Extra-anatomical biliary drainage is an effective alternative to relieve biliary obstruction in cases of failed ERCP. Two endoscopic access routes are currently used : hepatogastric drainage and choledochoduodenal drainage. The aim of our study is to evaluate the indications, techniques used, and outcomes of extra-anatomical drainage in our center.

This is a retrospective, descriptive, monocentric study conducted in the Medicine B Department of the Ibn Sina University Hospital in Rabat, between January 2019 and November 2025. All patients presenting with malignant biliary obstruction and who underwent extra-anatomical biliary drainage after failed ERCP were included.

The collected data included demographic, clinical, biological, radiological, and endoscopic parameters. Two techniques were used :

• Choledochoduodenal drainage (placement of a stent between the common bile duct and the duodenal bulb).

• Hepatogastric drainage (placement of a stent between a left intrahepatic bile duct and the stomach).

Post-drainage follow-up included clinical and biological monitoring at day 0, day 2, day 7, and one month.

10 patients were included. The median age was 53.6 ± 17 years, mostly between 45 and 75 years. The sex ratio M/F = 1. Half of the patients (5 cases, 50%) had no comorbidities. Type 2 diabetes was present in 3 patients (30%), arterial hypertension in 2 patients (20%), and heart disease in 1 patient (10%).

The most frequent etiologies were pancreatic cancer in 7 patients (70%), followed by hilar cholangiocarcinoma in 2 cases (10%), and ampullary carcinoma in 1 case (10%). The main cause of ERCP failure was tumoral infiltration of the papilla, found in more than half of the cases (n = 6, 60%). Other causes included anatomical abnormalities of the papilla (n = 2, 20%), duodenal stenosis (n = 1, 10%), and failure of intrahepatic bile duct cannulation (n = 1, 10%).

The main indication for drainage was cholangitis, found in half of the patients, followed by drainage for chemotherapy preparation (2 patients, 20%). The remaining patients (n = 3, 30%) presented with cholestatic jaundice with severe pruritus or general deterioration.

Two techniques were performed:

• Choledochoduodenal drainage in 6 patients (60%), using a fully covered metal stent.

• Hepatogastric drainage in 4 patients (40%), using a “dumbbell-type” stent in 2 cases (20%) and a partially covered metal stent in the remaining 2 cases (20%).

Initial evaluations showed a median total bilirubin level of 274 mg/L (predominantly conjugated), an average CRP of 52 mg/L, and an average prothrombin rate of 57%.

Regarding technical performance, hepatogastric drainage achieved 100% technical and clinical success. Choledochoduodenal drainage also had 100% technical success, but one case of biliary leak causing peritonitis reduced its clinical success to 83%.

Biological outcomes showed a clear and progressive improvement after the procedure :

• Bilirubin: 274 mg/L before drainage → 180 mg/L at 48 h → 121 mg/L at day 7 → 50.5 mg/L at one month.

• CRP: 52 mg/L before drainage → 27 mg/L at day 7 → 11 mg/L at one month.

• Prothrombin rate: 57% before drainage → 62% at 48 h → 69% at day 7 → 88% at one month.

Regarding follow-up, 4 patients (40%) died in a context of terminal tumor progression, with a mean post-procedure survival of 6 months. Four patients (40%) are still being followed in oncology palliative care, and 2 patients (20%) were lost to follow-up after discharge.

Extra-anatomical biliary drainage is an effective alternative after failed ERCP, particularly in cases of altered anatomy or tumoral involvement. Hepatogastric and choledochoduodenal techniques showed excellent technical success rates and significant biological improvement. The choice of method depends on patient characteristics, the etiology of the obstruction, and the expertise of the center.