Malignant biliary obstruction most commonly arises from cholangiocarcinoma and pancreatic cancer or as a metastasis from other cancer types. Most of the patients, at the time of diagnosis, are at an advanced stage of the disease that precludes surgical resection. In this condition, the neoplastic biliary obstruction must be drained because it predisposes to symptoms that can deteriorate patient general health status. Moreover, elevated bilirubin levels contraindicate an eventual chemotherapy. In cases of malignant biliary obstruction, the gold standard is endoscopic biliary drainage, which is less invasive compared to percutaneous or surgical drainage. However, percutaneous drainage appears to be superior to endoscopic drainage for the treatment of patients with advanced unresectable hilar malignant biliary obstruction.