Criteria of unresectability and the decision-making process.

Determination of the exact criteria for resectability in patients with cholangiocarcinoma and how they are most efficiently evaluated has many limitations. Among many factors taken into account in this decision-making process are: the condition of the patient, the biology of the disease, and the technical expertise of the surgeon and hospital. An attempt is made here to organize recommendations for the work-up of patients and the main criteria for resectability as best possible, keeping in mind that there will always be some limited room for exceptions, especially if the biology is favorable. Work-up and determination of resectability for patients with distal cholangiocarcinoma are more straightforward than at the other two sites of the disease (perihilar and peripheral). In general, these follow the same principles as those for other periampullary carcinomas (pancreas, ampullary, and duodenal). The work-up and determination of resectability for patients with peripheral cholangiocarcinoma can be relatively straightforward if the lesion is away from the hilus of the liver and does not involve a significant proportion of parenchyma, but can be problematic if it is more central or very large. Patients with perihilar cholangiocarcinomas are perhaps the most challenging, as factors such as patient condition, biology of the disease, local involvement of the major vessels and bile ducts at the hilum, and the future liver remnant all have a bearing in the decision-making process.