The transhepatic placement of adequately sized endoprostheses for the palliation of malignant biliary obstruction is painful and requires large hepatic parenchymal tracks. Endoscopically placed biliary stents are smaller, but may not be adequate for long-term patency. The authors have used a combined peroral-transhepatic approach successfully to pull large endoprostheses through the alimentary track and into the biliary tree.