Malignant obstruction of the bile duct from cholangiocarcinoma, pancreatic adenocarcinoma, or other tumors is a common problem which may cause debilitating symptoms and increase the risk of subsequent surgery. Treatment of obstruction is generally indicated to relieve symptoms and improve morbidity and mortality. First-line therapy consists of endoscopic biliary stent placement. Recent data comparing plastic stents to self-expanding metallic stents (SEMS) has shown improved patency with SEMS. For patients with resectable disease, preoperative biliary decompression is only indicated when surgery will be delayed or complications of jaundice exist. Patients who require neoadjuvant therapy will require decompression for the prolonged period until attempted surgical cure. For patients with locally advanced disease and pancreatic cancer patients, self-expanding metal stents are superior to plastic stents for long-term patency. For cholangiocarcinoma patients, treatment with percutaneous methods may be superior to endoscopic stent placement, with less risk of infectious complications or failure. For patients with advanced disease, the choice of metallic or plastic stent depends on life expectancy (plastic stents favored for survival of < 4 mo). Radiofrequency ablation may play a role in extending survival of patients with malignant biliary obstruction.