In our opinion, the diagnostic flow chart reported in Figure 4 allows a correct evaluation of resectability without performing direct cholangiography.

Further diagnostic investigation, such as the probable use of invasive technique, biliary drainage, or restoring hepatic function, should be decided by the hepatobiliary team based on the performance status of the patient (presence/absence of sepsis, alteration of hepatic function, malnutrition) and the feasible therapeutic approach.

Optimising management allows to avoid invasive, risky and useless manoeuvres, long hospitalisation and delay of definitive treatment, and can facilitate selection of the patients for different therapeutic options.

Fig. 4 Proposed noninvasive diagnostic flow chart for hilar cholangiocarcinoma

Study with MRI and MRCP, associated or not with CT and/or EUS, shows whether a cholangiocarcinoma is resectable or not. In presence of resectable tumour at preoperative non-invasive studies, a decision must be made considering jaundice, the concomitant presence of infection, the extent of the tumour along the biliary tract (Bismuth-Corlette staging), and the evaluation of remnant liver.

In presence of jaundice without signs of infection and in absence of lobar atrophy, one can proceed directly to surgery. In presence of cholangitis, preop-erative biliary drainage is mandatory, preferably unilateral on the future remnant liver, bilateral or multiple if bilirubin level does not decrease or cholangitis persists. In presence of homolateral lobar atrophy, the atrophic lobe does not need draining, unless the patient presents signs of sepsis sustained by the undrained lobe when the volume of the future remnant liver is less than 30-40% of the total liver volume, it can prove useful to adopt the technique of portal vein emboli-sation, with preventive biliary drainage (Fig. 5).


CP-MRI and/or CT

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