Malignant biliary tract obstruction is a common clinical entity. Patients with tumors causing biliary tract obstruction are often asymptomatic until disease is significantly advanced. Symptoms of obstructive jaundice can significantly impair quality-of-life unless intervention to decompress the biliary tract, either curative or palliative, is performed. This article reviews the evaluation and management of patients with malignant biliary tract obstruction, including the available imaging and treatment modalities (endoscopic, percutaneous, and surgical approach) for relieving malignant biliary tract obstruction.
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Malignant biliary tract obstruction (MBTO) is a frequent cause of jaundice. Primary pancreatobiliary tract cancers and other local cancers that can cause compression of the biliary tract (e.g., liver, gallbladder) account for approximately 80,000 new cancer cases and an estimated 58,000 deaths in the United States. 1 Despite advances in diagnosis and treatment, the 5-year survival rate of the most commonly encountered malignancies, pancreatic cancer and cholangiocarcinoma, remains dismal at less than 5%. 2 MBTO can also arise from gallbladder, duodenal, and ampullary cancers; metastatic cancers; or malignant lymphadenopathy. 3 Symptoms of obstructive jaundice (e.g., pruritus, dark urine, light stools) can adversely impact quality of life and promote hepatic dysfunction. In addition, many oncology protocols and chemotherapy regimens for treating pancreaticobiliary malignancies cannot be initiated in jaundiced patients.
This article reviews the common causes of MBTO and its evaluation and treatment, including endoscopic, radiologic, and surgical approaches.
Jaundice usually manifests as the presenting symptom in up to 90% of pancreatic cancer cases with lesions in the head of the gland. 4 This can be manifested by scleral icterus or yellowness of the skin. Pale stools, dark urine, pruritus, right upper quadrant discomfort, and nausea are usual accompaniments. Other nonspecific symptoms suggesting malignancy include weight loss, anorexia, and night sweats.
Symptoms indicative of pancreatic carcinoma include dull epigastric pain that radiates to the back (from pancreatic duct obstruction), palpable (Courvoisier's) gallbladder, generalized dyspepsia (from gastric outlet obstruction and malabsorption from lack of pancreatic enzymes), early satiety, new-onset diabetes, or acute pancreatitis. 5 Symptoms indicative of cholangiocarcinoma include abdominal pain (49%, mostly right upper quadrant), pruritis (66%), weight loss (56%), and fatigue (46%). 6 Perihilar and distal bile duct lesions tend to present with jaundice, and intrahepatic lesions tend to present with pain. 7
Laboratory workup is consistent with a cholestatic picture. Serum bilirubin (mainly direct) is universally elevated and accompanied by elevations in alkaline phosphatase and gamma-glutamyl transpeptidase. Tumor markers are usually nonspecific. CA 19-9 has been the most frequently studied biomarker in screening for pancreatic cancer and has a sensitivity of 79% and specificity of 82%. 8 However, CA 19-9 is frequently elevated in other gastrointestinal cancers (cholangiocarcinoma, gastric cancer, colorectal cancer, esophageal cancer, and hepatocellular cancer 9 ), and benign processes (e.g., acute cholangitis or pancreatitis) can also lead to elevated levels. 10 Biliary obstruction from many causes can raise CA 19-9 levels, limiting the specificity of this test.
Multiple imaging modalities have been used to diagnose and evaluate the extent of MBTO. Purely diagnostic modalities include transabdominal ultrasound, helical CT, and MRI/magnetic resonance cholangiopancreatography (MRCP). Additional modalities that are both diagnostic and allow for therapeutic interventions include endoscopic ultrasound (EUS), endoscopic retrograde cholangiopancreatography (ERCP), and percutaneous transhepatic cholangiopancreatography (PTC).
