Endoscopic management of malignant hilar biliary obstruction: The evolving role of endoscopic ultrasound-guided biliary drainage

Table 1 Endoscopic ultrasound-guided biliary drainage techniques in malignant hilar biliary obstruction

Technique	Description of technique	Technical efficacy	Clinical efficacy	Adverse events	Key considerations
EUS-HGS	EUS-guided creation of a fistula between the left intrahepatic bile duct and the stomach with plastic or metal stent placement	97%	88%	10%-35%	Most established technique; drains only left system; optimal for communicating ducts (Bismuth I)
EUS-HDS	EUS-guided drainage of the right intrahepatic bile duct into the duodenum	97%	80%	20%	Technically demanding; useful for right system drainage and in combination with HGS. Small series
Bridging technique	EUS-guided transgastric placement of a stent across the hilar stricture connecting left and right ducts, followed by HGS	90%	83%	33%	Allows complete liver drainage using EUS alone; high technical complexity
EUS-HDGS	Simultaneous EUS-guided hepaticogastrostomy and hepaticoduodenostomy for bilateral drainage	87%	75%	25%	Promising fully EUS-based bilateral approach; requires advanced expertise. Small series
CERES	ERCP drainage of one hepatic system combined with EUS-guided drainage of the contralateral system	84%	79%	26%	Hybrid approach; lower reintervention rate than PTBD

EUS: Endoscopic ultrasound; HGS: Hepaticogastrostomy; HDS: Hepaticoduodenostomy; EUS-HDGS: Endoscopic ultrasound-guided hepatico-duodeno-gastrostomy; CERES: Combined endoscopic retrograde cholangiopancreatography and endoscopic ultrasound-biliary drainage; ERCP: Endoscopic retrograde cholangiopancreatography; PTBD: Percutaneous transhepatic biliary drainage.