*Purpose: To compare the outcomes of patients with hilar cholangiocarcinoma (hCCA) who underwent either surgical resection or liver transplantion (LT).

*Methods: All hCCA patients who underwent resection or LT between 2010-2020 were included. Standard diagnostic criteria for hCCA were used. Surgical resectability was based on the likelihood of R0 resection and extent of tumor invasion into bile ducts (up to the second order branching)and vessels. Patients with nonresectable tumors underwent the LT protocol with neoadjuvant chemoradiation/brachytherapy, staging laparotomy and maintenance chemotherapy until LT. For LT , the lesion had to be located at the hilum with stricture above the cystic duct, with no evidence of metastasis, mass lesion less than or equal to 3cm and negative regional lymph node biopsies on endoscopic ultrasound. Survival of patients was evaluated with Kaplan Meier curves.

*Results: Twenty-six patients underwent surgical resection of hCCA and 22 patients underwent the LT protocol with 15 (68%) undergoing LT. Of the patients who underwent surgical resection, 13 (50%) are still alive. Sixteen (73%) patients who were enrolled in the LT protocol are alive and 14 (93%) patients who underwent LT are alive. On an intention to treat analysis, Kaplan Meier analysis showed no difference in survival between the two groups. However, there was a significant improvement in survival in patients who underwent LT compared to resection (93% vs 50% probability of survival at 5 years, P=0.04).

*Conclusions: Patients who complete the neoadjuvant chemoradiation protocol and undergo LT have a significantly higher a survival rate compared to those undergoing resection. However, on an intention to treat basis, the overall survival of patients undergoing the LT protocol is comparable to patients who undergo surgical resection. All patients with unresectable hCCA may benefit from neoadjuvant chemoradiation followed by LT.

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