Advanced Surgery for Gallbladder Cancer with Lymph Node Resection | Prof Dr Ünal Aydın

Gallbladder cancer is a rare but aggressive form of cancer. Because it may not cause symptoms in the early stages, it is usually diagnosed in advanced stages. This significantly impacts treatment options and the course of the disease. Advanced surgical interventions planned with a multidisciplinary approach are crucial, especially for gallbladder cancers that have spread (metastasized) to the lymph nodes. This article will discuss the surgical treatment of advanced-stage gallbladder cancer with lymph node involvement, current approaches in this field, and Prof. Dr. Ünal Aydın's expertise in this field.

What is Gallbladder Cancer? What are its Symptoms and Risk Factors?

The gallbladder is a small, pear-shaped organ located beneath the liver. Its primary function is to store bile produced by the liver and release it into the small intestine during digestion. Gallbladder cancer is the uncontrolled proliferation of cells that begins in the cells lining the inner surface of this organ.

Symptoms:

Early-stage gallbladder cancer usually doesn't cause specific symptoms. However, as the disease progresses, the following symptoms may appear:

• Abdominal pain: This pain is usually felt in the upper right abdomen, below the ribs. It may be constant or come and go.

• Jaundice: Characterized by yellowing of the skin and whites of the eyes, darkening of the urine, and lightening of the stool. It occurs as a result of bile duct obstruction.

• Nausea and vomiting: This can occur especially after fatty foods.

• Loss of appetite and weight loss: Significant and unexplained weight loss is an important sign.

• Itching: Generalized itching throughout the body may occur due to the accumulation of bile salts in the blood.

• Abdominal swelling: This may occur as a result of tumor growth or fluid accumulation in the abdomen (ascites).

• Fever: Although rare, it may occur as a result of inflammation caused by infection or tumor.

Risk Factors:

Some factors that play a role in the development of gallbladder cancer include:

• Gallstones: This is the most important risk factor. The risk increases in people with long-standing and large gallstones.

• Chronic cholecystitis: Long-term inflammation of the gallbladder.

• Porcelain gallbladder: This is a rare condition caused by calcification of the gallbladder wall and increases the risk of cancer.

• Gallbladder polyps: Especially polyps larger than 1 cm may carry the risk of becoming cancerous.

• Obesity: Being overweight increases the risk of gallbladder cancer just as it increases the risk of cancer in general.

• Advanced age: It is more common in people over 65 years of age.

• Female gender: It is more common in women than in men.

• Family history: In rare cases, people with a family history of gallbladder cancer may be at increased risk.

• Exposure to certain chemicals: The role of industrial chemicals and some toxins is being investigated.

• Abnormal bile duct junction (abnormal biliopancreatic junction): May cause reflux of pancreatic juice into the bile ducts, leading to chronic inflammation and cancer development.

Staging and the Importance of Lymph Node Involvement in Gallbladder Cancer

Staging gallbladder cancer is critical for treatment planning and determining prognosis. Staging assesses the tumor's depth within the gallbladder wall, its spread to adjacent organs, and whether it has metastasized to lymph nodes and distant organs.

Lymph Nodes and Cancer Spread:

The lymphatic system is a vital part of the body's immune system. Lymph nodes (lymph glands) are small, bean-shaped structures located along the lymphatic vessels and play a role in fighting infection. Cancer cells can travel from their organ of origin through the lymphatic vessels to the lymph nodes, where they can form new tumors (metastases).

Lymph node involvement in gallbladder cancer indicates that the disease has progressed locally and may take a more aggressive course. Spread to regional lymph nodes (lymph nodes close to the gallbladder) increases the stage of the disease and alters the treatment approach. Spread to distant lymph nodes or other organs (liver, lung, peritoneum, etc.) is considered advanced (metastatic) disease.

Surgical Treatment for Advanced Gallbladder Cancer with Lymph Node Involvement

Surgery is one of the most important treatment options for gallbladder cancer involving lymph nodes, controlling the disease, and prolonging survival. However, such surgeries are technically challenging and extensive. The goal is to completely remove the tumorous gallbladder tissue, some of the affected adjacent organs (if necessary), and the regional lymph nodes (radical surgery).

Advanced Surgical Techniques:

The main surgical procedures performed in gallbladder cancers with lymph node involvement are as follows:

1. Radical Cholecystectomy (Extended Cholecystectomy): Unlike simple cholecystectomy, which removes only the gallbladder, radical cholecystectomy involves the removal of the gallbladder along with a portion of the liver adjacent to the gallbladder (usually a segment IVb/V resection) and regional lymph nodes (hepatoduodenal ligament, portal, and retropancreatic lymph nodes). This is the most commonly performed standard surgical procedure.

2. Liver Resection: In cases of direct spread (invasion) of the tumor to the liver or lymph node metastases in the liver, more extensive liver resections (e.g., right hepatectomy, extended right hepatectomy) may be required.

3. Bile Duct Resection and Reconstruction: If the tumor has obstructed or spread to the bile ducts, removal of the affected bile duct segment and subsequent reconnection of the bile ducts to the small intestine (hepaticojejunostomy) may be necessary to maintain continuity of the digestive system.

