Editing Gallbladder cancer (section)

== '''Management''' ==

* Principles
** Resection is the only chance for cure
* Based on TNM stage
*
* '''T1a disease:'''
** Cholecystectomy is sufficient
** Out of 706 patients, only 1.8% had LN mets, and only 1.1% died from disease
** Carefully verify negative margins, especially cystic duct
** If GB wall margin is involved, liver resection will be necessary
** If cystic duct margin is involved, CHD and extra-hepatic CBD excision with Roux-en-Y reconstruction, but no staging workup or nodal dissection necessary
* '''T1b disease:'''
** Need complete staging workup
** Traditionally, simple cholecystectomy, but now aggressive resection is favoured, especially in setting of high-risk histopathological factors (perineural, lymphatic or vascular invasion)
** Higher rate of LN mets than T1a (10.9%) and up to 13% have residual disease at re-excision
** '''Offer re-excision with radical/extended cholecystectomy'''
* '''T2a disease:'''
** May not need to re-resect because rate of liver involvement is obviously lower, although this is partly controversial, and UTD still recommends '''re-resection as for T2b'''
* '''T2b disease:'''
** 10.4% have hepatic disease
** 31% have N1 LN involvement
** Strong indication for definitive extended re-excision - extend 5-year survival from 20% to >80%
** '''Radical cholecystectomy'''
* '''Advanced tumours (T3):'''
** '''Radical resection may be potentially curative''' in some patients, although outcomes are poor
** Start with staging laparoscopy - peritoneal or hepatic metastases preclude an operation
** Everything aimed at getting complete resection - no role for debulking if R0 cannot be obtained
** Likely to be considered for adjuvant chemotherapy
* '''T4'''
** UTD states that attempts at resection are likely futile. Could still be considered.
* '''Choice of re-resection procedure'''
** 2cm rim of liver tissue vs anatomic IVb/V resection - similar recurrence rate, as long as negative margins are obtained, but the anatomic resection has a lower complication rate
** Either way, remove lymph nodes from cystic triangle, hepatoduodenal ligament and porta hepatis
** May require resection of CBD margin, in which case reconstruction will be needed
** Consider port site resection although probably not
* '''Unresectable or metastatic disease'''
** Chemotherapy and radiotherapy have not shown survival benefits
** Jaundiced patient with advanced unresectable disease should have PTC or ERCP drainage
*** Biliary bypass is generally difficult because of advanced disease in porta hepatis
** Neurolysis of coeliac plexus can help with pain
** Can get GOO from local extension of tumour, which can be managed by an endoscopic duodenal stent
* '''Portal lymphadenectomy'''
** Indicated in T2-T4 tumours
** Most surgeons resect cystic, periportal, and hepatic artery nodes
** Guidelines suggest that you need six nodes to be considered node negative
* '''Port site resection'''
** Not associated with improved overall or disease-free survival
* '''Absolute contraindications to surgery:'''
** Medical comorbidities preventing surgery
** Distant mets including liver, peritoneum
** Involvement of N2 lymph nodes (coeliac, peripancreatic, peri-duodenal, or SMA
** Malignant ascites
** Significant involvement of hepatoduodenal ligament
** Encasement of major vasculature