Transabdominal ultrasound is the preferred initial test at many institutions because of its widespread availability, low cost, and noninvasive nature. 11 Biliary tract obstruction is indicated by the presence of dilated biliary ducts; however, the presence of normal bile ducts does not completely exclude obstruction, because the obstruction may be recent, thus not allowing for dilatation of the duct. Abdominal ultrasound is reported to be fairly accurate (78%–98%) for detecting extrahepatic obstruction and can distinguish this from liver parenchymal disease. 11 Significant limitations include the inability to accurately determine level and cause of obstruction. The overall accuracy in distinguishing malignant from benign causes of obstruction is 47% to 90%. 11 Abdominal ultrasound is more sensitive for pancreaticobiliary cancer (67%–81%) than for ampullary cancer (5%–15%). 11–13 Ampullary tumors can be difficult to see on ultrasound because of small tumor size, small area of focus, and the reliance on indirect evidence (dilated biliary ducts) to detect biliary tract obstruction. 13 Other significant limitations of ultrasound imaging include operator variability and difficulty visualizing retroperitoneal structures (e.g., pancreas) secondary to overlying bowel gas or obesity. 14
Conventional abdominal CT scans are highly accurate in determining presence and level of biliary tract obstruction. 11 CT is 93% accurate in delineating between benign and malignant processes. 15 For detecting pancreatic cancer, CT is more accurate than conventional ultrasound or MRI. 16 CT is highly accurate in detecting cholangiocarcinoma; however, this modality is less accurate in staging (60%–86%) because of limitations in detecting small lymph nodes and hepatic metastasis and evaluating the intraductal extent of tumor. 17 For detecting ampullary cancer, CT is poor (detection rates of 22%–29%). 11
The advantages of CT over other modalities include low level of invasiveness and operator independence; disadvantages include radiation exposure and use of contrast dye. 11 Major adverse reactions have been documented in 1% of cases, and minor reactions in 24%. 18 CT is limited in patients with high-grade obstruction (serum bilirubin > 35 mmol/L) because of poor uptake of contrast dye in the liver. 19
MRCP is an MRI modality that uses a T2-weighted protocol and rapid imaging acquisition to enhance the signal of fluids in the biliary system. 11 MRCP has excellent sensitivity and specificity for demonstrating the level and presence of biliary obstruction and is sensitive (88%) in distinguishing between benign and malignant processes. 20 In the presence of ductal dilatation, MRCP is comparable to ERCP for detecting pancreatic cancer. 21 In the absence of ductal dilation, pancreatic cancer is difficult to diagnose using MRCP. 11
For detecting cholangiocarcinoma, MRCP is highly accurate and can often identify the location, extent, and severity of the obstruction. 15 For detecting ampullary tumors, MRCP is poor because of difficulty in differentiating between tumors and benign causes of ampullary obstruction (e.g., small stones, ampullary stenosis). 22 MRCP is also sensitive in assessing the extent of periportal lymphadenopathy that results from MBTO. 22 When magnetic resonance angiography (MRA) is used in conjunction with MRCP, complete staging information of tumor size, bile duct involvement, and vascular invasion can be obtained, which can direct the next step of therapy, whether it is biliary drainage or surgical intervention. 21,23
The advantages of MRCP include low-level of invasiveness, the avoidance of intravenous contrast (except in MRA), and no radiation exposure. Disadvantages include high cost, lower spatial resolution compared with direct imaging modalities (e.g., ERCP), inability to evaluate patients with pacemakers or ferromagnetic implants, and poor patient tolerance because of claustrophobia. 24
EUS is highly sensitive (87%) and specific (88%) in determining the cause of extrahepatic obstruction. 25 EUS can detect pancreatic cancer because of its ability to image the entire pancreas, especially areas difficult to image on other modalities (the uncinate process and most distal tail near the splenic hilum). EUS also can detect and evaluate focal lesions with a minimum size of 2 to 3 mm. 26 For detecting pancreatic cancer, especially small lesions, EUS is more sensitive than CT, ultrasound, MRI, or ERCP. 11,27 EUS is routinely used in preoperative staging because of its accurate T and N staging of pancreatic tumors and high sensitivity for detecting tumor invasion of the local venous system (e.g., portal vein, splenic vein). However, CT and angiography are superior to EUS in detecting invasion of the superior mesenteric artery. 28
For detecting ampullary cancers, EUS and ERCP are equivalent to each other and superior to CT and ultrasound. 11 EUS is also the most accurate modality for performing locoregional tumor staging of ampullary tumors. 11,29
EUS is helpful in detecting cholangiocarcinoma, but is limited because of technical difficulty imaging the proximal extrahepatic biliary tree. 27 EUS can identify and aspirate portal adenopathy seen in patients with cholangiocarcinoma.
