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Endoscopic retrograde cholangiopancreatography (ERCP), with biliary brushings and deployment of a fully covered self-expanding metal stent, remains the standard of care to treat malignant distal biliary obstruction (MDBO) due to cancers of the pancreas, bile duct and ampulla.1–3 ERCP is, however, often unsuccessful in patients with duodenal stenosis, ampullary infiltration or high-grade biliary strictures. In spite of expertise, the rate of procedure-related pancreatitis in this cohort, reported as 7.2% in a recent meta-analysis,4 remains significant and can result in devastating delays to treatment. Even with the adoption of optimisation techniques, biliary brushings remain suboptimal with sensitivity rates in the region of 60%.5