Self-expandable Metal Stents Versus Multiple Plastic Stents for Palliation of Biliary Obstruction

Inclusion Criteria: * 18years of age or older * informed consent obtained after oral and written information * clinical data in accordance with a malignant bile duct obstruction * imaging evidence: (ultrasonography (US), computed tomography (CT) or magnetic resonance imaging (MRI) shows signs of extrahepatic malignant common bile duct obstruction * typical ERCP findings of a malignant common bile duct stenosis * proximal margin of the bile duct stenosis ≥2 cm from the hepatic confluence * bilirubin \> 50 micromol/L * radical surgery not deemed possible Exclusion Criteria: * patients with active hepatitis or other jaundice-causing hepatic diseases * informed consent not obtained or patient unable to give informed consent * patients with no understanding of English, Afrikaans or Xhosa where it is not possible to obtain informed consent * metastasis with multiple significant intrahepatic stenosis causing blockage of one or more segments of the liver (liver metastasis otherwise not an exclusion criteria) * the patient is a possible candidate for surgical resection * suspicion of a non-malignant bile duct obstruction, e.g. stones or benign stenosis (should initiate further investigations) * the proximal end of the stenosis is \< 2 cm from the hepatic confluence * previous BII or Roux-en-Y gastric reconstruction * significant duodenal obstruction making ERCP difficult * previous bile duct stent