EUS-guided Choledochoduodenostomy vs ERCP as First Line in Malignant Distal Obstruction (CARPEDIEM Trial)

Who May Qualify: - Malignant distal biliary obstruction diagnosed in patient considered RESECTABLE or POTENTIALLY RESECTABLE/BORDERLINE with biliary drainage indication: i) impaired hepatic enzymes (including hyperbilirubinemia) x3 times upper the superior normal value. ii) Radiologic singns of extrahepatic bile duct obstruction with presence of retrograde dilatation, of at least 12-mm axial diameter. - Consensual malignancy by a bilio-pancreatic multidisciplinar committe (histological confirmation is not mandatory) - Patient capable of understanding and/or singning the willing to sign a consent form. - Patient who understands the type of study and will comply with all follow-up tests throughout its duration Who Should NOT Join This Trial: - Pregnancy or lactation. - Severe coagulation disorder: INR \> 1.5 non correctable with plasma administration and/or platelet count \< 50.000/mm3. - Distal malignant biliary strictures in patients considered directly resectable, non-surgical, unresectable, or palliative - Benign or uncertain etiology of biliary strictures or strictures located proximally or in close proximity to the hilum. - Patients with prior biliary stents or other biliary drainages (e.g., PTCD). - Altered intestinal anatomy due to prior surgery that prevents or hinders papillary access (e.g., gastric bypass, Billroth II, duodenal switch, Roux-en-Y). - Stenosis in the antral or duodenal region that prevents access to the duodenum and reaching the papilla. - Situations that do not allow for upper gastrointestinal endoscopy (e.g., esophageal stricture). - Patients with functional diversity, who lack the capacity to understand the nature and potential consequences of the study, except when a legal representative is available. - Patients incapable of maintaining follow-up appointments (lack of adherence). - Lack of willing to sign a consent form. Always talk to your doctor about whether this trial is right for you.