Advantages of EUS include that it is less invasive than other direct imaging modalities (ERCP and PTC), it has increased sensitivity for pancreatic cancer, and it does not require exposure to radiation or contrast material. The disadvantages include high operator dependency, equipment cost, unit availability, and the need for conscious sedation. 30 In addition, visualization is limited to an 8- to 10-cm depth from the ultrasound probe, and imaging can be obscured by pneumobilia, surgical clips, calcifying pancreatitis, or a large duodenal diverticulum. 31
Beyond imaging, EUS interventions are crucial in patients with MBTO. 32 Endoscopic ultrasound-fine-needle aspiration (EUS-FNA) is more accurate than noninvasive biopsy techniques (e.g., ultrasound, CT) and less invasive than surgical biopsy. EUS-FNA is highly sensitive for detecting pancreatic adenocarcinomas (94.3%) and metastatic carcinoma in lymph nodes (95%). 33 Overall, EUS-FNA is a safe procedure with few complications. EUS-guided celiac plexus neurolysis is a palliative procedure that involves direct injection of analgesics (e.g., alcohol, triamcinolone with bupivacaine) into the celiac plexus and has been found to be superior to narcotics in recent clinical trials. 34
A limited number of case reports and small series have reported successful EUS-guided biliary drainage and stent placement in lieu of surgery in ERCP-refractory cases. However, these procedures are not considered standard of care yet, and no dedicated endoscopic accessories for EUS-guided biliary drainage are commercially available. 35,36
ERCP has historically been considered the gold standard of imaging for the biliary tree and allows for the attainment of definitive cholangiograms and pancreatograms. ERCP is also the standard platform for therapeutic interventions in the management of MBTO. However, ERCP is less sensitive than EUS for detecting pancreatic cancer. 27
ERCP is also considered the gold standard for detecting cholangiocarcinoma because of its direct visualization and sampling of the bile ducts. 27 It is highly sensitive and equivalent to EUS in detecting ampullary tumors. 11 ERCP is the most common biliary drainage procedure performed in patients with MBTO (Figure 1).
Although ERCP is an excellent diagnostic and therapeutic tool, it has significant complications (e.g., pancreatitis, perforation, cholangitis). 11,37 ERCP is not used as a preoperative staging tool because this modality provides little information about the surrounding parenchyma and lymphadenopathy. It also has an increased rate of failure in cases involving altered anatomy (e.g., Billroth II gastrectomy). 11
ERCP allows for tissue sampling. However, the low yield of cytology in the setting of malignant biliary tract obstruction often results in additional procedures (usually EUS-FNA) to make a tissue diagnosis of cancer. 11 At many centers ERCP and EUS are performed in one setting to maximize diagnostic and therapeutic benefit.
ERCP-guided biliary stent placement is the mainstay treatment for MBTO, especially in nonsurgical candidates and patients with long waiting times to surgery (particularly those expected to undergo neoadjuvant therapy). The deployment of a stent through strictures and other areas of narrowing is used to treat jaundice, cholangitis, and other signs and symptoms of biliary tract obstruction. Data are still evolving, and the question of which types of stents to use and in which situations to use them is the subject of several debates.
Plastic stents are usually composed of polyethylene or polytetrafluoroethylene (Teflon), are relatively inexpensive, and can be removed without difficulty if future surgical resection is planned. 38 However, plastic stents generally occlude after 3 to 6 months (because of small diameter and formation of biofilm) and patients require scheduled stent exchanges to avoid repeat obstruction or biliary infection. Rare complications of plastic stents include migration (either proximally into the duct or distally and out into the small bowel) or stent fracture. 39,40 No significant difference is seen in therapeutic efficacy or complications between the most commonly used plastic stents 41 (Figure 2).
Self-expanding metal stents (SEMS) are composed of various metal alloys and self-expand during deployment to 3 to 4 times the diameter of plastic stents. 38,42,43 The patency of metal stents (111–273 days) is significantly longer than that of plastic stents (62–165 days), while maintaining similar rates of success and complications 38 (Figures 3 and 4).
