The first endoscopic transpapillary insertion of biliary stents was performed in 1979. This procedure quickly becomes a standard method of palliation for pancreaticobiliary malignancies causing obstructive jaundice. The success rate exceeds 90% and the procedure related complications are rare.

First, a good quality Endoscopic Retrograde Cholangiopancreatography, ERCP in short is done. ERCP is done through injection of contrast into the bile ducts through a fine cannula inserted into the duodenal papilla. This clearly outlines the pathology of both the pancreatic and bile duct. As a result the patient need to be fit for endoscopy.

1. Sphincterectomy.  In general, sphincterectomy is performed to allow good access to the common bile duct for a range of other palliative procedures. However, sphicterectomy can be adequate palliation on its own for ampullary carcinoma. Placement of simple plastic stents can often be performed without prior sphinterectomy.

2. Dilatation. In order to insert stent, malignant biliary strictures must be dilated  Dilatation alone without stenting is not adequate. This leads to rapid re-occlusion. Scope ballons or graded bougies can be used. Most strictures caused by pancreatic carcinoma can be stented without the need for prior dilatation but cholangiocarcinomas are commonly tight and requires dilatation.

3. Plastic stents

4. Self Expanding Metal Stents

Unfortunately the plastic stents tend to clog as a result of bacterial biofilm formation and sludge deposition. The patients develop jaundice, fever and cholangitis. The use of long term antibiotics, bile salts, ultrasmooth stent materials, and new stent designs have shown promise in prolonging stent patency. Expandable metal stents, by providing a larger luminal diameter remain patent longer. Their routine use has been hampered by the high cost.