Palliative treatment of obstructive jaundice from advanced tumour of the distal bile duct is controversial. The aim of this study was to compare the clinical outcomes and costs between endoscopic stent insertion and surgery. Methods: The clinical data for 116 patients treated with either endoscopic plastic stenting (65 patients) or surgical bypass (51 patients) were reviewed and analysed. Results: No significant difference was found between the two groups in terms of the length of hospital stay, survival time, cost, effectiveness, and early complications. However, late complications were significantly more common in the stenting group (p = 0.007). Jaundice recurred in 15 stented patients at a median time of 3 months due to stent blockage, and one surgical patient had recurrent jaundice from anastomosis stricture. Late gastric outlet obstruction occurred in one of 36 surgical patients who did not undergo prophylactic gastroenterostomy and one of 65 stented patients developed this complication. Conclusion: Both techniques are equally effective in biliary drainage, but stenting has a higher rate of recurrent jaundice. We recommend surgery for patients with low surgical risks and endoscopic stent in those with a short life expectancy or those unfit for surgery.