How do you determine resectable vs unresectable (unable to be surgically removed) gallbladder cancer?

Determining Resectability in Gallbladder Cancer

Gallbladder cancer is resectable when delayed-contrast CT/MRI demonstrates no distant metastases, no involvement of major vessels (hepatic artery, portal vein), and nodal disease confined to the porta hepatis, gastrohepatic ligament, and retroduodenal regions—with staging laparoscopy confirming absence of peritoneal disease before proceeding to laparotomy. 1

Imaging-Based Assessment Algorithm

Required Initial Workup

• Delayed-contrast CT or MRI to characterize the primary tumor, its relationship to major vessels and biliary tree, presence of satellite lesions, distant liver metastases, and lymph node involvement 1
• Chest imaging to exclude pulmonary metastases 1
• Multidisciplinary review involving experienced radiologists and surgeons is mandatory to accurately stage disease and determine treatment options 1

Criteria for Unresectability (Absolute Contraindications)

• Distant metastases in liver, lungs, or peritoneum 1
• Major vascular involvement of hepatic artery or portal vein that cannot be reconstructed 1
• Nodal disease beyond regional stations: Celiac, retropancreatic, or interaortocaval lymph nodes indicate unresectable disease 1
• Extensive biliary tree involvement precluding adequate margin clearance 1

Staging Laparoscopy: Critical Step

Staging laparoscopy has high yield and is recommended before laparotomy for all patients with potentially resectable disease on imaging 1. This step is crucial because:

• 74% of patients have residual disease found at surgical exploration that was not detected on imaging 1, 2
• Laparoscopy identifies peritoneal metastases and unresectable disease, avoiding unnecessary laparotomy 1
• Should be performed if no distant metastasis is found on cross-sectional imaging 1

Stage-Specific Resectability Guidelines

T1a Disease

• Simple cholecystectomy is curative if margins are negative 1, 3
• No additional resection required 1

T1b Disease

• Extended cholecystectomy recommended (cholecystectomy with en bloc hepatic resection and lymphadenectomy) 1, 2, 3
• Requires confirmation of no metastatic disease via CT/MRI, chest imaging, and laparoscopy 1

T2 and Above

• Extended cholecystectomy is mandatory: en bloc hepatic resection (wedge resection of GB bed or segmentectomy IVb/V), lymphadenectomy including porta hepatis, gastrohepatic ligament, and retroduodenal regions, with or without bile duct excision 1, 3
• Major hepatectomy and bile duct excision should only be performed when necessary to achieve negative margins 1

Critical Pitfalls to Avoid

Do not proceed with surgery if resectability has not been established through proper imaging and multidisciplinary review 1. Common errors include:

• Attempting resection without staging laparoscopy in potentially resectable cases 1
• Operating without surgeon expertise in hepatobiliary cancer surgery 1
• Missing nodal disease beyond regional stations on imaging review 1
• Failing to obtain intraoperative frozen sections to confirm resectability 1

Real-World Resectability Rates

Only 15-47% of preoperatively known gallbladder cancers are suitable for resection 4, with actual curative resection rates ranging from 19.8-30% in contemporary series 5, 4. This emphasizes the importance of rigorous preoperative assessment, as most patients present with advanced disease precluding curative surgery 1, 5.

When Unresectable Disease is Confirmed

If imaging or laparoscopy reveals unresectable disease, biopsy confirmation is required before initiating palliative therapy 1. For patients with jaundice, biliary drainage should be performed before chemotherapy as it improves quality of life 1.