This report reviews the experience of the Hepatobiliary Unit, Royal Postgraduate Medical School, Hammersmith Hospital, London with 16 patients having proximal extrahepatic bile duct malignancy who underwent resection and a comparable group of 15 patients who had surgical bypass. The purposes of the review were to evaluate morbidity and mortality in both treatment groups, to assess whether either treatment influenced the natural history of the disease, and to examine the pathological features of the resected lesions, attempting to correlate the macroscopic and microscopic features with radiological and surgical observations and survival. The presenting symptoms, average age, clinical data, and length of hospital stay were similar in both groups. Hospital mortality, despite 12 major liver resections, was less in the resectional than in the bypass group--19% versus 26%. The average survival for resectional patients was 16.5 months with six of the 13 patients who left hospital still alive, one at 5 years. The bypass patients lived an average of 7 months with no patients surviving beyond 11 months. Both resectional and bypass treatments appeared to influence survival in this disease with greater length and quality of survival being associated with resection. While there were a number of distinctive pathological features associated with the resected tumors, none correlated with survival.