EUS - Guided Choledocho-duodenostomy Versus ERCP With Covered Metallic Stents in Patients With Unresectable Malignant Distal Common Bile Duct Strictures

Inclusion Criteria: * Age ≥ 18 years old with informed consent * Histologically (preferred) or radiologically confirmed distal malignant bile duct tumors * Inoperability by staging, comorbidities or patient wishes * Distal tumors 2cm away from the portal hilum * Bilirubin \> 50umol/L at diagnosis Exclusion Criteria: * Multiple hepatic metastases with significant blockage of one or more liver segments (if no segment blockage, metastasis is not an exclusion criteria) * Presence of main portal vein thrombosis * Prior SEMS placement * Intraductal papillary mucinous carcinomas * Prior Billroth II or roux-en Y reconstruction * History of bleeding disorder or use of anticoagulation * Child's B/C cirrhosis * Pregnancy * Performance status ECOG ≥3 (confined to bed / chair \> 50% waking hours) * Presence of other malignancy * Life expectancy \< 3months