Ninety-one patients with malignant biliary obstruction, excluding carcinoma of the head of the pancreas and periampullary cancer, are analyzed. Sixty-five patients had hilar tumors, 32 Klatskin tumors, and 33 malignant hilar biliary obstructions due to primary carcinoma of the gallbladder or metastatic spread to the hilum from other primary sites (pseudo-Klatskin tumors). There were 9 patients with carcinoma of the middle third and 16 patients with carcinoma of the lower third of the bile duct. Resection rates were 31% (10 of 32) for Klatskin tumors, 3% (1 of 33) for pseudo-Klatskin tumors, 22% (2 of 9) for carcinomas of the middle third, and 88% (14 of 16) for carcinomas of the lower third of the bile duct. Jaundice was completely relieved in all patients undergoing resection. Three patients are alive 2 months, 8 years, and 7 years, respectively, after resection of Klatskin tumors and 5 of the 16 patients with resection of lower third carcinomas are alive 8 months to 9 years after operation, respectively. Surgical bypass by the Hepp or Soupault approaches to the left duct or to the duct of segment V of the right lobe was used in 47% of patients with Klatskin tumors and 58% of patients with pseudo-Klatskin rumours. Median survival times were 6 months and 4 months, respectively, in these two groups. Surgical bypass,vas used in 67% of patients with carcinoma of the middle third and 13% of patients with carcinoma of the lower third of the bile duct. Median survival time was 6 months. Prosthetic bypass was used in patients considered unfit for major surgical intervention (9% of patients with Klatskin tumors, 14% of patients with pseudo-Klatskin tumors, and one patient with carcinoma of the middle third). Survival times were only days to weeks after intervention. In seven patients (7.7%) there was no active intervention on the grounds of the patients' condition or the advanced stage of the disease. Resection offers the only chance of cure and is feasible in most patients with carcinoma of the lower third and in a substantial number of patients with Klatskin tumors. Operative bypass results in high quality palliation for meaningful periods in patients with Klatskin tumors, but the duration of palliation in patients with pseudo-Klatskin tumors is disappointingly short. The overall dividend in this subgroup is questionable in view of the advanced stage of the disease at presentation, and some or most of these patients should probably fall into the category where a decision not to intervene actively by either operative or nonoperative means appears to be the most appropriate and humane course of action.
