The cholecystoretro- of Lymphadenecto · PDF file K, et al. Outcome of radical surgery...

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Transcript of The cholecystoretro- of Lymphadenecto · PDF file K, et al. Outcome of radical surgery...

  •  The cholecystoretro- pancreatic pathway

     Spirally –anterior

    surface of CBD to right

    rear.

     Straight , posterior

    surface of CBD

     Both into the retroportal node on

    the posterior surface

    of the pancreas. Lymphatic drainage of the gallbladder; Journal of HPB

    Surgery. Masashi Ito Yoshio Mishima. J Hep Bil Pancr Surg

    (1994) 1:302-308

  •  The cholecysto‐celiac pathway;

     This was the route

    running to the left through the

    hepatoduodenal

    ligament to reach the

    coeliac nodes.

    Lymphatic drainage of the gallbladder; Journal of HPB

    Surgery. Masashi Ito Yoshio Mishima. J Hep Bil Pancr Surg

    (1994) 1:302-308

  •  The cholecysto‐mesente ric pathway;

     this was the route

    running to the left in

    front of the portal

    vein to connect with

    the nodes at the

    superior mesenteric

    root.

    Lymphatic drainage of the gallbladder; Journal of HPB

    Surgery. Masashi Ito Yoshio Mishima. J Hep Bil Pancr Surg

    (1994) 1:302-308

  •  STUDY DESIGN:

     In 20 patients, 0.3 to 0.5 mL of carbon particle

    suspension was injected into first station nodes

    for the gallbladder, the cystic node or

    pericholedochal node, intra-operatively.

     After a Kocher manoeuvre was performed,

    lymph nodes and lymphatic vessels blackened

    by the stain were visualized macroscopically.

    Visualization of routes of lymphatic drainage of the gallbladder with a carbon particle suspension. Uesaka K et al. J Am Coll Surg. 1996 Oct;183(4):345-50.

  •  The right route, which ran along the common

    bile duct to the

    superior retro-

    pancreaticoduodenal

    node or the retroportal

    node and reached the

    para-aortic nodes, was stained in 95 percent

    of patients.

  •  The left route, which traveled toward lymph nodes medial to the hepatoduodenal ligament through the posterior aspect of the head of the pancreas, was stained in less than 50 percent of patients.

     Among lymph nodes along the left route, the posterior common hepatic node was most frequently stained (45 percent).

  •  The hilar route, which ascended toward the

    hepatic hilus, was

    stained in 20 percent

    of patients.

  •  While it is established that Radical Cholecystectomy-

     Removal of the Gall bladder with

     en-bloc hepatic resection and

     removal of the lymph nodes,

     Confers the maximal survival benefit.

     The number of lymph nodes resected contributes

     maximally to survival.

     Decreases cancer related mortality.

     And is the strongest prognostic factor contributing to long term survival.

  • Lymph Node Spread from Carcinoma of the Gallbladder. Tsukada et al

    Cancer, August 15, 1997 / Volume 80 / Number 4

    Studies on 111 patients with Gall Bladder Carcinoma.

  •  “However, the extent of lymph node (LN)

    clearance has not been well established

    and remains a subject of debate”.

    Surgery for gallbladder cancer in the US: a need for greater lymph

    node clearance. Thuy B. Tran, Nicholas N. Nissen. J Gastrointest Oncol

    2015;6(5):452-458

  •  Of 29 patients, with lymph node positive disease:-  7 had positive cystic nodes,

     22 had positive pericholedochal nodes,

     10 had positive hepatic hilum nodes,

     2 had positive retroportal nodes,

     3 had positive nodes along the common hepatic artery,

     12 had positive postersuperior pancreaticoduodenal nodes,

     1 had positive celiac nodes,

     1 had positive superior mesenteric nodes,

     3 had positive nodes at the greater curvature of the stomach,

     4 had positive para-aortic nodes.

    Metastasis of primary gallbladder carcinoma in

    lymph node and liver. Han-Ting Lin et al. World J

    Gastroenterol 2005;11(5):748-751

    7

    22

    10

    2

    3

    12

    1

    1

    3

    4

  •  3352 lymph nodes harvested from 152 Ca Gb patients.

     First echelon nodes –located along the cystic duct or CBD.

     Second echelon nodes – located postero-superior to the head of the pancreas and around the portal vein/hepatic artery. (Hilar nodes considered here as these usually harvested during a radical cholecystectomy).

     Other nodes considered as distant nodes.

