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Introduction and Aims Biliary decompression for suspected malignant and operable perihilar obstruction can be achieved endoscopically with endoscopic retrograde cholangiopancreatography (ERCP) or via percutaneous transhepatic biliary drainage (PTBD). PTBD is often preferred as it more reliably drains ≥ two-thirds of functional liver volume and is associated with higher technical success rates in complex hilar strictures. In contrast, ERCP carries risks of inadequate drainage and traditionally demonstrates variable diagnostic yield with brush cytology alone.Single-operator cholangioscopy (SOC), however, enables direct visualisation, targeted tissue acquisition, and selective sectoral ductal drainage, potentially improving both diagnostic accuracy and drainage outcomes. We hypothesized that ERCP-SOC is non-inferior to PTBD for primary biliary decompression in operable perihilar malignancy and may offer a more streamlined ambulatory/day-case pathway compared with inpatient PTBD.Methods We conducted a retrospective cohort study of all ERCP-SOC and PTBD procedures performed for potentially operable perihilar malignancies on cross-sectional imaging, over a 12-month period at a tertiary HPB centre. The primary outcome was effective biliary decompression, defined as the percentage reduction in serum bilirubin within 5–7 days post-procedure.Secondary outcomes included diagnostic yield of endobiliary biopsies obtained via SOC or PTBD, need for additional interventions to achieve adequate drainage or diagnosis, and procedure-related clinical outcomes.Descriptive statistics were summarized using means for normally distributed variables and medians for skewed distributions. Propensity score matching was performed to balance baseline characteristics, followed by multivariable logistic regression to evaluate the independent association between drainage modality (ERCP-SOC vs PTBD) and successful biliary decompression and diagnostic acquisition.Results Of 1,625 ERCP procedures performed during the study period, 46 (2.8%) were undertaken for primary hilar biliary decompression in potentially operable malignant obstruction using ERCP-SOC. After excluding benign strictures, 27 patients with proven malignancy were included (mean age 72 years [range 41–86], 56% female). These were compared with 20 patients who underwent PTBD as the initial drainage modality (mean age 67 years [48–90], 25% female), representing 5.2% of 384 PTBD procedures performed during the same interval.In the ERCP-SOC group, 15 patients (56%) were treated as day-case procedures, while 12 required admission for jaundice (mean inpatient stay 21 days [2–62]). Effective biliary decompression was achieved in 22 patients (82%), with a median 69% reduction in bilirubin within 7 days and progressive normalisation thereafter. ERCP-SOC achieved a histological diagnosis in 63% of cases; an additional 7 patients (26%) required EUS-guided sampling. Post-procedure complications were minimal, with pancreatitis occurring in 1 patient (3.7%).In the PTBD group, 16 patients (80%) achieved effective biliary decompression following the index procedure, and 14 (70%) had positive endobiliary biopsy results. Mean hospital stay was 15 days (2–61). On propensity-matched logistic regression, no significant differences were observed between ERCP-SOC and PTBD in terms of patient age (OR 1.10, 95% CI 1.01–1.19; p=0.08) or likelihood of obtaining diagnostic tissue (OR 0.90, 95% CI 0.09–9.39; p=0.93). PTBD was independently associated with longer inpatient stay (OR 1.14, 95% CI 1.04–1.26; p=0.007).Conclusion ERCP-SOC appears non-inferior to PTBD as a primary modality for biliary decompression in potentially operable malignant hilar obstruction, achieving comparable rates of effective drainage and tissue diagnosis. Importantly, ERCP-SOC can be performed as a day-case procedure in over half of patients, permits targeted multi-sectoral stenting, and avoids the need for external catheters, supporting its role as a viable and less resource-intensive alternative to PTBD in selected patients.