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Nevertheless, these techniques are technically demanding, time-consuming, and frequently affected by limited reach and unstable positioning. More recently, interventional endoscopic ultrasound (EUS)-guided procedures have emerged as highly effective alternatives, significantly improving clinical outcomes in selected patients, particularly in those with long-limb Roux-en-Y reconstructions where conventional methods are less effective. Percutaneous transhepatic biliary drainage continues to represent a valuable salvage option when endoscopic approaches fail, though it is associated with a greater burden of reinterventions and adverse events. This minireview provides a comprehensive overview of the main endoscopic strategies for biliary drainage in altered anatomy, focusing on technical considerations, efficacy, and safety profiles of DAE-assisted ERCP, EUS-guided interventions, and motorized systems. 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