Simple SummaryObstruction of the distal bile duct caused by various tumors arising in the region of the bile tract and pancreas has been traditionally treated by surgical or endoscopic therapy. However, in several cases, either surgical or endoscopic therapy via the conventional approach is not technically feasible. Recent advances in endoscopy techniques allow safe and effective relief of obstruction using a novel endoscopic device–the lumen apposing metal stent–which can be delivered using an endoscopic ultrasonography-guided approach. Our review analyzes the data on efficacy and safety of this new technique, compared to the already available therapeutic methods.AbstractMalignant biliary obstruction (DMBO) has been traditionally managed by endoscopic retrograde cholangiopancreatography (ERCP). In the case of ERC failure, percutaneous transhepatic biliary drainage (PT-BD) has been widely utilized as a salvage procedure. However, over the last decade, endoscopic ultrasound-guided biliary drainage (EUS-BD) has gained increasing popularity, especially after the advent of electrocautery-enhanced lumen apposing metal stent devices (EC-LAMSs) which enable a one-step procedure, granting prevention of biliary leakage and minimizing occurrence of adverse events (AEs). In parallel, increasing evidence suggests a possible role of EUS-BD in the management of DMBO as a primary palliative drainage modality. In the current paper, we aim to review all the available evidence on the role of EUS-BD performed with EC-LAMSs and discuss salient technical aspects of this type of procedure.