Endoscopic ultrasound-guided hepaticogastrostomy (EUS-HGS) and hepaticojejunostomy (EUS-HJS) have emerged as reliable techniques for internal biliary drainage when ERCP fails or is technically unfeasible. This study aimed to evaluate the feasibility, safety, and efficacy of EUS-HGS/HJS performed at a tertiary referral center over a seven-year period, across different anatomical settings and clinical indications. Secondary objectives included evaluating the impact of tract dilation on procedural outcomes and adverse events (AEs), and exploring long-term stent performance and recurrence rates.

We conducted a retrospective, single-center analysis including all consecutive patients who underwent EUS-HGS/HJS between October 2018 and August 2025. Demographic, anatomical, procedural, and outcome data were retrieved from institutional databases. Technical success was defined as successful creation of a patent biliary-enteric tract with stent placement; clinical success was defined as symptom resolution and/or ≥50% bilirubin reduction within 30 days without need for additional drainage. AEs were classified according to the AGREE criteria. Statistical analyses were performed using Fisher’s exact and Wilcoxon tests, with p<0.05 considered significant.

A total of 73 patients had an indication for EUS-guided biliary drainage. Biliary puncture proved to be feasible in 69 cases (63 HGS, 6 HJS); in four cases, all in surgically altered anatomy, biliary puncture was unsuccessful resulting in an overall procedural feasibility of 94.5%. The cohort included 42 males (60.9%) with a median age of 73.9 years [67.2–80.7]; 36 patients (52.2%) had surgically altered anatomy. Indications were malignant in 29 (42%) and benign in 40 (58%) cases. Technical success was achieved in 68/69 cases (98.6%), and clinical success occurred in 66 patients (95.7%), after a median of 2 endoscopic procedures [2-3]. Tract dilation was omitted in 20 cases (28.9%), performed mechanically in 29 (42%), by electrocautery in 16 (23.2%), or by balloon in 4 (5.8%). Dilation was more common in benign indications (82.5% vs. 55.2%, p=0.01). Plastic stents were placed in 50 patients (72.5%), and metal stents in 19 (27.5%), the latter more frequent in malignant disease (55.2% vs. 7.5%, p=0.001). Very early (inhospital) AEs occurred in 5 patients (7.2%) — 2 bleedings, 2 bile peritonitis (1 fatal), and 1 stent migration. One early (≤ 30 days) and two late (> 30 days) AEs were also recorded (overall AE rate 13.5%). Overall AEs  occurred more frequently after tract dilatation (14.3% VS 5%, p=0.21), among altered anatomies (87.5% vs. 47.5%, p=0.07) and after plastic stent placement (14% vs. 5.3%, p=0.22). HJSs were significantly more frequent among AE cases (37.5% vs. 4.9%, p=0.031). Median hospital stay was 6 days [2.5–14]. Twenty-eight stents (40.6%) were replaced, mainly (82.1% for a planned second approach), and 20 (28.9%) were removed, mostly (70%) for proved clinical success. To date, 21 original stents are still in place. During a median follow-up of 7 months [4.9–14.4], 11 recurrences (25%) occurred, with median time to recurrence of 8 months [3.5–16.5]. Recurrence tended to be lower among cases in which the stent was removed after resolution (18.2% vs. 50%, p=0.054). Only one death (1.4%) was procedure-related.

EUS-HGS/HJS demonstrated high feasibility, safety, and efficacy across various clinical scenarios, achieving 98.6% technical and 95.7% clinical success rates, with acceptable AEs and recurrence rates. Although retrospective and limited in size, these results confirm the robustness of EUS-guided intrahepatic drainage as a minimally invasive approach, both in malignant and benign settings. Notably, metal stenting without tract dilation did not compromise technical and clinical success, with reduced very early AEs rates, supporting the pivotal role of the dilatation-free technique in minimizing tissue trauma and subsequent complications, therefore optimizing outcomes. Future prospective studies are needed to confirm these findings, refine technical strategies, and clarify long-term outcomes and recurrence mechanisms. Within expert centers, EUS-HGS/HJS should be regarded as a cornerstone in the management of complex biliary drainage, providing durable, fully internal, and patient-centered palliation.