Primary Percutaneous Stenting Above the Ampulla Versus Endoscopic Drainage for Unresectable Malignant Hilar Biliary Obstruction

Inclusion Criteria: * Written informed consent must be given according to ICH/GCP and national/local regulations. * MHBO on imaging with histopathological confirmation or high clinical suspicion. * Ineligible for surgical resection. * Hyperbilirubinemia (a combination of a total bilirubin level \>50 mmol/l. Exclusion Criteria: * Fluctuation or spontaneous decrease of a total bilirubin level before start of any treatment suggesting a potential non-malignant diagnosis. * Patients who underwent previous biliary drainage procedures endoscopically or percutaneously. Patients who underwent an attempted but failed ERCP are eligible only when no papillotomy or cannulation was performed. * Clinical signs of cholangitis. Cholangitis is defined as the presence of both fever (i.e. body temperature \>38.5°C) and leucocytosis (i.e. ≥10 \*109/L) without clinical or radiological evidence of acute cholecystitis (22). * Uncorrectable coagulation disorder. * Uncorrectable contrast allergy.