Proximal tumors and Klatskin tumors are managed by resection of the extrahe-patic biliary tree and bifurcation with or without partial hepatectomy, followed by bilateral hepaticojejunostomy. Lesions located in the middle of the common duct can be resected then choledochoenterostomy performed. For distal tumors, pancreaticoduodenectomy (Whipple procedure) is performed.

Nonresectability criteria include:

• Distant metastasis

• Extensive tumor extension into both lobes of the liver

• Involvement of the portal vein or main hepatic artery

Nonoperative palliation is achieved by placement of transhepatic stents either percutaneously or endoscopically. Surgical palliation for patients without disseminated tumor, but have unresectable hilar CA at exploration, is Roux-en-Y choledochojejunostomy with cholecystectomy.

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