Metal stents, given their more complex construction and delivery systems, tend to cost 15 to 40 times as much as plastic stents. Cost-effectiveness studies weighing the increased costs of metal stents against the cost of reinterventions necessary with plastic stents have suggested that metal stents are, in general, superior to plastic stents when the estimated survival extends beyond 4 to 6 months, but as stent technologies develop and prices fluctuate, this question is subject to much debate. 38
Partially and fully covered metal stents were developed because of the risk for tumor ingrowth compromising the patency of uncovered metal stents. Partially and fully covered stents can also potentially be removed, if future surgical resection is planned, although none of these devices has been approved by the FDA for removability beyond the immediate postdeployment setting. Concerns with covered metal stents include a possible increased occlusion by sludge/food impaction, tumor overgrowth, and increased propensity for migration. An increased risk of cholecystitis or pancreatitis may be present through occlusion of the cystic and distal pancreatic ducts, although this association is unclear. More studies are needed to differentiate between covered and uncovered stents in terms of frequency and time course of occlusion and incidence of adverse events. 43
Several trials have compared different metal stents. 41,44 One study showed that covered polyurethane stents had significantly less stent occlusion (14%) than the uncovered Ultraflex Diamond Stent (38%; Boston Scientific, Natick, Massachusetts). 45 Other studies found the Spiral Z-Stent (Wilson-Cook, Winston-Salem, North Carolina) and Zilver (Wilson-Cook, Winston-Salem, North Carolina) to be comparable to the Wallstent in terms of technical and therapeutic efficacy and rate of stent occlusion. 46,47
Other commercially available stents include the Alimaxx-B (Merit Medical, Salt Lake City, Utah), Luminex Stent (Conmed Corporation, Utica, New York), X-suit stent (Olympus Corporation, Center Valley, Pennsylvania), and Viabil fully covered stent (manufactured by Gore Medical, Flagstaff, Arizona, and marketed by Conmed Corporation).
It is fair to say that all available biliary metal stents are effective for treating malignant obstructive jaundice, but definitive data favoring one stent over another, or even covered stents over uncovered stents, are currently lacking.
The role of preoperative biliary drainage with endoscopic stent placement has been controversial in recent years. Surgery in severely jaundiced patients has been associated with significant postoperative complications, including sepsis and renal failure. 48,49 The argument for preoperative biliary drainage includes symptomatic relief (i.e., acute cholangitis, pruritus) and a potential optimization of surgical outcomes through reversing the physiologic abnormalities caused by MBTO (i.e., immune response impairment, blood clotting abnormalities from fat soluble vitamin deficiencies). 50 In addition, patients can be treated with neoadjuvant chemoradiation or neoadjuvant chemotherapy while being relieved of their jaundice. 51,52 However, preoperative biliary drainage (both endoscopic and percutaneous) has, at times, been associated with increased surgical complications, particularly wound infections and intraabdominal abscesses. 53,54 Other drawbacks to preoperative biliary drainage include increased cost, possible malignant seeding along needle tracks (in PTC), and increased risk of periportal inflammation from stent placement, complicating surgical dissection. 51
In a recent retrospective analysis of 90 patients at a single university medical center, no difference was seen in mortality or morbidity between patients who underwent preoperative biliary tract drainage and those who did not. The lack of difference in complications between the groups, especially infectious, may be attributed to preoperatively stratifying each patient to a treatment arm based on their estimated risk, and aggressively treating with therapeutic antibiotics in the perioperative period. 52 Another recent study mentioned an increased rate of surgery-related complications in the preoperative biliary tract drainage group, but this study was limited by an unusually poor success rate for achieving biliary access in ERCP and also had a markedly high rate of complications, limiting is applicability. 55 However, the study used plastic stents, which are known to occlude at a higher rate and earlier than SEMS. 50 This study also had exceptionally high ERCP failure and complication rates that are difficult to explain. Furthermore, no patients underwent neoadjuvant therapy, further limiting the value of the results.
This debate remains unresolved and trials with partial and fully covered SEMS (which theoretically can be removable) in preoperative biliary drainage may be indicated in the future. Preoperative biliary stenting, in most institutions, remains the standard of care to allow for complete preoperative evaluation and treatment. Metal or plastic stents can be removed during pancreaticoduodenectomy.
PTC is an interventional radiologic procedure that uses fluoroscopic guidance through the liver parenchyma to enter the bile ducts and obtain imaging of the biliary tree through the direct injection of contrast. It is highly accurate in determining the level and cause of biliary obstruction, and in distinguishing benign from malignant lesions. 11 PTC is both a procedure and an imaging modality during which diagnostic and direct therapeutic interventions can be performed. Generally, PTC is considered more invasive than ERCP because of the need for liver puncture and an internal/external catheter for drainage. PTC catheters require care and maintenance by medical personnel and patients.
