RIVOS Feasibility (MBO)

Inclusion Criteria: * Patient with malignant biliary obstruction and who is indicated to receive EUS-guided hepaticogastrostomy for biliary drainage, as documented by dilated left hepatic duct and hyperbilirubinemia * Patient who failed ERCP (e.g., inability to access the obstructed biliary system via a transpapillary route) or for whom ERCP is not an option (e.g., due to altered anatomy, gastric outlet obstruction) * 18 years of age or older * Patient willing and able to provide written informed consent and comply with specified study visits Exclusion Criteria: * Patient whose general medical condition and degree of respiratory failure would not allow them to tolerate endoscopy and/or the manipulation required to perform the study procedure * Abnormal coagulopathy: * INR \>1.5 and not correctable * presence of bleeding disorder * platelets \<50,000 mm3 * Patient with contraindication to use of electrical devices * Female of childbearing potential with a positive pregnancy test prior to the procedure or who intends to become pregnant during the study * Patient from a vulnerable population * Current participation in another investigational drug or device study that could interfere with the endpoints of this study