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AIM:To compare diverse endoscopic interventions in the management of occluded uncovered self-expanding metal stents(SEMSs) that had been placed for palliative treatment of unresectable malignant biliary obstruction.METHODS:A retrospective review was undertaken in 4 tertiary endoscopic centers to determine optimal management of different types of occluded SEMSs.The technical success of performed treatment in occluded SEMSs,the patency of the stent,the need for re-intervention and the financial costs of each treatment were analyzed.RESULTS:Fifty four patients were included in the analysis;21 received Hanaro,19 Wallstent and 14 Flexus.For the relief of obstruction,a plastic stent was inserted in 24 patients,a second SEMS in 25 and mechanical cleaning was performed in 5 patients.The overall median second patency rates between second SEMSs and plastic stents did not differ(133 d for SEMSs vs 106 d for plastic stents;P = 0.856).Similarly,no difference was found between the overall survival of SEMS and plastic stent groups,and no procedure-related complications occurred.Incremental cost analysis showed that successive plastic stenting was a cost-saving strategy at least in Greece.CONCLUSION:Insertion of uncovered SEMSs or plastic stents is a safe and effective treatment for occluded uncovered SEMSs;insertion of plastic stents appears to be the most cost-effective strategy.