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Endoscopic ultrasound (EUS) has been suggested as the primary modality in lieu of endoscopic retrograde cholangiopancreatography (ERCP) for drainage of malignant distal biliary obstruction. However, the presence of a dilated bile duct (≥12 mm) is a prerequisite for the success of the EUS approach. In a retrospective study, we found that 44.9% of 439 ERCP patients over a 3-year period had insufficiently dilated bile duct that was not conducive for an EUS-based intervention. 29 patients were treated by a salvage EUS approach, with median bile duct diameter of 16 mm (IQR 13–18 mm). Although indispensable as a rescue technique, adopting current techniques and technology, this study does not suggest a universal primary role for EUS in this setting.