EUS guided bile duct drainage (EUS-BD) has been well established as an alternative to ERCP for bile duct drainage. This encompasses EUS-CDS, EUS-HGS EUS – Antegrade stenting and EUS-RV. With evolving expertise in EUS, emerging technological and stent advances, EUS-BD has become a viable first line alternative to ERCP  in expert hands. EUS guided biliary interventions have become much more acceptable in recent times with several randomised controlled trials proving the clinical efficacy, safety and success . What is unknown is the preferred route of drainage- Is trans-papillary drainage safer than trans-luminal route nor do we have data on the stent patency of the trans papillary route vs. trans-luminal route?  Trans papillary drainage is well into its 5^th decade with acceptable complication rates, with well-known short and long term results and negligible chances of bile leak. However there is a significant chance of pancreatitis and wire manipulation may be difficult. Trans luminal stenting is safe in expert hands with little chance of pancreatitis, shorter procedure times. The disadvantage being higher chance of bile leak (? exaggerated risk) and the prohibitory cost of the stents.

Hypothesis:

We hypothesize that the stent patency via trans-luminal route is better than that via trans-papillary route. 

Possible adverse event and its treatment

GI tract damage

                Gastric haemorrhage or perforation

                Surgical operation may be required.

Stent migration

                Abdominal pain and fever accompanied by elevation of inflammation.

                Surgical operation may be required.

 Conclusion:

To evaluate safety and long term outcomes of such EUS guided procedures