Both endoscopic ultrasonography （EUS）-guided choledochoduodenostomy （EUS-CDS） and EUSguidedhepaticogastrostomy （EUS-HGS） are relativelywell established as alternatives to percutaneoustranshepatic biliary drainage （PTBD）. Both EUSCDSand EUS-HGS have high technical and clinicalsuccess rates （more than 90%） in high-volume centers.Complications for both procedures remain high at10%-30%. Procedures performed by endoscopistswho have done fewer than 20 cases sometimes resultin severe or fatal complications. When learning EUSguidedbiliary drainage （EUS-BD）, we recommend amentor＇s supervision during at least the first 20 cases.For inoperable malignant lower biliary obstruction,a skillful endoscopist should perform EUS-BD beforeEUS-guided rendezvous technique （EUS-RV） andPTBD. We should be select EUS-BD for patientshaving altered anatomy from malignant tumors beforeballoon-enteroscope-assisted endoscopic retrogradecholangiopancreatography, EUS-RV, and PTBD. Ifboth EUS-CDS and EUS-HGS are available, we shouldselect EUS-CDS, according to published data. EUSBDwill potentially become a first-line biliary drainageprocedure in the near future.