Background: Malignant obstructive jaundice is a frequent complication of pancreaticoduodenal and hilar hepatic tumors. It significantly impairs quality of life, reduces survival, and often prevents continuation of oncological treatment. The standard method of treatment is endoscopic retrograde cholangiopancreatography (ERCP) with biliary stenting; however, some patients require alternative biliary decompression.

Aim: The study aimed to compare the effectiveness, complications, and overall survival of endoscopic ultrasound-guided (EUS) transluminal procedures with those of percutaneous transhepatic biliary drainage (PTBD).

Materials: A retrospective analysis was performed on 104 patients with malignant biliary obstruction in whom ERCP with biliary stenting had failed. Thirty-nine patients underwent EUS-guided procedures, and sixty-five patients underwent PTBD. Clinical success was defined as a reduction in serum bilirubin concentration. Demographic data, complications (Clavien–Dindo classification), length of hospitalization, and survival were analyzed using logistic and linear regression.

Results: Clinical success was achieved in 91 out of 104 patients (87.5%), and the efficacy of both techniques was comparable (EUS: 91.9%, PTBD: 87.7%, p = 0.742). Complications occurred more frequently in the EUS group (41% vs. 12.3%, p = 0.001), including death in three individuals. PTBD-related complications were limited to Clavien-Dindo II. The mean hospital stay did not differ significantly (5.4 vs. 4.9 days, p = 0.258). Median survival was 66 days in the EUS group and 93.7 days in the PTBD group, with a higher 30-day mortality rate in the PTBD group (33.9% in the PTBD group, 10.3% in the EUS-guided group).

Conclusion: Both methods, PTBD and EUS-guided drainage, are equally effective alternatives after failed ERCP. EUS-guided drainage offers a slightly higher success rate but carries a greater risk of severe complications. PTBD was associated with higher short-term mortality but had a better safety profile.