Inclusion Criteria:  Patients with malignant obstruction of the distal common bile duct e.g. adenocarcinoma of the pancreatic head or periampullary tumor Hyperbilirubinemia, total bilirubin level more than 10 mg/dL Cholangitis, pruritis, coagulopathy, nausea and anorexia  Exclusion Criteria:  Patients with advanced disease metastatic disease Patients undergoing neoadjuvant therapy