Skip to main page content
U.S. flag

An official website of the United States government

Dot gov

The .gov means it’s official.
Federal government websites often end in .gov or .mil. Before sharing sensitive information, make sure you’re on a federal government site.

Https

The site is secure.
The https:// ensures that you are connecting to the official website and that any information you provide is encrypted and transmitted securely.

Access keys NCBI Homepage MyNCBI Homepage Main Content Main Navigation
. 2025 Jul 13:18:17562848251356099.
doi: 10.1177/17562848251356099. eCollection 2025.

Clinical outcomes of endoscopic ultrasound-guided hepaticogastrostomy-based internal drainage for unresectable malignant hilar biliary obstruction: a comprehensive evaluation with malignant distal biliary obstruction

Daiki Yamashige  1 , Susumu Hijioka  2 , Yoshikuni Nagashio  1 , Shota Harai  1 , Yasuhiro Komori  1 , Aoi Kita  1 , Masaru Kuwada  1 , Soma Fukuda  1 , Shin Yagi  1 , Kohei Okamoto  1 , Daiki Agarie  1 , Shunsuke Sugawara  3 , Miyuki Sone  3 , Yutaka Saito  4 , Takuji Okusaka  1
Affiliations

Clinical outcomes of endoscopic ultrasound-guided hepaticogastrostomy-based internal drainage for unresectable malignant hilar biliary obstruction: a comprehensive evaluation with malignant distal biliary obstruction

Daiki Yamashige et al. Therap Adv Gastroenterol. .

Abstract

Background: Endoscopic retrograde cholangiopancreatography (ERCP) may not provide adequate drainage for patients with malignant hilar biliary obstruction (MHBO). Endoscopic ultrasound-guided hepaticogastrostomy (EUS-HGS) is a salvage method for malignant distal biliary obstruction (MDBO); however, its effectiveness for MHBO remains unclear.

Objectives: We aimed to evaluate the short- and long-term outcomes of EUS-HGS for MHBO.

Design: This was a single-center retrospective cohort study.

Methods: Unresectable patients who underwent initial EUS-HGS because of ERCP failure were recruited. Distal biliary stenosis or Bismuth types I and II-IV were defined as MDBO and MHBO, respectively. We defined EUS-HGS for MDBO as the control and analyzed the outcomes for MHBO.

Results: The MDBO group (n = 208) was treated using EUS-HGS alone. In the MHBO group (n = 63), EUS-HGS alone (unilateral drainage, n = 26), EUS-HGS with bridging (EUS-HGSB, bilateral drainage, n = 21), and ERCP + EUS-HGS (bilateral drainage, n = 16) were performed. In EUS-HGS (MDBO), EUS-HGS (MHBO), EUS-HGSB, and ERCP + EUS-HGS, the technical success rates were 98.6%, 96.3%, 95.5%, and 94.1%; clinical success rates were 88.5%, 76.9%, 85.7%, and 75.0%; adverse event rates were 19.7%, 15.4%, 9.5%, and 25.0%; and non-recurrent biliary obstruction (RBO) rates at 180 days were 45.5%, 19.8%, 61.9%, and 68.4%, respectively. In multivariate analysis of the MHBO group, EUS-HGSB tended to have a lower risk of RBO (adjusted hazard ratio (aHR), 0.39; p = 0.09), and ERCP + EUS-HGS showed a significantly lower risk (aHR, 0.25; p = 0.03) compared to EUS-HGS alone (unilateral drainage).

Conclusion: ERCP + EUS-HGS followed by EUS-HGSB, providing bilateral drainage, can offer preferred palliation for MHBO. These drainages may serve as potential salvage options in the management of MHBO.

Keywords: endoscopic ultrasound-guided hepaticogastrostomy; interventional endoscopic ultrasound; malignant hilar biliary obstruction.

