Percutaneous biliary interventions have established their role in the management of benign and malignant biliary disease. There are limited data comparing procedures performed by gastroenterologists and interventional radiologists in managing malignant biliary obstruction. Endoscopic procedures performed by gastroenterologists are not completely benign with reported complications ranging from 2% to 15%. It is important that gastroenterologists and interventional radiologists collaborate to form algorithms for management of malignant biliary obstruction which provide safe and efficacious care to these patients. K E Y W O R D S biliary intervention, biliary stenting, interventional radiology, percutaneous transhepatic cholangiography 2.2 | Indications Cholangitis: If a patient has fever, right upper quadrant pain, and jaundice, there should be a very high suspicion of cholangitis. Biliary drainage can help prevent sepsis which can be catastrophic. Pruritus: Itching may also be a reason to perform a procedure. Most patients with pruritus due to biliary obstruction have a diurnal variation of itch intensity (worst in the evening). Itching worsens with heat and most often affects limbs (palms of the hands and soles of the feet). Pruritus related to biliary obstruction is likely caused by lysophosphatidic acid. 1 Drainage of even a small portion of the biliary tree can decrease/resolve pruritus. Anorexia: Obstructive jaundice can alter taste and decrease appetite. Anorexia has been associated with hyperbilirubinemia, increased alkaline phosphatase, and increased cholecystokinin levels. 2 Drainage can improve appetite. Presurgical drainage: Patients with resectable malignancy without cholangitis should not be drained. A 75-patient randomized prospective trial demonstrated no improvement in 30-day mortality in patients who had been drained compared to those who had not been drained. A systematic review of randomized trials on J Surg Oncol. 2019;120:45-56. wileyonlinelibrary.com/journal/jso

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