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

<0.001 1-3 LN 89.8 69.2 180.0

4+LN 89.9 65.2 124.0

Stage II

0 LN 68.2 36.9 94.2

<0.001 1-3 LN 84.7 56.0 117.3

4+LN 90.4 76.9 165.6

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

<0.001 1-3 LN 59.5 19.2 39.5

4+LN 64.5 35.8 56.5

Stage IIIb

0 LN

<0.001 1-3 LN 26.6 4.3 30.3

4+LN 42.6 11.6 51.8

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

f9637b991ce7444f37eca38ddc5d8e50f6dd75e1

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.

AN

TER

IOR

PO

STE

RIO

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- and low-risk regions of India. Indian J Med Paediatr Oncol

2019;40:90-3

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