EUS Biliary Drainage vs. ERCP

Inclusion Criteria: * Radiological diagnosis (with or without pathological diagnosis) of borderline resectable, locally advanced, or unresectable malignant distal biliary obstruction at least 2 cm distal to the hilum. Resectability based on tumor staging on axial imaging and surgeon evaluation. * Elevated liver tests with serum bilirubin at least 3 times above the upper limit of normal (18.9 umol/L) * Dilated extra-hepatic bile duct measuring at least 1.2 cm on axial imaging or US * Confirmation of bile duct accessibility and size of at least 1.2 cm on endoscopic ultrasound * Karnofsky index \> 30% * ASA score \<IV * Provision of informed consent Exclusion Criteria: * Hilar obstruction (biliary obstruction \< 2 cm from the hilum) * Uncorrectable coagulopathy and/or thrombocytopenia * Age \< 18 * Liver metastasis involving \> 30% of the liver volume * Liver cirrhosis with portal hypertension or ascites * Prior biliary sphincterotomy or stent placement * Surgically altered anatomy * Common bile duct measuring less than 1.2 cm will be excluded * Patient with clinical and radiological evidence of gastric outlet obstruction