ERCP With and Without EUS Guided HGS for Bilateral Biliary Decompression in Malignant Hilar Biliary Obstruction

Inclusion Criteria: * Presence of inoperable malignant hilar biliary obstruction on magnetic resonance cholangiography, computed tomography and/or direct cholangiography bismuth type III \& IV only. * Histologically confirmed malignant hilar biliary obstruction. * Elevated serum bilirubin at least 3 times above the upper limit of normal (1.2 mg/dL). * Absence of duodenal narrowing/obstruction. * Accept sharing in the study Exclusion Criteria: * Pregnancy. * Distal biliary obstruction as the main lesion. * Benign biliary stenosis. * Malignant hilar biliary obstruction bismuth type I and II. * Presence of duodenal obstruction. * Surgically altered anatomy or inability to access the major duodenal papilla. * Patients underwent previous intervention for biliary drainage. * Previously failed biliary cannulation at ERCP. * Large volume ascites. * Patients unfit for anesthesia. * Patients having uncorrectable coagulopathy or thrombocytopenia. * History of allergy to radiocontrast agents. * Refuse sharing in the study.