Biliary drainage in surgically altered anatomy remains a major challenge, as ERCP is often unsuccessful and percutaneous drainage carries significant morbidity. EUS-guided hepaticojejunostomy (EUS-HJ) has emerged as a minimally invasive alternative, though data remain limited. We report our experience with EUS-HJ in patients with surgically altered anatomy, after total or partial gastrectomy, and failed ERCP.

This retrospective series included patients who underwent EUS-HJ between March 2020 and September 2025 at a tertiary referral center. All procedures were performed using linear echoendoscopes under general anesthesia. Technical success was defined as successful stent deployment between the intrahepatic bile duct and jejunal limb. Clinical success was defined as ≥10% bilirubin reduction or resolution of cholangitis within three days. Adverse events were graded according to CTCAE v5.0.

A total of nine patients (mean age 65.8 years; 66.6% male) with surgically altered anatomy following total gastrectomy (n = 7), pancreaticoduodenectomy (n = 1), or subtotal gastrectomy (n=1) underwent EUS-guided hepaticojejunostomy after failed ERCP. All cases were malignant, mostly recurrent, or metastatic. Technical success was 100%, and clinical success was 66.7% (6/9). The median procedure time was 41.6 min, and self-expanding, partially covered metal stents were used in all cases. A delayed adverse event occurred in one patient (10%), who developed a localized infected biloma two months post-procedure (CTCAE Grade II), successfully managed with percutaneous drainage and complete recovery. The median post-procedural hospitalization was 5.4 days. During follow-up, long-term stent patency was preserved in most patients. Three patients (33%) required endoscopic reintervention for stent dysfunction at 3, 5, and 21 months after the index procedure; all were successfully managed with endoscopic tract revision, without the need for surgery. One patient developed multiple intrahepatic abscesses 17 months after the initial EUS-HJ, treated with percutaneous drainage, followed by tract revisions at 21 and 23 months, achieving sustained biliary drainage afterwards. In another case, cholangioscopy performed during tract revision enabled targeted biopsy and histologic confirmation of disease progression, highlighting the diagnostic potential of EUS-HJ. No episodes of stent migration, bleeding, or procedure-related mortality were observed, confirming the durable efficacy and safety of EUS-HJ in this challenging cohort.

EUS-HJ is a safe, effective, and physiologic alternative to percutaneous drainage for malignant biliary obstruction in surgically altered anatomy. With high technical success, low morbidity, and durable stent patency, it is evolving from a rescue procedure to a frontline therapeutic option. The maintained transluminal access further allows repeat cholangioscopy and histologic assessment, extending the clinical scope of interventional EUS beyond drainage alone.