The vast majority of patients with pCC have jaundice at pre­sentation requiring a prompt management. In particular, a prolonged obstructive jaundice due to pCC might cause hepatic dysfunction and increase the risk of postoperative mortality in patients undergoing major/extended liver resec­tion [9]. Even though Farges et al. reported that patients undergoing left-sided hepatectomy should not undergo pre­operative biliary drainage, pCC patients undergoing right­side major hepatectomies should undergo biliary drainage to reduce the post-operative complications [10]. While there is a general consensus on the bile drainage of the FLR, the opti­mal type of biliary drainage (i.e., percutaneous transhepatic biliary drainage [PTBD] or endoscopic biliary drainage [EBD]) is still being debated [11]. In particular, while Eastern authors have reported that PTBD might increases the incidence of metastasis and EBD is recommended as the optimal method for preoperative biliary drainage, several Western authors did not identify any difference when com­paring PTBD and EBD [12, 13]. A recent randomized clini­cal trial comparing PTBD and EBD for resectable pCC patients was prematurely stopped because of higher all-cause mortality in the PTBD group [14]. Interestingly, post-drain­age complications were similar between the two groups indi­cating the need of more evidence to identify the optimal strategy for biliary drainage for pCC patients [14]. Finally, even though Eastern surgeons suggest to perform an endo­scopic nasobiliary drainage (ENBD) for pCC patients under­going liver surgery based on studies reporting a low incidence of preoperative cholangitis, currently, ENBD is rarely per­formed in Western centers [15].

Accurate cross-sectional imaging is required to diagnose and stage the tumors as well as plan resection or other possible treatments. Most patients will be imaged with a number of modalities.

The treatment protocols for ICC are in the development phase when compared to other intrahepatic tumors, owing to the rarity of the tumor. Surgical resection is the most effective treatment for ICC at the present time, but its resect­ability and curability remain low. Less commonly, liver transplantation has also been applied. The current roles of neoadjuvant and adjuvant chemotherapy, both systemic and regional; conformal radiation therapy; and ablative thera­pies are under investigation. We aim to review the surgical aspects of the management of ICC including major hepatic resection.

chemotherapy and/or radiotherapy has failed to improve sur­vival in most patients of ICC [11].

The main goal of surgical resection for ICC is to perform R0 margin negative resection with preservation of an adequate future liver remnant (FLR), which means two or more con­tiguous liver segments with adequate arterial and portal inow, biliary drainage, and venous outow [11]. Unlike HCC, most ICC cases have poor blood supply and rare liver cirrhosis, thus extended hepatectomy is often required, including bloc resection with resection of the vessel, bile duct, and adjacent tissue invaded by the tumor in some cases. The extent of resection should be determined by the size and location of the lesion, satellite situation, and the degree of tumor inltration [2].

or more contiguous liver segments with adequate arterial and portal inow, biliary drainage, and venous outow [11].

A FLR size of at least 20% is generally recommended for patients without underlying liver disease. For patients with underlying hepatic steatosis, the FLR size should be at least 30%. For patients with liver cirrhosis and brosis with preserved hepatic function (Child A patients), at least 40% are required to avoid the risk for the development of posthepatectomy liver dysfunction and failure [15]. For patients with marginal expected FLR volume, measures to improve the FLR volume had been applied. Preoperative portal vein embolization (PVE) is usually employed to cause hypertrophy of the contralateral lobe and achieve greater FLR volume. It is applied under radiologic guidance where selective embolization of the target branches of the portal vein is performed. If PVE is properly selected and managed, patients with Child A cirrhosis may achieve similar long­term oncologic outcomes compared to patients with no underlying liver disease [16, 17]. Improvement of FLR with the application of preoperative PVE had been reported to be around 30%–50% after 4–8 weeks from preoperative PVE. The FLR volume increase caused by PVE ranges between 30% and 50% after 4–8weeks; however, it also may increase the risk of drop-out by up to 30% [18].