Philosophy of Management of Gall Bladder Cancer

Abstract

The philosophy of management of gall bladder cancer ranges from the Japanese aggressive approach (major supra-radical multi-organ resections for advanced disease) at one end to the western pessimistic nihilism (inappropriate management of even early disease) at the other. An Indian “Buddhist” middle path, i.e., aggressive surgical approach towards early (and incidental) gall bladder cancer and non-surgical palliation for advanced gall bladder cancer has been advocated by the author (VKK).

Please also see an Invited Commentary on Philosophy of Management of Gall Bladder Cancer by Hiroaki Shimizu (pp **–**)

Invited Commentary on Philosophy of Management of Gall Bladder Cancer

• Hiroaki Shimizu 

The contents of this chapter include a review of the surgical indications and operative procedures for gallbladder cancer (GBC) (early and advanced stage) in the West and Japan, and clearly show the differences in philosophy and surgical management for GBC between the two. Comparing the two different approaches, the Author (VKK) has established his own philosophy of surgical management (the Indian approach) for GBC, taking good points from each, which seems to be in the middle of Japanese aggressive and Western pessimistic approaches.

The majority of GBC is diagnosed at advanced stage. Surgical complete resection (R0 resection) is the only potentially curative treatment and remains mainstay of management to achieve long-term survival in patients with GBC, but postoperative prognosis is closely correlated with the stage of the disease. In pT1 GBC, lymph node metastasis has almost never been found in Japan; therefore, good prognosis can be achieved even after simple cholecystectomy. As to pT2 GBC, the appropriate surgical strategy can achieve a prognostic improvement, but standard surgical procedure remains controversial in Japan; gallbladder bed resection or resection of liver segments IVA + V (subsegment IVB is called IVA in Japan), and combined with or without extrahepatic bile duct resection for lymph node dissection. There is still no definitive conclusion as to the most preferable surgical procedures for pT2 GBC.

On the other hand, the prognosis is quite poor in pT3 and pT4 GBC, even after complete resection of the tumor. In 1980s, Japanese hepatobiliary surgeons aggressively challenged to perform extended surgical procedures, such as extended right hepatectomy (ERH), hepato-pancreatico-duodenectomy (HPD) or hepato-ligamento-pancreatico-duodenectomy (HLPD) to increase resectability (Takasaki et al. 1980; Nimura et al. 1991). These ultimate procedures carried a high risk of postoperative morbidity and subsequent mortality. In spite of this, very few patients could be cured. Therefore, surgeons in the West have criticized these procedures.

At present, with improvement of surgical techniques and perioperative patient care, including preoperative biliary drainage (PBD) and portal vein embolization (PVE), mortality rate after extended surgical procedures, such as HPD have gradually decreased in Japan. Higher hospital volume is also associated with lower morbidity and mortality rates. However, recent reports have shown still extremely poor survival in patients with locally spreading GBC requiring HPD. The Nagoya group in Japan clearly stated that the indication for HPD for advanced GBC is not recommended from an oncological viewpoint (Mizuno et al. 2019a). That is, advanced GBC requiring HPD, represents technically resectable but oncologically unresectable disease, because of aggressive tumor biology. At present, the role and indication for extended resections such as HPD to achieve complete resection of the tumor in patients with locally spreading GBC should be reconsidered.