EUS-guided Choledochoduodenostomy for Primary Drainage of Malignant Distal Biliary Obstruction

Inclusion Criteria: * Radiographically (CT or EUS) distal malignant bile duct obstruction * Histology or cytology proven malignancy of the primary tumour or metastasis; onsite cytology evaluation after EUS guided fine-needle sampling that is highly suspected of a malignancy suffices * Indication for biliary drainage; in case of a resectable tumour this should be discussed during a clinical multidisciplinary meeting * Written informed consent Exclusion Criteria: * Age \< 18 year * Surgically altered anatomy after previous gastric, periampullary or duodenal resection * Cancer extending into the antrum or proximal duodenum * Extensive liver metastases * WHO performance score of 4 (in bed 100% of time) * Uncorrectable coagulopathy, defined by INR\>1.5 or platelets \< 50 x 10\^9/L\* * Clinically relevant gastric-outlet obstruction * Unable to complete sign informed consent * Inclusion is allowed after corrective treatment measures are taken, according to local protocol and treating physician.