Surgical management of gallbladder cancer.

Gallbladder cancer is a very common malignancy in the northern part of India. Surgery is the only potentially curative modality of treatment for this disease. Radical cholecystectomy is the optimal surgical standard for resectable gallbladder cancer. This includes cholecystectomy, liver resection (wedge, segments 4b and 5, or extended right hepatectomy), and regional lymphadenectomy along the hepatoduodenal ligament, behind the duodenum and pancreatic head, common hepatic artery and celiac axis. Controversies regarding extent of liver resection, lymphadenectomy and role of multiorgan resection have been discussed. Incidental gallbladder cancer is often detected on histopathologic examination of the simple cholecystectomy specimen removed for a presumed gallstone disease. Revision surgery should be performed for incidental cancers that invade muscularis propria or beyond (T1b or more). Advanced gallbladder cancer should be treated non-operatively with a palliative intent. Obstructive jaundice in the setting of an advanced gallbladder cancer can be palliated with biliary stenting by endoscopic or transhepatic means. Occasionally, a surgical biliary bypass may be indicated to relieve intractable pruritus in a jaundiced patient with gallbladder cancer. There is no role of a planned R2 resection of advanced gallbladder cancer for the purpose of cytoreduction. Further improvement in the management of gallbladder cancer will need integration of systemic chemotherapy with radical surgery.