Abstract
Recently, bilateral biliary drainage has been considered as the recommended approach for malignant hilar biliary obstruction (MHBO).1 Patients with surgically altered anatomy (SAA) usually represent a challenge for enteroscopy-assisted ERCP (E-ERCP), with its demanding procedure and dedicated technique. This challenge is greatly increased if SAA is combined with MHBO, especially with the limited availability of suitable metal stents for E-ERCP. EUS-guided hepaticogastrostomy (EUS-HGS) has become a feasible alternative approach for this group of patients, allowing bilateral drainage through the bridging technique using an uncovered self-expandable metal stent (SEMS) across the hilar malignant stricture joining the right and left hepatic ducts (RHDs and LHDs, respectively).
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