Changing the Flow: How EUS-Guided Drainage is Reshaping the Management of Distal Malignant Biliary Obstruction

Endoscopic ultrasound-guided biliary drainage (EUS-BD) has evolved from a rescue therapy into a viable alternative to endoscopic retrograde cholangiopancreatography (ERCP) and percutaneous drainage for distal malignant biliary obstruction (dMBO). Among the available techniques, EUS-guided choledochoduodenostomy (EUS-CDS) has become the preferred approach, supported by expanding evidence, and wider adoption beyond expert centres. EUS-guided hepaticogastrostomy (EUS-HGS) currently retains a role in high-volume centres and in patients with combined biliary and duodenal obstruction, while other approaches, including EUS-guided gallbladder drainage, antegrade stenting, and rendezvous procedures, are applied selectively due to limited evidence or narrower applicability. This review summarizes the current role of EUS-BD in dMBO, with emphasis on EUS-CDS. Technical and clinical considerations, training requirements, and remaining challenges are discussed, and future perspectives are outlined, focusing on device innovation and patient-centred outcomes to guide safe and structured integration of EUS-BD into clinical practice.