PubMed Disclaimer

Figures

Study flowchart for MBO and MDBO treatment plans. Includes EUS-HGS, EUS-HDS, EUS-HGSB, and FVEUS-BD. Details technical failures and patient outcomes.
Figure 1.
Study flowchart. ERCP, endoscopic retrograde cholangiopancreatography; EUS-HDS, endoscopic ultrasound-guided hepaticoduodenostomy; EUS-HGS, endoscopic ultrasound-guided hepaticogastrostomy; EUS-HGSB, endoscopic ultrasound-guided hepaticogastrostomy with bridging; FVEUS-BD, forward-viewing endoscopic ultrasound-guided biliary drainage; MBO, malignant biliary obstruction; MDBO, malignant distal biliary obstruction; MHBO, malignant hilar biliary obstruction.
Figure presents the adverse event rates observed in various medical procedures. 1) Malignant distal (MDBO: 41/208) malignant hilar biliary obstruction (MHBO: 10/63) are endoscopic retrograde cholangiopancreatography (ERCP: 4/26) and endoscopic ultrasound-guided hepaticogastrostomy (EUS-HGS: 2/21) treatments. Additionally, rates are noted for unilateral (4/37) and bilateral drainage (6/37) when treating MDBO using EUS-HGSB.
Figure 2.
Adverse events. ERCP, endoscopic retrograde cholangiopancreatography; EUS-HGS, endoscopic ultrasound-guided hepaticogastrostomy; EUS-HGSB, endoscopic ultrasound-guided hepaticogastrostomy with bridging; MDBO, malignant distal biliary obstruction; MHBO, malignant hilar biliary obstruction.
In panel (a), the TRBO Kaplan-Meier curves compare MHBO (red line) versus MDBO (black line); panel (b) shows unilateral (red line) versus bilateral drainage (blue line); panel (c) illustrates EUS-HGS, EUS-HGSB, ERCP + EUS-HGS (blue line).“TRBO. Kaplan–Meier curves for TRBO according to (a) MHBO (red line) versus MDBO (black line), (b) unilateral (red line) versus bilateral drainage (blue line), and (c) drainage methods (EUS-HGS, red line; EUS-HGSB, green line; ERCP + EUS-HGS, blue line).
Figure 3.
TRBO. Kaplan–Meier curves for TRBO according to (a) MHBO (red line) versus MDBO (black line), (b) unilateral (red line) versus bilateral drainage (blue line), and (c) drainage methods (EUS-HGS, red line; EUS-HGSB, green line; ERCP + EUS-HGS, blue line). ERCP, endoscopic retrograde cholangiopancreatography; EUS-HGS, endoscopic ultrasound-guided hepaticogastrostomy; EUS-HGSB, endoscopic ultrasound-guided hepaticogastrostomy with bridging; MDBO, malignant distal biliary obstruction; MHBO, malignant hilar biliary obstruction; TRBO, time to recurrent biliary obstruction; vs., versus.
In the image, comparative Kaplan-Meier survival curves for the time to recurrent biliary obstruction (TRBO) in Bismuth type II and ⩾III cohorts are displayed using three different drainage methods. The horizontal axis measures time in days, and the vertical axis measures the renal free rate (%) with distinct color-coded lines for each method.
Figure 4.
TRBO by drainage techniques in Bismuth type II or ⩾III cohorts. Kaplan–Meier curve for the TRBO in three drainage methods (EUS-HGS, red line; EUS-HGSB, green line; ERCP + EUS-HGS, blue line) in the Bismuth type (a) II and (b) III or more. ERCP, endoscopic retrograde cholangiopancreatography; EUS-HGS, endoscopic ultrasound-guided hepaticogastrostomy; EUS-HGSB, endoscopic ultrasound-guided hepaticogastrostomy with bridging; TRBO, time to recurrent biliary obstruction.
See this image and copyright information in PMC

References

    1. Yasuda I, Mukai T, Moriwaki H. Unilateral versus bilateral endoscopic biliary stenting for malignant hilar biliary strictures. Dig Endosc 2013; 25(Suppl. 2): 81–85. - PubMed
    1. Xia MX, Cai XB, Pan YL, et al. Optimal stent placement strategy for malignant hilar biliary obstruction: a large multicenter parallel study. Gastrointest Endosc 2020; 91: 1117–1128. - PubMed
    1. Kitamura H, Hijioka S, Nagashio Y, et al. Use of endoscopic ultrasound-guided biliary drainage as a rescue of re-intervention after the placement of multiple metallic stents for malignant hilar biliary obstruction. J Hepatobiliary Pancreat Sci 2022; 29: 404–414. - PubMed
    1. Vienne A, Hobeika E, Gouya H, et al. Prediction of drainage effectiveness during endoscopic stenting of malignant hilar strictures: the role of liver volume assessment. Gastrointest Endosc 2010; 72: 728–735. - PubMed
    1. Speer AG, Cotton PB, Russell RC, et al. Randomised trial of endoscopic versus percutaneous stent insertion in malignant obstructive jaundice. Lancet 1987; 2: 57–62. - PubMed