Modern radiologic diagnostic approaches that identify patients with high bile duct cancer can predict resectability and provide information for biliary-enteric bypass in the case of irresectability. Twenty percent to 40% of patients are resectable by local excision with or without hepatic resection, and this represents the only opportunity for cure. Operative mortality is now acceptable and resection is associated with a median survival of approximately 35 months. Numerous palliative operative and nonoperative approaches are available, including biliary-enteric bypass, transtumoral stenting, and percutaneous endoprostheses. The role of both intraluminal and external beam radiotherapy also is discussed.