Endoscopic ultrasound-guided biliary drainage  ( EUS- BD) increasingly provides its role in the management of benign biliary diseases particularly in patients with surgically altered anatomy or after failed selective biliary cannulation during ERCP .The aim of this study is to evaluate the safety, clinical effectiveness and long-term outcomes of EUS-BD  for the management of benign biliary diseases.

This is a single- center  retrospective study, which  included  all consecutive patients, who underwent EUS-BD for benign indications  between March 2020 and October 2025. All the procedures were evaluated in terms of technical, clinical success and adverse events. Long- term follow-up data were also provided.

We identified  15  patients  who underwent EUS-BD during the study period due to benign biliary diseases (men- 7, women- 8; mean age 62.3 years).

Some of them (n= 11,73.3%) were addmited as emergency  with acute cholangitis, while others (n=4, 26.7%) with progressive jaundice. In 4 (26.7%)  cases surgically altered anatomy was present, while in 11(73.3%)  patients EUS-BD was used to assist ERCP after failed transpapillary canulation.

We performed EUS- guided hepaticogastrostomy (EUS-HGS) using fully covered self expanding metal stent in 11(73.3%) patients, EUS- guded rendezvous technique to assist transpapillary canulation was used in 2 (13.3%) and 2(13.3) patients underwent EUS choledochoduodenostomy. Antegrade cholangioscopy using the transgastric route was performed in 4( 26.7%)cases. EUS-HGS was successfully performed in 3(20%) cases with complete iatrogenic bile duct transsection duringcholecystectomy.

Second procedure was performed in 12 (80%) cases after median period of 45 days.

Technical success, defined as successful biliary access and stent placement was achieved in 86.7%. Clinical success (defined as  ≥50% reduction in serum total bilirubin and cholestatic  enzymes or resolution of  cholangitis  within 2 weeks after  the procedure)  was achieved in 14 (93.3%) patients.

During follow-up, 13 patients (86.7%) remained under multistenting management, with a median follow-up duration of 8 months. One patient (6.7%) achieved complete resolution of the stricture after 2 procedures, with no recurrence observed after 2 years. Adverse events, mostly episodes of cholangitis,  were managed conservatively and endoscopically. Surgery was required in only 2 ( 13.3%)  patients due to technical failure of EUS-BD and high risk of severe cholangitis. In 1 ( 6.7%) additional case, cholangioscopy- guided biliary drainage was performed following technical failure of EUS-HGS. 

During the study period 1( 6.7%) patient died from unrelated comorbidities.

EUS-BD demonstrates favorable clinical efficacy and satisfactory technical success rates, suggesting that it is a viable option for the management of benign biliary diseases. Further development of dedicated devices and accessories is essential to enhance the safety and effectiveness of the procedure, particularly in benign indications. Long-term follow-up remains necessary to confirm the durability and overall outcomes of this technique.