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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
www.drsanjaydebakshi.org
www.drsanjaydebakshi.org