Unusual complications following endoscopic ultrasound-guided hepaticogastrostomy: A call for refined techniques and dedicated devices.

We read with great interest the case report by Zhang et al describing unusual complications after endoscopic ultrasound-guided hepaticogastrostomy (EUS-HGS) in a patient with pancreatic cancer. The patient developed dark green urine, bile-colored pleural effusion, and ascites, suggesting bile leak and possible biliary-vascular fistula. We believe the complication profile is more consistent with transdiaphragmatic bile leakage during segment 2 puncture, as microperforation near the diaphragm can explain bilothorax. Device selection for fistula dilation and stent type may also have contributed. High pleural fluid-to-serum bilirubin ratios further support the diagnosis of bile leak, with urinary discoloration likely reflecting systemic absorption. This rare case highlights the need for refined techniques, careful puncture site selection, and dedicated devices to enhance safety in EUS-HGS.