4. Lymphadenectomy (Lymph Node Dissection): This is an integral part of surgical treatment. Systematic removal of regional lymph nodes (portal, peripancreatic, celiac, and lymph nodes surrounding the superior mesenteric artery) not only contributes to accurate disease staging but also helps eliminate microscopic cancer cells, reducing the risk of recurrence. The number of lymph nodes removed and their involvement are important factors in prognosis. A comprehensive lymphadenectomy increases the oncologic efficacy of surgery.

5. Adjacent Organ Resections: If the tumor has directly spread to adjacent organs such as the stomach, duodenum, or colon, partial or complete removal of these organs (multivisseral resection) may be necessary. These types of surgeries are quite complex and must be performed by experienced surgical teams.

Preoperative Evaluation and Preparation

Before surgery for advanced gallbladder cancer, a detailed evaluation of the patient is essential:

• Imaging Methods: Advanced imaging techniques such as Computed Tomography (CT), Magnetic Resonance Imaging (MRI), and Positron Emission Tomography (PET-CT) are used to assess tumor size, spread, lymph node involvement, and the presence of distant metastases. Endoscopic ultrasonography (EUS) can also be helpful in assessing regional spread and lymph node involvement.

• Biopsy: A biopsy is usually performed before surgery to make a definitive diagnosis. However, in some cases, especially for tumors that are considered resectable (removable), a diagnosis may be made during surgery.

• Blood Tests: Liver and kidney function tests, blood count, and tumor markers (CEA, CA 19-9) are evaluated. CA 19-9 is an important marker for follow-up and prognosis in gallbladder cancer.

• General Condition Assessment: The patient's age, additional diseases (cardiovascular, respiratory system diseases, etc.) and performance status are important in determining the risk and suitability of surgery.

• Nutritional Status: Weight loss and nutritional deficiencies, common in cancer patients, can negatively impact postoperative recovery. Preoperative nutritional support is provided if necessary.

• Jaundice Management: In patients with severe jaundice due to biliary obstruction, preoperative bile flow restoration may be necessary, either endoscopically (with ERCP and stenting) or percutaneously (with PTK drainage). This helps restore liver function and reduce surgical risks.

Prof. Dr. Ünal Aydın and His Approach to Advanced Gallbladder Cancer Surgery

Prof. Dr. Ünal Aydın is one of Türkiye's leading experts in general surgery, particularly hepatopancreatobiliary (HPB) surgery. With extensive experience in the surgical treatment of liver, pancreas, and biliary tract diseases, Prof. Dr. Aydın also has a keen interest in complex conditions requiring advanced surgical skills, such as gallbladder cancer.

Prof. Dr. Ünal Aydın's approach to advanced gallbladder cancer surgery is based on a multidisciplinary approach. Detailed preoperative evaluation, accurate staging, and patient-specific surgical planning are fundamental principles. In cases of lymph node involvement, radical resection and comprehensive lymphadenectomy, in accordance with oncological principles, are aimed at achieving local control and reducing the risk of recurrence.

Prof. Dr. Aydın's success in such complex surgeries stems not only from his surgical skills but also from his close knowledge of current literature, his adoption of innovative techniques, and his patient-centered approach. He meticulously monitors patients postoperatively and manages potential complications.

Postoperative Period and Treatment

The period after surgery for advanced gallbladder cancer is important for the patient's recovery and the planning of additional treatments.

• Intensive Care and Ward Monitoring: After surgery, patients are generally monitored in the intensive care unit for a period of time. Afterward, they continue to be monitored in the ward. Pain control, wound care, breathing exercises, and early mobilization accelerate the healing process.

• Nutrition: Postoperatively, the patient's nutrition is gradually initiated. If necessary, nutritional support is provided intravenously or through special tubes.

• Pathology Results: The surgically removed tumor and lymph nodes are sent for pathological examination. The pathology results contain important information such as the tumor type, grade, surgical margin status, and the exact number of lymph nodes involved. This information influences the decision to prescribe additional treatment (adjuvant therapy).

• Adjuvant Therapy: Chemotherapy and/or radiotherapy (radiation therapy) may be administered after surgery to reduce the risk of recurrence, depending on the pathology results. Adjuvant therapy is often recommended, especially for patients with positive lymph nodes or those with surgical margins close to the tumor.

• Follow-up: Patients are followed up regularly after surgery and adjuvant therapy. Follow-up includes physical examination, blood tests (especially CA 19-9), and imaging methods (CT, MRI, PET-CT). The goal is to detect and intervene in potential recurrence at an early stage.

Prognosis in Advanced Gallbladder Cancer

The prognosis of gallbladder cancer varies depending on the stage of the disease, the tumor's biological behavior, the effectiveness of the treatment administered, and the patient's general health. Advanced-stage gallbladder cancer with lymph node involvement has a worse prognosis than early-stage disease. However, in appropriate patients, radical surgery followed by adjuvant therapy can significantly improve survival.

The main factors affecting prognosis are:

• Stage of the tumor (TNM stage)

• Presence and number of lymph node metastases

• Whether surgical margins are clear (R0 resection)

• The degree of the tumor (grade)

• Presence of distant metastasis

• The patient's general health status and performance status

It should be remembered that every patient is different and the prognosis should be evaluated individually.