Surgery for cancer gall bladder a stage wise approach

1. Management Strategy in Cancer Gall bladder
Dr Harischandra Mishra
M.S., FAIS, D.N.B. (G.I.Surgery), Asian Institute of Gastroenterology, Hyderabad
SR, Dept. of Surg. Gastro. SCBMCH, Assoc Prof & HOD, Sum hospital, BBSR
Consultant Endoscopic, Laparoscopic, Cancer & Gastro-intestinal Surgeon ,LIGG,Cuttack
Life Institute of Gastroenterology and Gynaecology
Potapokhari, Nayabazar, Cuttack, Orissa
Details : www.ligg.co.in
For Appointment : 9338312205,06712444902

2. Points of Discussion
• Investigations in patients suspected to have Ca GB
• Staging of Ca GB
• Management in Different stages
• Recent Updates of Role of Surgery

3. Ultrasonography
• Most frequently the initial diagnostic study

5. Multislice Spiral CECT – in triple phase
 The most common evaluative imaging in Ca GB
 Useful in both diagnosis and staging.
 Detect liver or porta hepatis invasion,
lymphadenopathy, and inv. of the adjacent organs.
 Four patterns of gallbladder cancer
 a polypoid mass within the gallbladder lumen (15–25%),
 focal wall thickening,
 diffuse wall thickening (20% Ca GB), and
 mass replacing the gallbladder (40–65%).

6. D/d : Xanthogranulomatous Cholecystitis, Adenomyomatosis, GB Polyp

8. Lymphatic
drainage of GB

11. Nevin’s staging
Stage Definition
 I Tumour invades mucosa
 II Tumour invades mucosa + muscularis
 III Tumour invades mucosa + muscularis + subserosa
 IV Tumour invades all 3 layers of gallbladder + cystic lymph node
 V Tumour extends into liver bed or metastases

14. Incidental or missed Gallbladder cancers
( who have undergone - simple cholecystectomy)
• T1a tumors - simple cholecystectomy is adequate
• Stage T1b or more - radical repeat resection
(after a thorough workup : role of PET CT )
• * better survival compared with only simple cholecystectomy

15. BD resection (Intraoperative dilemmas)
• Desmoplasia vs tumour infiltration of BD
– Unclear on frozen section examination
• Incidental GBC
– Cystic duct margin status not known
– Cystic duct stump not discernible at completion radical surgery
• Node encroaching onto BD
• To permit adequate nodal clearance
• Devascularised bile duct after lymphadenectomy

16. Bileductinvolvement

17. Combined EHBD resection for locally
advanced GBC without EHBD invasion
• No benefit
• Increases morbidity
– Donohue 2001, Kondo 2002, Suzuki 2004, Chijiiwa 2001,
– Foster 2007, D’Angelica 2009, Choi 2013, Wigger 2014
Role of routine resection of the CBD in Gall bladder Ca
Selective and Not routine

18. Early lesions
• T1a :
– simple cholecystectomy  (90–100% cure rate)
• T2 :
– simple cholecystectomy  5-yr DSS of 24–40%
– cholecystectomy combined with liver resection and
regional lymphadenectomy  >80% long-term survival
rate

19. Radical resection for T3 and T4 gallbladder disease
(especially in the absence of nodal metastasis )
• Has gathered support in recent years
• Data confirming 5-year survival rates
– 15% to 67% for T3 Tumors,
– 7% to 33% T4 tumors

20. Wedge Resection (2cm) vs Segment IV b & V
– no difference

21. SURGICAL PROCEDURE
• Diagnostic laparoscopy performed only in selective cases (2) – if any suspicion
is there in Pre Op CECT scan for liver / peritoneal metastasis.
• On laparotomy (Extended Right Subcoastal Incision) : metastatic lesion
excluded, extensive celiac and para-aortic lymphadenopathy excluded.
• Radical cholecystectomy performed with 2cm margin from grossly involved
area by using Clamp crushing (Kelly-clysis) , Harmonic Scalpel and Vessel
sealer of KLS Martin.

