Malignant obstructive jaundice is a yellowish discoloration of the skin and sclera caused by various types of malignant lesions compressing the biliary system, resulting in the normal drainage of bile into the intestine, which can lead to serious complications such as liver failure and secondary infection if left untreated. In recent years, percutaneous hepatic perforated biliary drainage (PTCD) has become a common palliative treatment for malignant obstructive jaundice, which can improve the quality of life and prolong the survival time of patients. After admission, detailed preoperative examination and initial medical treatment were performed. Those with poor liver function and ascites were given supportive, hepatoprotective and diuretic treatment, and those with signs of biliary tract infection (abdominal pain, fever and elevated white blood cells) were given anti-infective treatment. After the general condition improved, percutaneous hepatic puncture biliary stenting was performed. Firstly, a percutaneous transhepatic cholangiogram is performed, then the ideal intrahepatic bile duct branch is selectively punctured, a guidewire catheter is fed through the obstructed section of the bile duct and then an ultra-hard exchange guidewire is introduced, along which a balloon is fed to pre-dilate the diseased segment and then a domestic biliary metal endoprosthesis is placed, and finally an internal and external – drainage tube is fed and withdrawn for about 5 days for drainage observation. In cases of left and right bile duct stenosis due to hilar lesions, double stenting or stenting of one bile duct and internal-external drainage of the other bile duct or external drainage alone is performed. In a few cases, only one bile duct was drained if it was estimated to be effective in reducing yellowing. II. Results The patients had no serious intraoperative complications after stent placement. They were hospitalized for 5-10 days postoperatively and discharged after general improvement. Serum total bilirubin and direct bilirubin decreased significantly 1 week after surgery, and both total bilirubin decreased to less than 1/2 of the preoperative level after 1 month. Glutamate aminotransferase and glutamate transpeptidase decreased significantly compared with preoperative levels. No deformation or displacement of the stent occurred during the survival period after follow-up. After stent placement, the survival was more than 2 years in combination with local perfusion or modality radiotherapy. III. DISCUSSION Internal-external biliary drainage and metal endoprosthesis placement are mainly used in patients with obstructive jaundice due to malignant strictures lost to surgery and in patients of advanced age. The placement of a metal internal stent in the biliary stricture restores physiological bile drainage channels. This treatment method is characterized by minimal trauma and can be performed without open surgery; it has rapid recovery and good results. Combining with local perfusion or moderate radiotherapy can significantly prolong the survival period, and the effect is completely comparable to surgery. IV. Operation technique 1. Percutaneous transhepatic puncture to establish intrahepatic bile duct to duodenal channel Right axillary midline approach: ① Comprehensive analysis of imaging data to initially determine the needle path. Bony markers can be used as an important reference, focusing on the vertebral plane where the dilated bile duct and hepatoportal are located, to determine the anterior and posterior position of the puncture point (with the mid-axillary line) and the depth of needle entry (with the right edge of the spine). (ii) Deep breathing under fluoroscopy to observe the position of the right rib diaphragm angle. The puncture point must be on the foot side of the right rib diaphragm angle, mostly in the right axillary midline between 8 and 10 ribs. ③The patient should hold the needle after shallow inspiration to reduce the mobility of the liver with respiratory movements. ④It is appropriate to inject contrast agent until 3 to 4 levels of bile duct branches are visualized in the liver; too much will cause distension and retrograde infection, and too little will be detrimental to the next operation. ⑤ Lateral fluoroscopy after percutaneous transhepatic percutaneous cholangiography (PTC) to understand the anterior-posterior relationship between the bile duct and the needle tip of the needle tract. Adjust the direction before puncturing the ideal bile duct. Aim to enter through the smaller bile duct branches and make the puncture tract as parallel as possible to its proximal bile duct, which is very advantageous for operations such as placement of drainage tubes, balloon dilation tubes or internal stents. Sometimes the left intrahepatic bile duct is punctured, and the best route is usually chosen according to the left dilated bile duct shown on enhanced CT, with the skin puncture point slightly to the right of the subxiphoid process. Under ultrasound guidance, the success rate of left hepatic puncture is higher than that of right hepatic puncture. In critical conditions and with only dilated left intrahepatic bile ducts, left intrahepatic bile duct puncture should be preferred. The use of a stiffer single-curved catheter (e.g., vertebral artery duct) with a mudskipper guidewire delivered alternately helps to pass the stenotic segment, and sedatives, antispasmodics, and analgesics are used if necessary. 2, non-smooth hard exchange guidewire and pre-expansion of balloon catheter can help biliary stent placement The choice of balloon catheter (1~2mm smaller than the diameter of the stent to be inserted) to pre-expand the stented segment is conducive to the release and expansion of the stent, which can overcome the weakness of the self-expansion of domestic stent compared with imported stent; at the same time, it helps to further understand the degree, exact location and length of the stented lesion. The non-superslip hard exchange guidewire (cordis green exchange guidewire) has good support force, which is conducive to the smooth feeding of balloon, stent and drainage tube, and solves the disadvantages of thick, hard and difficult feeding of domestic stent pushers. However, the hard guidewire is easy to deform the lower part of the common bile duct and change the positioning after feeding. The non-superslip guidewire has a high friction force, which minimizes the possibility of the guidewire dislodging by itself due to respiratory motion during the operation. After the release of the internal stent, if the diameter of the stented segment has expanded to 70%~80% of the diameter of the stent, it is not necessary to use balloon expansion because the stent’s own expansion force can be expanded to the original design diameter after 2~3 days. 3. Temporary internal-external drainage tube is still needed after stent placement The main advantages of placing temporary internal-external drainage tube after stent placement are ① rapid bile drainage, which helps liver function recover as soon as possible and reduces mortality. ② Observe the nature of drainage fluid to understand whether there is biliary infection and biliary bleeding and deal with it in time. ③Stale viscous bile or blood clot is drained through the drainage tube, combined with necessary regular flushing to prevent obstruction in the stent or blockage of the mesh between the double stents in the hepatoportal area. ④As far as possible, avoid placing external drainage tubes, which have a short anterior end that is difficult to fix and may partially dislodge during relative movements of the liver and abdominal wall that are difficult to observe on the body surface, resulting in drainage fluid entering the abdominal cavity. The internal-external drainage tube was kept for 3 days, and the external drainage tube was closed when the drainage fluid became clear and no fever or painful symptoms appeared. Another observation for about 2 days, no fever, pain symptoms, confirmed by the imaging of the stent lumen channel, you can remove the drainage tube, gelatin sponge closed channel. 4.Multi-stent placement It is generally believed that the more the number of biliary stents placed in the same patient, the greater the probability of restenosis. However, in patients with obstruction of both right and left hepatic ducts due to hilar tumor and laboratory tests suggesting significant abnormal liver function, recanalization of only one hepatic duct cannot effectively reduce yellowing and improve liver function as soon as possible, and placement of double stents is more effective [5]. Even in patients with metastases in the hilar region of the lower bile duct or the head of the pancreas, resulting in multisegmental biliary obstruction, separate biliary stenting of the lower bile duct and the hilar region is still better than single stenting. After biliary stent placement, some patients may feel dull pain in the right quadrant of the rib cage, which is usually tolerable and does not require sedation and will resolve on its own after a few days. Stenting only solves the problem of biliary obstruction, and postoperative liver preservation therapy is needed to prevent chronic irreversible liver and kidney failure caused by prolonged yellow obstruction. After recovery of liver function, it is still necessary to combine local radiotherapy and chemotherapy with comprehensive treatment of primary malignant lesions to prolong the patient’s life.