Endoscopic ultrasound (EUS) is a cost-effective strategy for managing malignant distal biliary obstruction (MDBO) after failed ERCP, leading to better outcomes.

• EUS-guided biliary drainage (EUS-GB) cost $14,520, yielding 0.38 QALYs and an incremental net monetary benefit (NMB) of $37,768.
• EUS-guided choledochoduodenostomy (EUS-CBD) cost $17,694, providing 0.55 QALYs and an incremental NMB of $52,171.

EUS techniques show comparable outcomes to percutaneous options, offering advantages with potentially lower reintervention rates.

• PTBD costs $14,988 but provides fewer QALYs and is deemed less effective.