PTC is often used for biliary decompression and drainage when ERCP has been unsuccessful, usually because of abnormal anatomy (i.e., roux-en-Y gastric bypass) or anatomic distortion of biliary ducts or ampulla from tumor. 56,57 SEMS stent placement through PTC is also considered a viable and effective treatment in hilar strictures. Bilateral access catheters may be required in this setting because both the left and right biliary systems may require separate drainage. 58
The most common complications with PTC placement are infectious: cholangitis (6.5%–22%), cholecystitis (1.9%–12%), and liver abscess (0.3%–0.5%). 59 Other complications include bleeding, dehydration from bile fluid losses through external drain, pneumonia, and pain.
Recent development has focused on a combined percutaneous–endoscopic stenting method in cases of unsuccessful ERCPs, in which PTC is used to pass a guidewire or catheter into the duodenum. This guidewire allows for ERCP access and maneuvers (i.e., stent placement) to be performed and allows for a smaller transhepatic puncture site than PTC. 57 This method has been found comparable to PTC stent placement in terms of technical and clinical success. 57 Furthermore, combined stent placement may be more cost-effective in selected patients with limited life expectancy (≤ 3 months), because both plastic and metal stents can be placed through this method 57 (Figure 5).
Despite advances in diagnosis and therapy, pancreatic cancer is still associated with a poor prognosis (5% 5-year survival rate). 1 Only 15% to 20% of patients are considered surgically resectable at diagnosis. 60 Curative resection for cancers in the head of the pancreas is performed through pancreatoduodenectomy (Whipple), which is a major abdominal surgical procedure involving removal of the pancreatic head, gallbladder, common bile duct, duodenum, gastric antrum, and the first 15 cm of jejunum. 61
This procedure has 2 main operative techniques: the classic pancreatoduodenectomy that involves a partial gastrectomy, and a modified version that retains the stomach in situ, known as a pyloruspreserving pancreatoduodenectomy. In a meta-analysis comparing the techniques, both were found to be equivalent in mortality, morbidity, and overall survival. Operating time and estimated blood loss were significantly less in the pylorus-preserving pancreatoduodenectomy group. 62
Cancers of the pancreatic body and tail are less common and tend to have poor prognosis unless they are detected early, as symptoms related to common bile duct occlusion do not present unless hepatic metastases develop. 63 Cancers of the body and tail are generally treated with a distal pancreatectomy, often performed with a concomitant splenectomy. These surgeries do not involve a biliary reconstruction.
Currently, the perioperative mortality rate for pancreaticoduodenectomy is less than 5% at large centers with experienced surgeons. 64 The most common postoperative complications include delayed gastric emptying (7%–18%), pancreatic leak/fistula complications (9%–12%), and wound infection (5%–7%). The incidence of cardiopulmonary events varies significantly (3%–15%). 65,66 Surgical resection has been shown to be associated with a modest increase in median survival (13–21 months) compared with no surgical resection (2.58 months), 60 and an overall 5-year survival rate of approximately 20%. 64–66
Extrahepatic cholangiocarcinoma can be classified as distal or proximal (perihilar). 74 Distal lesions tend to have higher resectability rates than perihilar lesions. 75 Distal cholangiocarcinoma can sometimes be indistinguishable from pancreatic adenocarcinoma on imaging studies. The preferred curative surgical procedure for distal cholangiocarcinoma is a pyloruspreserving pancreatoduodenectomy. Five year survival rates can range between 20% to 30%. 76,77 For perihilar cholangiocarcinoma, current surgery recommendations in those with resectable lesions not involving both major ducts nor the portal vein are a partial hepatectomy and caudate lobe resection, and selective pancreaticoduodenectomy depending on extent of tumor. 69 Resections vary according to tumor stage, Bismuth classification, and have varying overall survival rates. These are aggressive procedures with substantial morbidity and mortality. The 5-year survival rate has been reported to be low (11%–34%). 69
Ampullary cancers (primary malignancies that arise from the ampulla of Vater) are very rare (5–7 cases per million per year). 78 These malignancies tend to have a better prognosis than other periampullary cancers. Curative surgery is typically performed with a pylorus-preserving or classic pancreatoduodenectomy. In one study, 98% of patients were found to be resectable, with a morbidity rate of 38% and mortality rate of 0%. The 5-year survival rate was 38%. 79
Surgical palliation has been a mainstay option for the management of unresectable MBTO for several years. Historically, surgical bypass has been associated with an appreciable risk of postoperative morbidity and mortality. 80,81 A meta-analysis comparing surgery (cholecystojejunostomy or choledochoduodenostomy) and ERCP-guided plastic stent deployment showed no differences in technical success, therapeutic success, quality of life, or length of survival. Although the rate of complications was significantly reduced in endoscopy, the relative risk for developing recurrent jaundice was significantly higher, likely because of the high rate of occlusion with plastic stents. 41,82 These data may not be applicable in the setting of SEMS placement. The literature reflects ongoing debate regarding which approach is best, with surgeons generally favoring surgery and endoscopists generally favoring stents. Over time, the rates of surgical palliation have decreased dramatically, whereas the use of endoscopy and especially SEMS has increased markedly.
