biliary obstruction is preferentially managed by endoscopic retrograde cholangiopancreatography ( ercp ) . however , after ercp failed , alternatives include percutaneous transhepatic drainage , surgery and more recently , endoscopic ultrasonography ( eus)-guided hepaticogastrostomy . the limitation of this technique is that the drainage is restricted to the left side . the aim of this study is to describe a new method of drainage of both hepatic ductal systems by hepaticogastrostomy in patients with hilar obstruction . nine prospectively patients were included , all with hilar obstruction ( metastasis of a pancreatic adenocarcinoma n = 4 , cholangiocarcinoma n = 1 , gallbladder cancer n = 2 and metastasis from a pancreatic neuroendocrine tumor n = 2 ) . a total of four patients had previously whipple surgery and the others five had duodenal involvement by the tumor . the topography of the stenosis varied from bismuth type 2 ( n = 7 ) and hilar infiltration in the others two . the first one consisted in a transgastric eus - guided puncture of the left - side bile duct with a 19 gauge needle , insertion of a 0.0035 inch guide wire which was positioned at the right biliary tree crossing the bile bifurcation . after a dilatation with 6 fr cystotome , a non - covered self - expandable metal stent was placed communicating the right and left biliary ducts . finally , a second stent , partially covered , was inserted at the left biliary duct , with the distal part inside the previously stent and the proximal edge positioned at the stomach . successful drainage was observed in seven patients , two of them presented abdominal pain during the first 72 h. one patient developed sepsis and death 7 days after the procedure and the other one had drainage failure . this pilot study shows the feasibility of this new technique to drain the right biliary duct in patients with hilar obstruction , with few major complications rates .