Meso-hepatectomy in a Locally Advanced Carcinoma Gallbladder in 21st Century: Is it Justified?

Abstract

Introduction: Based on the 2017 systematic review and meta-analysis meso-hepatectomy appears to be safe and comparable in both peri-operative and long term outcomes while comparing patients undergoing extended hepatectomy. Majority included hepatocellular carcinomas(>95%), cholangiocarcinomas but none have carcinoma(ca) gallbladder(gb). Right extended hepatectomy after biliary drainage and portal vein embolisation is the treatment modality for advanced ca gb. It is common in low socioeconomic strata of India(South Asia). Majority(90%) of them don't achieve R0 resection due to disease progression and procedural complications. Chemotherapy can't be given unless bilirubin< 5. The main difference between cholangiocarcinoma and ca gb is that cholangiocarcinoma spreads along ducts but ca gb infiltrates locallly. Hence meso-hepatectomy is not an inferior oncologic surgery in advanced ca gb. Methods: 30 year old male presented with jaundice, weight loss. Scan showed gall bladder mass with hilar block and right hepatic artery(RHA) involvement. Maximum bilirubin was 24. He underwent biliary drainage and bilirubin came down to 14. Ultrasound doppler showed RHA block with good intra-hepatic flow. He underwent meso-hepatectomy with RHA excision and hepaticojejunostomy to right posterior sectoral duct and left duct. Blood loss was 1 litre with a duration of 10 hour. Post operatively neither there was liver failure nor bile leak. Histopathology report was T4N2Mx(ductal margins negative). He completed adjuvant chemotherapy and on follow up of 18 months found to have segment 6 metastasis and still on chemotherapy without jaundice. Conclusion: Meso-hepatectomy is a safer onco-surgical alternative to extended hepatectomy in selected cases of advanced gall bladder cancers.