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Background Endoscopic ultrasound–guided biliary drainage is an established rescue approach for failed Endoscopic Retrograde CholangioPancreatography (ERCP) in malignant distal biliary obstruction (MDBO). Data on EUS-guided antegrade stenting (EUS-AGS) and hepaticogastrostomy with antegrade stenting (EUS-HGAS) remain limited. A systematic review and meta-analysis were conducted to compare efficacy and safety of these two techniques.Methods PubMed, Embase, and the Cochrane Library were searched from inception to January 2026 according to PRISMA 2020 guidelines. Studies reporting EUS-AGS or EUS-HGAS outcomes in ≥5 patients were included. The primary outcome was clinical success; secondary outcomes included technical success, adverse events, reintervention rates, stent dysfunction, patency, and mortality. A random-effects meta-analysis was performed.Results Fourteen studies (9 EUS-AGS, 5 EUS-HGAS) comprising 545 patients were included. Clinical success was 90.1% (95% CI, 85.5–93.4%; I 2=4.5%) versus 95.7% (95% CI, 91.2–98.1%; I2=0.0%) for EUS-HGAS (p=0.044). Technical success was 89.0% (95% CI, 83.9–92.7%; I2=0%) for EUS-AGS and 93.8% (95% CI, 90.2–96.3%; I2=0%) for EUS-HGAS (p=0.107). Overall, pooled adverse events were 13.2% each (p=0.998). Breakdowns were cholangitis 3.1% vs. 1.3% (p=0.185), pancreatitis 4.7% vs. 7.5% (p=0.151), bleeding 0.3% vs. 2.6% (p=0.012), and bile leak 4.0% vs. 0.9% (p=0.023). Stent dysfunction occurred in 18.6% vs. 15.4% (p=0.346), and re-intervention rates were 14.2% vs 11.5% (p=0.387). Median stent patency was 145 versus 226 days (p=0.421), and 30-day mortality was 1.3% vs.0.9% (p=0.671).Conclusion EUS-AGS and EUS-HGAS are equally effective and have comparable safety following failed ERCP in MDBO. EUS-HGAS shows statistically significant superior clinical success and a trend towards longer stent patency.