Background: The intact gall bladder and biliary tree after failed ERCP is a potential risk factor for the occurrence of 
biliary complications. The aim of this non-randomized prospective and retrospective study was to evaluate the role of timing of common bile duct exploration and the type of biliary drainage after failed ERCP to clear the bile duct from stones and to prevent the complications. 
Patients and Methods: In this study, 173 patients with calcular obstructive jaundice had ERCP for common bile duct stone extraction. They were divided into two groups. The G1E group was studied prospectively and included 133 patients with 39 failed ERCP whom were transferred for surgery within 24 hrs (immediate referral). The G2E group was studied 
retrospectively and included 40 patients with 14 failed ERCP, they were referred to department of surgery after 24hrs and up to 12 days (delayed referral). The surgical groups were divided according to the method of drainage into two main groups, the first group (G1S, n=39) included subgroups A & B and the second group (G2S, n=14) included subgroups C & D. The subgroup; A: G1ST (21 patients) had T-tube external drainage, B: G1SS (18 patients) had home made stent internal drainage, C: G2SO (6 patients) had stoma formation internal drainage and D: G2SS (8 patients) had ERCP stent internal drainage. 
Results: Mortality rate was mainly in G2S group (C & D) with delayed referral in which 5 patients died due to Systemic 
inflammatory Response Syndrome (SIRS) and Multiple Organ Failure (MOF). There was no mortality in G1S group (A & B) 
with early surgical intervention. Internal drainage revealed more favorable results than the external one in the term of shorter operative procedure and hospital stay with less complication. 
Conclusion: Immediate surgical intervention and internal biliary drainage after failed ERCP revealed more favorable results than delayed and internal ones.