EUS-guided hepaticogastrostomy (EUS-HGS) is among the preferred rescue techniques for biliary drainage when ERCP fails or when the papilla is inaccessible due to altered anatomy or neoplastic invasion. Although the majority of published experience originates from Eastern centers, and despite its demonstrated technical feasibility and clinical effectiveness, safety concerns have limited widespread adoption of EUS-HGS in Western practice, even among expert institutions. Recently, however, growing experience with EUS-guided interventions and accumulating evidence supporting the superiority of this technically demanding approach in select clinical scenarios have highlighted the need for robust data from Western centers.

We conducted a retrospective study of all consecutive patients who underwent EUS-HGS at six Italian institutions from 2017 to October 2025. Technical outcomes were technical success rate and procedure time. Clinical outcomes included the rates of clinical success—defined as a ≥50% bilirubin reduction within two weeks for malignant disease or resolution of the underlying condition for benign indications—and adverse events, which were defined and graded according to the ASGE lexicon.

A total of 183 patients underwent attempted EUS-HGS: 142 for malignant and 41 for benign conditions. Most procedures (n=98, 53.6%) were performed from January 2024 onward. In 116 patients, the papilla was inaccessible due to duodenal or pyloric strictures (n=61) or altered anatomy (n=55). Adequate transmural stent placement was achieved in 174 cases (95.1%), with a mean procedure time of 50.2 ± 26.3 minutes. Following bile duct puncture, a cystotome was the preferred device for tract creation. Dedicated stents were used in 110 cases. Among the 174 technically successful procedures, clinical success was achieved in 146 patients (83.9%). Twenty-three patients (12.5%) experienced adverse events, ranging from moderate (n=16) to severe (n=7) according to the modified ASGE lexicon. Cholangitis was the most common complication. One patient required surgery for biliary peritonitis, and two procedure-related deaths occurred due to post-procedural cholangitis leading to septic shock.

EUS-HGS is increasingly adopted in tertiary centers and demonstrates high technical and clinical success rates, particularly considering that these procedures are performed in patients with

limited—and often clinically ineffective—alternative options. Nevertheless, the incidence and severity of adverse events underscore the need for careful pre-procedural patient counseling and emphasize that EUS-HGS should be performed exclusively by experienced endoscopists in centers equipped to manage complications within a multidisciplinary framework.