Advanced Carcinoma of the Gallbladder-Diagnosis of Extension and Choice of Operative Procedure

Abstract

Advanced carcinoma of the gallbladder can be classified by mode of infiltration into four types: Adjacent organs are involved by localized carcinoma of the liver bed type, whereas the hilar type is diffusely infiltrating carcinoma involving the liver along the bile duct at the hepatic hilus. The liver bed and hilar type of carcinoma shows a large mass involving the liver, hepatic hilus, adjacent organs and regional lymph nodes. The lymph node metastatic type has a rather small primary lesion with extended metastatic nodes involving the pancreas, duodenum and/or portal vein. Intrahepatic extension and lymph node metastasis are shown by ultrasonography and computed tomography. Duodenal involvement is demonstrated by hypotonic duodenography and endoscopic ultrasonography. Extension of cancer invasion to the bile duct can be diagnosed by selective cholangiography through transhepatic biliary drainage and percutaneous transhepatic cholangioscopy. Selective hepatic arteriography and percutaneous transhepatic portography are helpful for diagnosing the vessel involvement. Standard operations are hepatic segmentectomy for the liver bed type of carcinoma and extended right hepatic lobectomy with caudate lobe resection for the hepatic hilar type. Hepatopancreatoduodenectomy is indicated for extremely advanced carcinoma of the liver bed and hilar type which also involves the pancreas and duodenum, forming a large mass. The lymph node metastatic type of carcinoma requires liver bed resection for the primary lesion and extended lymphadenectomy combined with aggressive resection of the adjacent organs. Resection combined with that of the surrounding organs should be chosen not only to minimize the operative hazards but also to improve the curability.