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

Management of Gallbladder Cancer with Peritoneal Nodules

Based on the clinical findings of a dilated gallbladder and peritoneal nodules in a 65-year-old female with right hypochondrial pain, the most appropriate management is option A: Enblock gallbladder resection.

Disease Assessment and Staging

The clinical presentation strongly suggests gallbladder cancer (GBC) with peritoneal metastasis. The key findings include:

• 65-year-old female with right hypochondrial pain
• Dilated gallbladder on laparoscopic exploration
• Peritoneal nodules visualized during laparoscopy
• No stones in the distal common bile duct (CBD)

These findings are consistent with stage IVB gallbladder cancer with peritoneal carcinomatosis, which has traditionally been considered unresectable.

Rationale for Enblock Gallbladder Resection

The presence of peritoneal nodules indicates metastatic spread, which significantly impacts prognosis. However, recent evidence supports aggressive surgical management in selected cases:

• Enblock resection provides the best chance for R0 margins, which is essential for improved survival 1
• Complete resection of visible disease may improve long-term outcomes even in the presence of limited peritoneal disease 2, 3
• Peritoneal carcinomatosis is a common pattern of recurrence in GBC, and addressing it during initial surgery may prevent future relapse sites 4

Why Other Options Are Less Appropriate

1. Simple Cholecystectomy (Option B) is inadequate for suspected malignancy with peritoneal spread, as it:

   • Does not address the peritoneal disease
   • Increases risk of tumor cell dissemination
   • Is only appropriate for T1a lesions without evidence of spread 5

2. Palliative Cholecystectomy (Option C) would not provide adequate oncologic control and:

   • Fails to address the peritoneal disease
   • May lead to rapid disease progression
   • Does not offer the potential for long-term survival 6

3. Drainage stents/bypass (Option D) is purely palliative and:

   • Does not address the primary tumor
   • Offers no chance for disease control
   • Is appropriate only for patients unfit for surgery or with extensive unresectable disease 1

Multidisciplinary Approach

The management should include:

1. Surgical Approach:

   • Enblock gallbladder resection with wedge liver resection (segments IVb and V)
   • Total omentectomy to address peritoneal disease
   • Regional lymphadenectomy
   • Consideration of peritonectomy for visible peritoneal nodules 1, 4

2. Perioperative Management:

   • Careful assessment of resectability with high-quality imaging
   • Consideration of exploratory laparoscopy to confirm extent of disease 1
   • Perioperative antibiotics to prevent infectious complications

3. Adjuvant Therapy:

   • Systemic chemotherapy (gemcitabine plus cisplatin) following resection 2, 3
   • Close surveillance for recurrence

Evidence for Aggressive Approach

Case reports demonstrate long-term survival is possible with aggressive surgical management even in the presence of peritoneal disease:

• A patient with residual GBC and peritoneal dissemination survived 6 years after multidisciplinary therapy including extended resection following chemotherapy 2
• Another patient with initially unresectable GBC with peritoneal carcinomatosis survived 31 months after conversion surgery following chemotherapy 3

Cautions and Considerations

• Patient selection is critical - factors such as extent of peritoneal disease, patient's performance status, and liver function must be carefully evaluated
• The procedure carries significant morbidity and should be performed at centers with expertise in hepatobiliary surgery
• R0 resection (complete removal with negative margins) is the goal, as positive margins significantly worsen prognosis 1, 5
• Laparoscopic approach should be converted to open if adequate oncologic resection cannot be achieved 1

While the prognosis remains guarded, an aggressive surgical approach with enblock resection offers the best chance for disease control and potential long-term survival in this challenging clinical scenario.