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Endoscopic ultrasound-guided biliary drainage: Bilateral systems drainage via left duct approach. Endoscopic ultrasound (EUS)-guided biliary drainage is accepted as a less invasive, alternative treatment for patients in whom endoscopic retrograde cholangiopancreatography has failed. Most patients with malignant hilar obstruction undergo EUS-guided hepaticogastrostomy. The authors present the case of a 77-year-old man with advanced hilar cholangiocarcinoma who had undergone a roux-en-Y hepaticojejunostomy several months prior. He developed progressive jaundice and a low-grade fever that persisted for one week. The enteroscopic-assisted endoscopic retrograde cholangiopancreatography failed, thus the patient was scheduled for EUS-guided biliary drainage. In order to obtain adequate drainage, both intrahepatic systems were drained. This report describes the technique used for bilateral drainage via a transgastric approach. Currently, only a few different techniques for EUS-guided right system drainage have been reported in the literature. This case demonstrates that bilateral EUS-guided biliary drainage is feasible and effective in patients with hilar cholangiocarcinoma, and thus can be used as an alternative to percutaneous biliary drainage.