Endoscopic biliary procedures are 89-97% successful in skilled hands. The commonest causes of failure are inability to cannulate the papilla of Vater due to difficult anatomy or tortuosity of the distal common bile duct and failure to cross a rigid biliary stricture. In nearly all of these cases, successful endoscopic procedures can be completed after percutaneous antegrade placement of a small catheter or guidewire to the duodenum. In 44 such combined procedures on 42 patients, the success rate was 43 (98%). There were two severe and eight mild complications. Combined procedures overcome the difficulties caused by tortuous biliary ducts and rigid strictures while obviating the need for more extensive percutaneous procedures and transhepatic tract dilatation.