1. Gallbladder Cancer Surgical Management
GI Conference Review
Department of Surgery

3. Introduction Poor prognosis Early GB cancer vs Advanced GB cancer
Except early-stage cases
Aggressive malignancy, predominantly in the elderly
Location of GB; liver, bile duct, major vessel invasion
Extensive L/N metastasis
At the time of presentation
25 % ; localized disease
35 % ; LN metastasis or adjacent organ invasion
40 % ; Already distant metastasis
Radiation, chemotherapy ; not effective
Early GB cancer vs Advanced GB cancer
Depth of invasion
Correlate with tumor spread, long term survival

4. Risk Factors Female gender ; F: M (2-6 : 1) Old age
Ethnic, geographical variation
Gallstones
GB polyp
Porcelain GB
Biliary tract anomaly ; APBDU
Exposure to carcinogen

6. TNM Staging

7. TNM Staging

8. Lymphatic Spread Cholecysto-celiac Cholecysto-mesenteric
Cholecysto-retropancreatic

9. Clinical Presentation
Presenting Syndrome
Signs and Symptoms
Percentage of Patients with GB ca.
Chronic cholecystitis
Postprandial RUQ pain, often recent change in character
40-45 %
Acute cholecystitis
Short-duration RUQ pain, N/V, Fever, Tenderness
15-20 %
Malignant biliary obstruction
Jaundice, Weakness, Weight loss, Anorexia, Pain
30-35 %
Malignant nonbiliary tract tumor
Anorexia, Weight loss, Weakness
25-30 %
Other GI problem
GI bleeding or obstruction
<5 %

10. Imaging Study Ultrasonography EUS Cholangiography CT MRI
Heterogenous mass replacing GB lumen
Irregular GB wall
EUS
Depth of invasion
Cholangiography
Long stricture of the CHD CT
Invasion into adjacent organs
Adjacent vascular anatomy
MRI

11. Clinical Groups Incidental GB cancer Apparent GB cancer
discovered during or after laparoscopic or open cholecystectomy for assumed benign disease
1~2% of cholecystectomy for gallstones
Apparent GB cancer
suspected and confirmed after clinical or diagnostic investigation
Advanced GB cancer

12. Surgical Management Early GB cancer Laparoscopic cholecystectomy
Bile spillage(30%)  peritoneal dissemination,
Port site recurrence(10-29%)
Open cholecystectomy ; gold standard
Simple cholecystectomy ; T1a
Extended cholecystectomy
GB + Liver bed + LN dissection

13. Incidental GB cancer

14. Mode of spread

15. Operation Rt Hepatic Duct Lt Hepatic Duct Pancreas Liver Stomach
Gallbladder
Cystic Duct
Common Bile Duct
Pancreatic Duct
Common Bile Duct
Duodenum

16. Extended cholecystectomy + PD

17. Apparent GB cancer

18. Advanced GB cancer Extended Cholecystectomy + Bile duct resection
Gross bile duct invasion
to facilitate LN Dissection
Extended Cholecystectomy + PV resection
PHA, LHA invasion ; contraindication
Extended Cholecystectomy + Liver resection
Extended hepatectomy after PVE
Extended Cholecystectomy + Extensive LND
Extended Cholecystectomy + PD
Hepatopancreatoduodenectomy (HPD)

19. Survival

20. References SABISTON. Textbook of Surgery 17th
Sasaki R, et al. Significance of extensive surgery including resection of the pancreas head for the treatment of gallbladder cancer--from the perspective of mode of lymph node involvement and surgical outcome. World J Surg Jan;30(1):36-42.
Sikora SS, et al. Surgical strategies in patients with gallbladder cancer: Nihilism to optimism. J Surg Oncol May 24;93(8):
Sicklick JK, et al. Controversies in the surgical management of cholangiocarcinoma and gallbladder cancer. Semin Oncol Dec;32
Wistuba II, et al. Gallbladder cancer: lessons from a rare tumour. Nat Rev Cancer Sep;4(9):
Misra S, et al. Carcinoma of the gallbladder. Lancet Oncol Mar;4(3):
Kondo S, et al. Mode of tumor spread and surgical strategy in gallbladder carcinoma. Langenbecks Arch Surg Oct;387(5-6):222-8.