The management of complex hilar biliary strictures is therefore evolving from an ERCP-centered strategy toward an individualized, anatomy-based approach integrating ERCP, EUS-BD, and, when necessary, percutaneous drainage. The goal is not simply to place more stents, but to achieve effective drainage of the appropriate functional liver segments with the fewest interventions and lowest risk. Combined ERCP and EUS techniques represent an important step toward comprehensive endoscopic management of complex hilar obstruction.