Candidates:  Benign structures only

Procedure

1. Initial external-only PTBD placement (internal-external placement is fine if the lesion is initially easy to cross)

2. Conversion to 8-10 Fr internal-external PTBD 1-2 weeks following initial placement.  It can be capped the day after the exchange.

3. Upsize 2 Fr every 2-3 weeks with the goal of 20 Fr PTBD.  It can be capped the day after the exchange.

4. Leave 20 Fr PTBD in place for 6 months with a 3-month exchange.

5. Sheath cholangiogram at 6 months with conversion to 14 Fr external only drain if drainage is adequate.

6. Remove 14 Fr External biliary drain after 2 weeks if no difficulties while capped.