What is the management for a 65-year-old lady with right hypochondrial pain, a dilated gallbladder, and peritoneal nodules, but no stones in the distal common bile duct (CBD)?

Management of Gallbladder Cancer with Peritoneal Metastasis

For a 65-year-old lady with right hypochondrial pain, dilated gallbladder, and peritoneal nodules, palliative cholecystectomy is the most appropriate management option.

Clinical Assessment and Diagnosis

The presentation of this elderly patient with:

• Right hypochondrial pain
• Dilated gallbladder on laparoscopy
• Peritoneal nodules
• No stones in distal CBD

Strongly suggests gallbladder cancer with peritoneal metastasis. This clinical picture is consistent with malignancy rather than a benign biliary condition.

Key Diagnostic Considerations:

• The presence of peritoneal nodules is highly suggestive of peritoneal carcinomatosis
• Dilated gallbladder without CBD stones indicates possible malignant obstruction
• The age of the patient (65 years) places her in the high-risk demographic for gallbladder cancer

Management Options Analysis

Option A: En bloc Gallbladder Resection

• While this would be appropriate for localized gallbladder cancer, the presence of peritoneal nodules indicates metastatic disease
• En bloc resection is typically reserved for potentially curative cases without distant metastasis
• Not appropriate given the evidence of peritoneal spread

Option B: Simple Cholecystectomy

• Inadequate for suspected malignancy
• Does not address the peritoneal disease
• Insufficient for symptom management in this clinical scenario

Option C: Palliative Cholecystectomy

• Most appropriate option for this patient with likely gallbladder cancer and peritoneal metastasis
• Provides symptom relief from the right hypochondrial pain
• Allows for tissue diagnosis and staging
• Addresses the primary tumor while acknowledging the non-curative nature of the intervention given the metastatic disease

Option D: Drainage Stents Bypass

• While biliary drainage procedures are useful in managing biliary obstruction, they don't address the primary gallbladder pathology
• The British Society of Gastroenterology recommends that "stenting as definitive treatment should be restricted to a very few patients who have limited life expectancy or are judged to be at prohibitive surgical risk" 1
• May be considered as an adjunctive procedure if biliary obstruction develops later

Evidence-Based Rationale

The management approach is supported by case reports of similar presentations. A case report by Hiramatsu et al. described a patient with "acute acalculous cholecystitis caused by gallbladder metastasis due to the peritoneal dissemination of gastric cancer" who was successfully treated with laparoscopic subtotal cholecystectomy 2. This case demonstrates the feasibility and appropriateness of palliative surgical intervention in the setting of peritoneal carcinomatosis.

Another relevant case report by Sato et al. described conversion surgery following chemotherapy for initially unresectable gallbladder cancer with peritoneal carcinomatosis 3. This suggests that palliative procedures may be part of a broader treatment strategy that could later include systemic therapy.

Management Algorithm

1. Initial Management: Palliative cholecystectomy

   • Provides symptom relief
   • Obtains tissue for definitive diagnosis and molecular testing
   • Prevents complications like acute cholecystitis

2. Post-operative Care:

   • Histopathological confirmation of diagnosis
   • Staging workup (if not already completed)
   • Multidisciplinary tumor board discussion

3. Subsequent Management:

   • Systemic chemotherapy (gemcitabine plus cisplatin is standard first-line therapy for advanced biliary tract cancers)
   • Consider conversion surgery if excellent response to chemotherapy
   • Ongoing symptom management and supportive care

Potential Complications and Considerations

• Palliative cholecystectomy may be technically challenging due to inflammation or tumor infiltration
• Risk of bile leak or bleeding
• Need for careful dissection around Calot's triangle
• Subtotal cholecystectomy may be necessary if anatomy is unclear

Conclusion

Based on the clinical presentation and available evidence, palliative cholecystectomy (Option C) is the most appropriate management for this 65-year-old lady with right hypochondrial pain, dilated gallbladder, and peritoneal nodules. This approach addresses her symptoms while allowing for tissue diagnosis and potential subsequent systemic therapy.