Palliative surgical drainage is often prompted by obstructive jaundice, which is often encountered with concomitant gastric outlet obstruction that prevents endoscopic biliary drainage. A hepaticojejunnostomy is commonly performed, and has been shown to be superior to both cholecystojejunostomy and cholecystoenterostomy. 83,84 A hepaticojejunostomy is often performed after gallbladder removal in patients with advanced disease or metastases or to decompress the biliary tract in cases of extrinsic compression by nongastrointestinal cancer metastases or significant portal lymphadenopathy. 83
For gastric outlet obstruction, which often develops simultaneously in pancreatic head tumors or distal cholangiocarcinoma, a gastrojejunostomy can be performed (in conjunction with the procedures described earlier) without additional mortality or morbidity if the patient is symptomatic (nausea, vomiting). 83 Prophylactic gastrojejunostomy in the setting of unresectable tumor remains controversial, because late gastric outlet obstruction can develop in up to 20% of cases. 85 Currently, gastric outlet obstruction is commonly treated through the placement of endoscopic enteral stents, but gastrojejunostomy can be performed in patients who are not candidates for stenting. 86 Institutional protocols vary, and often local experience is a major factor when selecting stents over surgery for gastric outlet obstruction. A recent systematic review showed that stents are likely superior in patients with a relatively shorter lifespan, whereas surgery should be reserved for those with a better performance status. This study also showed similar clinical outcomes for stents and surgery in terms of symptomatic improvement. 87
MBTO remains a commonly encountered clinical entity. Multiple diagnostic and therapeutic modalities exist, and almost all patients with MBTO can have their obstruction relieved through one or more treatment options. Endoscopic, radiologic, and surgical approaches should not be seen as competitive entities, but rather as complimentary techniques. Individual drainage procedures should be selected based on the location and type of biliary obstruction, local expertise, and patient preference.
EDITOR
Kerrin G. Robinson, MA, Assistant Managing Editor, Journal of the National Comprehensive Cancer Network
Disclosure: Kerrin G. Robinson, MA, has disclosed no relevant financial relationships.
Laurie Barclay, MD, Freelance writer and reviewer, Medscape, LLC
Disclosure: Laurie Barclay, MD, has disclosed no relevant financial relationships.
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Correspondence: Douglas G. Adler, MD, Department of Internal Medicine, Division of Gastroenterology and Hepatology, Huntsman Cancer Institute, University of Utah School of Medicine, 300 North 1900, East SOM 4R118, Salt Lake City, UT 84132. E-mail: douglas.adler@hsc.utah.edu
Disclosure: David Chu, MD, has disclosed no relevant financial relationships.
Disclosure: Douglas G. Adler, MD, has disclosed no relevant financial relationships.
Representative fluoroscopic image obtained during endoscopic retrograde cholangiopancreatography showing a distal biliary stricture in a patient with pancreatic cancer. Note proximal intra- and extrahepatic ductal dilation.
Endoscopic image of a plastic biliary stent.
Endoscopic image of an uncovered biliary self-expanding metal stent in a patient with pancreatic cancer.
Endoscopic image of a fully covered biliary self-expanding metal stent in a patient with ampullary cancer.
Fluoroscopic image obtained during endoscopic retrograde cholangiopancreatography of a combined endoscopic and percutaneous biliary drainage procedure. Note percutaneous transhepatic cholangiopancreatography catheter entering from the right hepatic duct system and the endoscopic stent in the common hepatic duct and common bile duct.
