endoscopic placement of plastic biliary stents for biliary obstruction is a well - established technique . although percutaneous placement of stents at other sites is well known , as is the use of percutaneous placement of metallic biliary stents , we were unable to find a reference for percutaneous placement of plastic biliary stents in the literature . a 49-year - old man presented with jaundice of 3 months duration and no clinical evidence of cholangitis . mri of the abdomen showed moderate intrahepatic and extrahepatic biliary dilatation ; the common bile duct ( cbd ) was dilated up to the distal portion , with no obvious lesion . on endoscopy , a proliferative growth of the periampullary area was seen and a biopsy was taken from this . ten days later , his bilirubin was 4 mg / dl and surgical treatment of the periampullary carcinoma is awaited . the procedure was performed in a digital subtraction angiography ( dsa ) suite ( siemens multistar t.o.p ) under local anesthesia , with all aseptic precautions and antibiotic cover . the tract was dilated and an 8f external - internal biliary drainage was placed and connected to an external drainage bag . frontal fluoroscopy spot radiograph shows opacification of the biliary system ( arrow ) after injection of contrast medium through the external biliary drainage tube three days later , an internalization procedure was performed under local anesthesia . the site of obstruction was visualized after injecting contrast through the tube and a long 0.035 after removal of the drainage tube a 7f 35-cm sheath [ figure 2 ] was inserted over the wire and advanced until the distal end projected into the duodenum across the stricture . a 7f 10-cm plastic stent [ figure 3 ] cotton - leung ( amsterdam ) sof - flex biliary stent ( cook medical , usa ) with a flap mechanism was passed over the wire into the sheath . the tapered distal few centimeters of the sheath dilator were cut transversely using a pair of scissors and the dilator was then used to advance the stent through the sheath till it was positioned at its tip [ figure 4 ] . once the stent was located correctly , the sheath was withdrawn over the dilator , leaving the stent positioned across the biliary obstruction [ figure 5 ] . a temporary external drainage tube ( 8f pigtail ) was placed to prevent any clots from blocking the plastic stent , and this was removed after 2 days . frontal fluoroscopy spot radiograph shows a 7f 35-cm sheath ( arrow ) placed over the wire ( arrowhead ) , with its distal end ( curved arrow ) protruding into the duodenum across the stricture cotton - leung ( amsterdam ) sof - flex biliary stent . the tapered terminal few centimeters of the sheath dilator was transversely cut using a pair of scissors the plastic stent ( arrow ) is seen over the wire ( arrowhead ) ; it is followed by the dilator ( curved arrow ) as a pusher device frontal fluoroscopy spot radiograph shows the plastic stent ( curved arrow ) positioned across the stricture ( arrow ) we describe a simple technique for placing a biliary plastic stent percutaneously . the procedure can be performed in patients who require a plastic biliary stent for drainage but are not suitable for the endoscopic approach or when endoscopy is unsuccessful . the common designs to secure biliary stents in situ include flaps , pigtail , or mushroom . the advantage of percutaneous placement of plastic stents when compared to endoscopic placement is that the patient can be kept in the supine position . we recommend that the sheath size be just large enough to take the stent so as to minimize liver surface trauma at the entry point . we have performed a similar procedure without any complications in five patients ( three with malignant and two with benign pathology ) . although we did not encounter any complications , potential complications include those related to percutaneous biliary drainage and misplacement of the stent . compared to metal stents , the chances of blockage and migration of plastic stents are higher , and therefore plastic stents are perhaps best deployed in the short term , prior to definitive surgery ; they may not be suitable for palliative therapy . an advantage with plastic stents is that they are very cheap compared to metal stents . though biliary plastic stents are usually placed through the endoscopic route , it is also possible to place them percutaneously .
endoscopic biliary plastic stent placement is a well - established technique for unresectable and recurrent biliary obstructive disease and provides significant improvement in the quality of life . 
 we describe a new technique of percutaneous placement of biliary plastic stent that has not been previously mentioned in the literature .