Bridging the Gap between Literature and Practice: Nationwide Outcomes of Endoscopic Ultrasound-guided Hepatico-gastrostomy.

Background Endoscopic ultrasound-guided hepatico-gastrostomy (EUS-HGS) enables internal biliary drainage via the stomach in patients with altered anatomy, inadequate left hepatic duct drainage, or duodenal obstruction. The technically demanding procedure is only performed at expert centers in the Netherlands. Most available evidence originates from selected cohorts, overestimating real-world outcomes. We evaluated outcomes of EUS-HGS in a nationwide cohort. Methods This nationwide retrospective cohort study included all patients in the Netherlands who underwent EUS-HGS attempts between 2009 and 2025, outside of prospective studies. The primary outcome was technical success. Secondary outcomes included clinical success, complications, time to recurrent biliary obstruction (RBO), and overall survival. Results A total of 107 procedures in 105 patients were analyzed (median age: 68 years [IQR: 59-76]; 55%: male). Technical success was achieved in 77% (81/105). Failures were due to absence of a safe puncture tract ( n = 7), unsuccessful bile duct puncture ( n = 3), inability to achieve deep guidewire insertion ( n = 3), failed fistula formation ( n = 3), or unsuccessful or nonattempted stent placement ( n = 7). Clinical success occurred in 78% of technically successful cases (63/81), corresponding to 60% in intention-to-treat analysis (63/105). Procedural complications occurred in 16/107 (15%), and postprocedural complications in 17/107 (16%). One procedure-related death occurred. RBO occurred in 28% (23/81) during a median follow-up of 61 days [IQR: 23-131]. Median overall survival was 91 days [IQR: 66-155]. Conclusion In this nationwide real-world cohort, technical and clinical success rates of EUS-HGS were modest compared with selected expert series, underscoring the need for prospective studies to improve patient selection, stent strategies, and procedural safety.