22. SURGICAL PROCEDURE
• Complete excision of bile duct with hilum (1cm above the level of obstruction)
is performed, Lower end CBD closed in supraduodenal part after Portal LN
dissection.
• Cystic Lymph node , Periportal (Both anterior and posterior) and common
hepatic artery and celiac axis Lymph nodes are excised.
• 2 cases involved segment of Right hepatic artery was excised

23. Ca GB with SOJ : CBD division at supraduodenal part

24. Adjacent Organ resection:- distal Gastrectomy / segmental colectomy
Localorganinvolvement:Stomach/colon

25. • Reconstruction by two separate hepaticojejunostomy (one for RHD and one for
LHD) [in 1 case LHD reconstructed after joining the ducts of segment 4 with
duct of left lateral segment] was done in 4cases. In 10 cases single HJ was
performed using PDS 4-0.
• Anastomotic stent using No 5/6 Infant feeding tube was routinely used and
removed after Post operative cholangiogram revealed no leak.
SURGICAL PROCEDURE

26. MRCP : Separation of RHD & LHD

27. Porta dissection & Reconstruction using two HJ

28. Given the poor prognosis of patients with gallbladder cancer with T ≥ 2 and/or
node-positive disease, we recommend adjuvant therapy
Review Article
Gallbladder Cancer in the 21st Century
Journal of Oncology
Volume 2015, Article ID 967472, 26 pages

29. Patients Data
Total No of patients with Ca GB
operated
(Between June 2009 to May 2015)
42 N0 N1 N2
Only Radical cholecystectomy 24 pts 9 9 6
CBD resection + HJ 14 Pts (30%) 4 4 6
Whipples Pancreaticoduodenectomy 1 Pt 0 1 0
Transverse colectomy 1 Pt 1 0 0
Distal gastrectomy 1 pt 0 1 0
Distal gastrectomy + Transverse
colectomy
1 pt 0 1 0
Total 14 pts 16 pts 12 pts
LYMPH NODE POSITIVITY ( N=28, 67% )

30. Results
Follow up : 6-66 months
Median : 38 months
Total = 42 pts Only Radical
Cholecystectomy Pts
N= 24pts
Pts with CBD excision or PD/
gastrectomy/ colectomy
(n=18 pts)**
IN HOSPITAL MORTALITY NIL Nil Nil
MORBIDITY
a) Wound infection
b) Bleeding
c) Bile leak
6 Pts (14%) 3pts
wound infection
Minor - 2
Major – 1
3pts
wound infection
Minor - 2
Minor Bile leak – 1pt
R0 resection 34 pts (81%) 19 pts (3pts *) 15 pts
R1 resection 8 pts (19%) 5pts 3pts
LN s N0/N1**/N2** 14/16/12 9/9/6 5/7/6
1yr DFSS 32 pts 18 pts (67%) 14 pts (77%)
Recurrence at 1yr 10 pts 6pts 4pts
2 yr DFSS 26 PTS (62 %) 15pts (62.5%) 11pts (61.11%)
Recurrence at 2yr 16 pts 9pt 7pt
* 3 cystic duct margin + ve on frozen section underwent CBD excision
** All patients received 6 cycles of chemotherapy (Gemcitabine + Cisplatin) , 2 patients received further
6cycles of CT.

31. Conclusions:
• Resection of T3-4 Gall Bladder Cancer is worthwhile only if R0 surgery is
achievable. Outcomes improved in most recent years.
• Limited N2 metastases should not preclude surgery.
• Good results are possible even with CBD resection or adjacent organ resection.
1. A. X. Zhu, T. S. Hong, A. F. Hezel, and D. A. Kooby, “Current management of gallbladder carcinoma,” The
Oncologist, vol. 15, no. 2, pp. 168–181, 2010.
2. Rani Kanthan,1 Jenna-Lynn Senger,2 Shahid Ahmed,3 and Selliah Chandra Kanthan4, Gallbladder Cancer in
the 21st Century Journal of Oncology Volume 2015, Article ID 967472, 26 pages.
3. Michael D’Angelica, Kimberly Moore Dalal, Ronald P. DeMatteo, Yuman Fong, Leslie H. Blumgart and
William R. Jarnagin Analysis of the Extent of Resection for Adenocarcinoma of the Gallbladder Analysis of the
Extent of Resection for Adenocarcinoma of the Gallbladder
Reference:

32. Management Strategy in Cancer Gall bladder
Dr Harischandra Mishra
Consultant Endoscopic, Laparoscopic, Cancer
& Gastro-intestinal Surgeon ,LIGG,Cuttack
Life Institute of Gastroenterology and Gynaecology
Potapokhari, Nayabazar, Cuttack, Orissa
For Appointment : 9338312205,06712444902
Thank You all
For Details : www.ligg.co.in
Consult for all Gastrointestinal, Hepatobilliary
pancreatic and Gynaecological Cancer