow-up, 10 patients died, mostly due to tumor progression, at intervals ranging from 2 to 5 months after drainage. 2 patients died two weeks after drainage due to septic shock related to an infectious pneumonia, and one other died due to combined respiratory and neurological failure. Five patients remained alive at the time of evaluation, maintaining good clinical and biological status

EUS-guided biliary drainage constitutes a reliable and minimally invasive alternative to percutaneous drainage and ERCP in the management of malignant biliary obstruction, especially in cases of ERCP failure.The technique provides rapid relief of cholestasis and infection, with high technical and clinical success rates. Mortality in this series was primarily related to disease progression rather than the procedure itself highlighting the value of rigorous patient selection and appropriate follow-up