Jaundice is a clinical sign characterized by yellowing of the skin and sclera due to an increase in serum bilirubin. It is one of the most direct signs of disease of the hepatobiliary system. It is clinically classified as hemolytic jaundice, hepatocellular jaundice and obstructive jaundice. It has been a difficult task for clinicians to control and correct jaundice. So far, our department has carried out more than 250 cases of interventional treatment for patients with malignant obstructive jaundice, including PTCD and biliary stent placement, after which the majority of patients have significantly improved their general condition after surgery, offering the possibility of further treatment and improved quality of survival. It provides a good approach for the effective treatment of patients with advanced tumors complicated by obstructive jaundice in Ningbo and surrounding areas. Classification of obstruction sites Malignant obstructive jaundice can often be classified as low, intermediate and high obstruction. Low-medium obstruction is usually located in the common bile duct and jugular abdomen, and the main causes are: cancer of the jugular abdomen, pancreatic cancer, bile duct cancer, gallbladder cancer, adjacent malignant tumor invasion and malignant metastatic lymph node enlargement, etc. High-grade obstruction refers to obstruction above the common hepatic duct, and the causes include: advanced gallbladder cancer, hilar cholangiocarcinoma, peripheral cholangiocarcinoma, hepatic metastatic cancer and high-grade cholangiocarcinoma, etc. According to Bismuth’s staging, it can be divided into type I-IV. Type I is a tumor invading the common hepatic duct without invading the bifurcated bile ducts; type II involves the bifurcated bile ducts without invading any of the bile ducts; type III invades any of the hepatic ducts without involving the secondary bifurcations; type IV mainly involves the secondary bile ducts. Patients with high obstruction have poorer outcomes and often have more severe liver function impairment, so clinically, early release of obstruction is required, and PTBD is the preferred approach, and multiple drainage is advocated for rapid and effective drainage. With the widespread use of MRCP technology, preoperative biliary imaging is routinely performed to help the initial determination of the site and extent of obstruction. Percutaneous hepatic biliary drainage Non-surgical biliary drainage includes percutaneous hepatic penetration and endoscopic retrograde biliary drainage. In the past, percutaneous retrograde biliary drainage (ERCP) was widely used in clinical practice, but for patients with malignant obstruction at or above the porta hepatis, the failure rate and complication rate are significantly higher, so percutaneous percutaneous biliary drainage (PTBD or PTCD) has gradually replaced ERCP in clinical practice, and with the improvement of interventional techniques and minimally invasive instruments, PTBD has opened up a broader prospect. PTBD or PTCD has gradually replaced ERCP, and with the improvement of interventional techniques and minimally invasive devices, a broader perspective has been opened for PTBD. The indications for PTBD include: 1) reducing obstructive jaundice caused by biliary tumors, 2) treating acute cholangitis, treating common bile duct or intrahepatic bile duct stones that are difficult to be resolved by ERCP, 3) dilating benign biliary strictures, and 4) correcting biliary fistulas caused by surgical procedures. However, it should be listed as a contraindication for those with difficult-to-correct coagulation dysfunction and giant hemangioma. Although large amount of ascites may cause difficulty in puncture, catheter displacement or catheter dislodgement, it can be basically corrected after measures of ascites release, diuresis and albumin supplementation, so it should be regarded as a relative contraindication. Complications of PTBD include biliary hemorrhage (pseudoaneurysm, arteriovenous fistula, portal vein-biliary fistula), biliary perforation, sepsis or cholangitis (intestinal fluid reflux, infection), bile leak, intra-abdominal hemorrhage, pancreatitis, peritonitis, pneumothorax, catheter dislodgement, or death. PTBD has a high success rate, with most malignant obstructive jaundice passing through the strictured or obstructed segment. Serum bilirubin decreases at a rate of approximately 2 mg/day in those with successful drainage, and fever due to biliary tract infection decreases within 24 hours in many patients. Drainage tubes connected to drainage bags to maximize drainage are effective in reducing the incidence of sepsis. After about 1 week of normal drainage, the external drainage is closed and complete internal drainage is performed. If the drainage is very clear, internal stenting or endotracheal tube placement can be considered. If the obstruction is significant and the guidewire is difficult to pass through the narrowed section, external drainage can be performed first. After the biliary pressure decreases, the bile sludge disappears, the bile is clarified and the infection is controlled, further drainage can be placed to convert the external drainage into internal and external drainage, and then stenting or internal drainage can be performed at an optional stage. It is important to highlight that excessive catheter and guidewire manipulation should not be performed in septic cholangitis to prevent the occurrence of hematogenous infection, sepsis and infectious shock. Indications and contraindications for PTBD Indications 1. Low-grade malignant obstruction that cannot be removed surgically, such as pancreatic cancer and carcinoma of the jugular abdomen. 2.Primary biliary tract malignancy, such as bile duct cancer, gallbladder cancer, hepatoportal bile duct cancer. 3.Obstructive jaundice due to primary hepatocellular carcinoma. 4.Obstructive jaundice due to metastatic tumor. 5.Jaundice due to tumor recurrence after surgical resection. 6.The risk of surgical operation due to various factors, but still able to tolerate percutaneous hepatopexy. 7.Temporary drainage before surgical operation for the time of surgery. Acute septic obstructive cholangitis can be listed as a relative indication. 8.Biliary fistula complicated by biliary surgery 9.Obstructive jaundice after liver transplantation. Contraindications 1.Poor coagulation function, which cannot be corrected after treatment 2.Severe systemic infection or sepsis 3.Hepatic coma, massive ascites, oliguria and other hepatic and renal failure 4.End-stage patients Timing and prospect of dual intervention Malignant biliary obstruction involving the biliary system, surgical resection of the tumor to reconstruct the bile duct is the best method, however, less than 20% of patients can be surgically resected. However, surgical resection can be performed in less than 20% of patients, and most patients are already unresectable, thus seriously threatening patient survival and patient quality of life. For palliative care, PTBD is clinically recognized as an effective means of yellowing reduction. Obviously, its main purpose is to improve the organism’s condition for elective or simultaneous interventional treatment, i.e., the application of dual interventional methods. This approach has been the focus of clinical research in malignant obstructive jaundice. The occurrence of hepatic impairment, ascites, jaundice, and generalized edema due to malignant obstruction, as well as biliary tract infection, sepsis, cholestasis, poor reabsorption, and even transient hepatorenal syndrome, strongly suggest the increased risk that interventional procedures may entail. Therefore, it is particularly important to know how to accurately time dual interventions for obstructive jaundice. In general, excessive serum bilirubin levels seriously affect the detoxification function of the liver and biliary excretion, and simultaneous tumor intervention in PTBD will further damage liver and kidney function, or even cause liver and kidney failure. Therefore, it is safer to perform dual interventional treatment when the bilirubin level drops to normal, or when the intra-biliary pressure decreases, bile drainage is smooth, and there is no intrahepatic bile duct dilatation. Some scholars also believe that hilar obstruction, tumor compression or invasion of multiple bile ducts in the hilar region, which makes smooth drainage difficult, embolization chemotherapy while establishing effective drainage can effectively stop tumor progression and speed up the release of obstruction, thus improving the patient’s physical condition more quickly. In the future, with the development of highly targeted drugs, tumor progression will be more easily controlled. The introduction of some angiogenesis-inhibiting drugs, the deepening of the understanding of the mechanism of tumor gene mutation, and the improvement of the theory of mutation gene repair will all be beneficial to the interventional treatment of malignant biliary obstruction. It is believed that the future of interventional treatment of malignant obstructive jaundice is even better.