1. Perform percutaneous transhepatic cholangiogram
2. Choose a duct in the right lobe of the liver with horizontal or caudal course
3. Study the duct on US and insert 22G Chiba needle under US or fluoroscopic guidance
4. Use coaxial introducer system over 0.018 guidewire to allow 0.035 wire and catheter access
5. If duct not successfully punctured, withdraw Chiba needle but leave in liver capsule for further attempt
6. Once 0.035 wire established, insert sheath e.g. 7-F
7. Drain bile through side arm of sheath while manipulating catheter over wire
8. For internal drainage or stent, pass wire and catheter through stricture into duodenum or jejunal loop
9. For external drainage, insert suitable catheter over wire after sheath withdrawn
10. May need variety of wires and catheters to cross difficult strictures
11. If fails, institute external drainage and attempt to pass stricture again in a few days
12. May place internal/external catheter across stricture and secure to skin
13. May position and deploy metal biliary stent across malignant stricture
14. May require balloon dilatation before or after stent deployment
15. May leave temporary external drainage tube for 24-48 hours