    After-Regional lymphadenectomy for gallbladder cancer: Rational extent, technical details, and patient outcomes. Shirai Y et al. World J Gastroenterol 2012 June 14; 18(22): 2775-2783

  • NODE GROUP No. of L.N.

    evaluated

    No. with

    +ve nodes

    (%)

    FIRST ECHELON

    Pericholedochal 410 43 10

    Cystic duct 109 30 27

    SECOND ECHELON

    Retroportal 458 23 5

    Post sup pancreaticoduodenal 341 20 6

    Hepatic artery 536 20 4

    Rt coeliac (post. common hepatic nodes) 320 15 5

    Hilar 37 0 0

  • NODE GROUP No. of L.N.

    evaluated

    No. with

    +ve nodes

    (%)

    MORE DISTAL NODES

    Superior Mesenteric 171 4 2

    Posterior inf

    pancreaticoduodenal

    56 3 5

    Anterior sup

    pancreaticoduodenal

    19 1 5

    Anterior inf

    pancreaticoduodenal

    15 2 13

    Perigastric 205 4 2

    Para-aortic nodes 675 15 2

  •  Nodal involvement is the strongest prognostic factor associated with long- term survival in patients undergoing radical resection for Gall Bladder Cancer (GBC).

     The aim of this study was to find out the impact of extended lymph node dissection on survival based on the Surveillance, Epidemiology, and End Results (SEER) database.

    Surgery for gallbladder cancer in the US: a need for greater lymph

    node clearance. Thuy B. Tran, Nicholas N. Nissen. J Gastrointest Oncol

    2015;6(5):452-458.

  •  A total of 11,816 patients were identified

    diagnosed with Carcinoma Gall Bladder

    with adequate information in the SEER

    database to permit staging, from 1988 to

    2009.

  • STAGE 0 LN(%) 1-3LN(%) 4+LN(%)

    I 79.1 17.4 3.2

    II 72.2 19.9 7.7

    IIIa 79.9 14.9 4.9

    IIIb 0 67.4 17.7

    IV 61.2 23.3 8.0

  • TREND IN NUMBER OF LYMPH NODES EXAMINED BY YEAR OF DIAGNOSIS

    (STAGE I-IIIA).

    TREND IN NUMBER OF LYMPH NODES EXAMINED BY YEAR OF DIAGNOSIS

    (STAGE IIIB).

  • No of L N

    examined

    Cancer Specific Survival

    1-year(%) 5-year(%) Mean P value

    Stage I

    0 LN 78.6 56.7 141.2

  • No of L N

    examined

    Cancer Specific Survival

    1-year(%) 5-year(%) Mean P value

    Stage IIIa

    0 LN 34.2 7.3 20.4

  •  No definite or standardization of the extent of

    lymph node dissection despite intense debate.

     The camp of Surgical Nihilism have held that

    aggressive lymph node dissection does not add to

    survival.

     The Surgical Optimists club point to the high

    incidence of spread to “distant” lymph nodes in

    Advance Stage tumours. (22% to 50% to para-

    aortic lymph nodes in pT2 and above tumours).

    Tsukada K, et al. Outcome of radical surgery for carcinoma of the gallbladder according to the TNM stage. Surgery 1996; 120: 816‐21.(22%). Kondo S, et al. Rationale of paraaortic lymphnodes dissection for advanced

    gallbladder cancers [in Japanese with English abstract]. J Jpn Surg Soc 1990; 91: 223‐7. (50%).

  • https://www.semanticscholar.org/paper/An- anatomical-study-of-the-lymphatic- drainage-of-Ito-Mishima

    f9637b991ce7444f37eca38ddc5d8e50f6dd7 5e1

    NODES

    AROUND THE

    MAIN VESSELS

    SECOND

    ECHELON

    NODES

  •  In 10 patients out of 28 (36%), metastasis was found in the

    dissected paraaortic nodes.

     The incidence of paraaortic

    lymph nodes metastasis was 50% when the gallbladder serosa or

    adjacent organs were involved

    by cancer.

     Their suggestion was that the “para-aortic nodes” should be

    regarded as an interim nodes

    between the retropancreatic

    and retroduodenal nodes and the nodes along the mesenteric

    root.

    Rationale of paraaortic lymph nodes

    dissection for advanced gallbladder

    cancer. Kondo et al. Nihon Geka Gakkai

    Zasshi. 1990 Feb;91(2):223-7.

    A N

    TE R

    IO R

    P O

    S TE

    R IO

    R

  • Dutta U, Bush N, Kalsi D, Popli P, Kapoor VK. Epidemiology of

    gallbladder cancer in India. Chin Clin Oncol 2019;8(4):33.

  • Phadke PR, Mhatre SS, Budukh AM, Dikshit RP. Trends in gallbladder cancer

    incidence in the high- an