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Updated: Sep 5, 2026
Endoscopic Ultrasound-Guided Biliary Drainage: Endoscopic Ultrasound-Guided Hepaticogastrostomy in Malignant Biliary Obstruction
Published on: March 25, 2022
Biliary stricture management: European Society of Gastrointestinal Endoscopy (ESGE) Guideline
Arnaud Lemmers1, Andrea Tringali2, Sara Teles de Campos1
1HUB (Hôpital Universitaire de Bruxelles), Université Libre de Bruxelles (ULB), Gastroenterology, Hepatopancreatology and Digestive Oncology Department, Erasme Hospital, Belgium, Brussels.
Main Recommendations:
BENIGN BILIARY STRICTURES.
Main Recommendations:
1: ESGE suggests temporary insertion of multiple plastic stents (MPSs) to treat postcholecystectomy benign biliary strictures. A fully covered self-expandable metal stent (FCSEMS) can be considered in these patients when the stricture is located >2 cm distally from the main hepatic confluence or for patients who are noncompliant with repeated endoscopic retrograde cholangiopancreatographies (ERCPs).
Main Recommendations:
2: ESGE suggests treating anastomotic biliary strictures following liver transplantation with either MPSs or temporary insertion of an FCSEMS when located >2 cm distally from the main hepatic confluence.
Main Recommendations:
3: ESGE suggests treating biliary strictures secondary to chronic pancreatitis with temporary insertion (6-12 months) of an FCSEMS.
Main Recommendations:
4: ESGE suggests using balloon dilation alone for high grade biliary strictures secondary to primary sclerosing cholangitis. There is no added benefit of stenting following balloon dilation, and stenting may increase the risk of adverse events.
Main Recommendations:
5: ESGE suggests avoiding the insertion of uncovered SEMSs (USEMSs) for the drainage of extrahepatic biliary obstruction of unconfirmed etiology.
Main Recommendations:
DISTAL MALIGNANT BILIARY STRICTURES.
Main Recommendations:
6: ESGE recommends the endoscopic placement of a 10-mm diameter SEMS for preoperative biliary drainage (PBD) of extrahepatic malignant biliary obstruction (MBO).
Main Recommendations:
7: ESGE recommends the endoscopic placement of a 10-mm diameter SEMS for neoadjuvant biliary drainage of extrahepatic pathologically confirmed MBO.
Main Recommendations:
8: ESGE recommends endoscopic over surgical or percutaneous biliary drainage for primary decompression of inoperable, extrahepatic MBO.
Main Recommendations:
HILAR MALIGNANT BILIARY STRICTURES.
Main Recommendations:
9: ESGE recommends ERCP over percutaneous transhepatic biliary drainage (PTBD) for PBD in hilar malignant obstruction.
Main Recommendations:
10: ESGE suggests palliative drainage of malignant hilar strictures by means of ERCP for Bismuth types I-II. For Bismuth III-IV, ERCP or a combination of ERCP with endoscopic ultrasound-guided biliary drainage (EUS-BD) is preferable over primary PTBD. Complementary drainage using PTBD might be required in some cases.
Main Recommendations:
11: ESGE suggests obtaining drainage of more than 50%, and ideally 70% or more, of the viable nonatrophic liver volume for palliative drainage of proven malignant Bismuth II-IV strictures, using a multimodal approach (EUS-BD/PTBD if needed, as complementary methods to ERCP).
Main Recommendations:
12: ESGE suggests using either plastic stents or USEMSs for palliative drainage of proven malignant hilar obstruction. ESGE suggests a plastic stent when the optimal drainage strategy has not been defined. ESGE suggests using a USEMS in expert centers to reduce the need for revisional procedures based on the patient's expected survival and the likelihood of achieving complete biliary drainage.
Main Recommendations:
MALIGNANT BILIARY STRICTURE IN CASES OF FAILED OR UNFEASIBLE ERCP.
Main Recommendations:
13: ESGE recommends EUS-BD over PTBD in cases of malignant biliary stricture following failed or unfeasible ERCP.In patients with distal stricture, ESGE suggests using EUS-guided hepaticogastrostomy (EUS-HGS) where a duodenal stricture is present, and either EUS-HGS or EUS-guided choledochoduodenostomy where there is no duodenal stricture.ESGE suggests using PTBD when EUS-BD fails or is not feasible.
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