Management of Gallbladder Cancer with Peritoneal Nodules
Enblock gallbladder resection (option A) is the recommended management for a 65-year-old lady with right hypochondrial pain, dilated gallbladder, and peritoneal nodules. 1
Clinical Presentation and Diagnosis
The clinical presentation of right hypochondrial pain with dilated gallbladder and peritoneal nodules on laparoscopic exploration, without stones in the distal CBD, strongly suggests gallbladder cancer with peritoneal metastasis. This is consistent with stage IVB gallbladder cancer with peritoneal carcinomatosis 1.
Key diagnostic considerations:
- Absence of gallstones does not rule out malignancy
- Peritoneal nodules are highly suspicious for metastatic spread
- Dilated gallbladder may indicate obstruction from the tumor
Rationale for Enblock Gallbladder Resection
Enblock resection provides the best chance for achieving R0 margins (complete removal with negative margins), which is essential for improved survival in patients with gallbladder cancer, even with peritoneal metastasis 1. The surgical approach should include:
- Enblock gallbladder resection with wedge liver resection
- Total omentectomy
- Regional lymphadenectomy
- Peritonectomy for visible peritoneal nodules
Why Not the Other Options?
Simple Cholecystectomy (option B) is inadequate for gallbladder cancer with peritoneal spread as it fails to address the extent of disease and would result in positive margins, significantly worsening prognosis 1.
Palliative Cholecystectomy (option C) would not provide adequate oncologic control and is insufficient for addressing the peritoneal disease.
Drainage stents/bypass (option D) is purely palliative, offering no chance for disease control, and is appropriate only for patients unfit for surgery or with extensive unresectable disease 1.
Evidence for Conversion Surgery
Recent case reports demonstrate that even patients with initially unresectable gallbladder cancer with peritoneal carcinomatosis can benefit from aggressive surgical approaches:
A case of conversion surgery following gemcitabine plus cisplatin therapy for initially unresectable gallbladder cancer with peritoneal carcinomatosis resulted in the patient surviving without recurrence for 19 months postoperatively 2.
Another report described a long-term survivor with residual gallbladder cancer with multiple peritoneal disseminations who underwent extended resection after effective chemotherapy and remained disease-free 6 years after surgery 3.
Surgical Considerations
The surgical approach should be carefully planned:
- Laparoscopic approach should be converted to open if adequate oncologic resection cannot be achieved 1
- Complete resection of visible disease may improve long-term outcomes even with limited peritoneal disease 1
- R0 resection (complete removal with negative margins) is the goal, as positive margins significantly worsen prognosis 1
Perioperative Management
- Careful assessment of resectability with high-quality imaging
- Consider exploratory laparoscopy to confirm extent of disease
- Perioperative antibiotics to prevent infectious complications 1
- Consider neoadjuvant chemotherapy if the disease appears initially unresectable
Postoperative Considerations
- Adjuvant chemotherapy should be considered following surgery
- Regular surveillance for recurrence
- Patient selection is critical, considering factors such as extent of peritoneal disease, patient's performance status, and liver function 1
In conclusion, while gallbladder cancer with peritoneal metastasis presents a challenging clinical scenario, enblock gallbladder resection offers the best chance for disease control and potential long-term survival in this 65-year-old patient.