EUS-HGS has become an established technique either as a primary or salvage treatment modality for MBO. However, it remains a technically challenging procedure associated with a high risk of procedure related morbidity and mortality in a frail patient population. Current guideline recommendations recommend a gradual approach to performing EUS-guided therapy, suggesting that an endoscopist undertaking this new technique should perform a minimum of 25 procedures under expert supervision¹. However, real life data about learning curves and upskilling in EUS-guided therapy are lacking. Furthermore, there are significant limitations in access to expert supervision for such advanced techniques as EUS-HGS. We aimed to assess the clinical and technical outcomes of the initial series of  EUS-HGS performed by an experienced bilio-pancreatic endoscopist with limited access to expert supervision. 

We performed a retrospective analysis of a prospectively updated endoscopy database at a tertiary referral center where this technique was recently introduced. All consecutive patients who underwent EUS-HGS for malignant biliary obstruction either as a primary or as a rescue drainage procedure between June 2024 and November 2025 were included in the analysis. The primary outcome was technical success, defined as placement of a metal stent between the intrahepatic bile ducts and the stomach. Secondary outcomes included clinical success, defined as a decrease of > 25% in bilirubin levels at 14 days after the procedure and procedure-related adverse events (AEs). EUS-HGS was performed using an Olympus linear scope. Access to the intrahepatic bile ducts was obtained with a 19G FNA needle and a hydrophilic guidewire (0.025 or 0.035i) was used for deep access after obtaining a cholangiogram. Tract dilation was performed with a 6Fr cystotome. Finally, an 8cm FC or PC SEMS (Boston Wallflex) was deployed into the stomach from the left intrahepatic ducts to achieve adequate biliary drainage, which was confirmed through endoscopy and fluoroscopy.

Seventeen patients (64.7% male; median age 69 years) underwent EUS-HGS during the study period. Underlying malignancies included duodenal and pancreatic cancers (4 each), cholangiocarcinoma, gastric and colonic cancers (2 each) and other tumor types (3). Indications for EUS-HGS were duodenal obstruction in 9/17 (52.9%), failed ERCP in 5/17 (29.4%), and altered anatomy in 3/17 (17.6%) cases. Technical failure occurred in 5/17 (29.4%). The causes included an unfavourable puncture window in surgically altered anatomy (1 patient), loss of echoendoscope position after adequate puncture in the bile ducts with subsequent loss of wire access (2 patients), inability to advance the guidewire despite adequate injection of ducts (2 patients). 4 out of these 5 patients underwent alternative drainage: one via EUS-guided choledochoduodenostomy and three through external percutaneous biliary drainage. In one case, no further endoscopic drainage was feasible and the patient was referred for palliative end of life care. We recorded a total of 5 procedure-related adverse events (2 early – 1 self-limited intraprocedural bleeding and 1 bilioma treated by percutaneous drainage and 3 late AEs – stent dysfunction with cholangitis).

Our findings suggest that EUS-HGS can be safely attempted as an alternative drainage procedure by experienced bilio-pancreatic endoscopists proficient in both EUS and ERCP, even if no expert supervision is available. Further studies are required to better define the learning curves and milestones required for achieving efficient and safe independent practice of advanced EUS procedures, but autonomous upskilling seems to be feasible in certain scenarios.