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

In this editorial, we comment on the article by Pietrzak et al published in the recent issue of the World Journal of Gastrointestinal Endoscopy . Malignant hilar biliary obstruction remains a formidable challenge for endoscopists. While endoscopic retrograde cholangiopancreatography continues to represent the cornerstone of biliary drainage, malignant hilar biliary obstruction often requires a multimodal approach that incorporates percutaneous-guided techniques, either as complementary or salvage strategies. Emerging evidence also supports the integration of endoscopic ultrasound-guided biliary drainage as a planned adjunct in selected cases to optimize biliary drainage, reduce the need for re-intervention, and improve clinical outcomes. In this editorial, we review current guideline recommendations and key technical considerations, emphasizing the role of endoscopic ultrasound-guided biliary drainage in expert hands for patients with complex hilar anatomy or incomplete drainage after endoscopic retrograde cholangiopancreatography.