Heterogeneity of management practices surrounding operable gallbladder cancer – results of the OMEGA-S international HPB surgical survey



      Gallbladder cancer (GBC) is an aggressive, uncommon malignancy, with variation in operative approaches adopted across centres and few large-scale studies to guide practice. We aimed to identify the extent of heterogeneity in GBC internationally to better inform the need for future multicentre studies.


      A 34-question online survey was disseminated to members of the European-African Hepatopancreatobiliary Association (EAHPBA), American Hepatopancreatobiliary Association (AHPBA) and Asia–Pacific Hepatopancreatobiliary Association (A-PHPBA) regarding practices around diagnostic workup, operative approach, utilization of neoadjuvant and adjuvant therapies and surveillance strategies.


      Two hundred and three surgeons responded from 51 countries. High liver resection volume units (>50 resections/year) organised HPB multidisciplinary team discussion of GBCs more commonly than those with low volumes (p < 0.0001). Management practices exhibited areas of heterogeneity, particularly around operative extent. Contrary to consensus guidelines, anatomical liver resections were favoured over non-anatomical resections for T3 tumours and above, lymphadenectomy extent was lower than recommended, and a minority of respondents still routinely excised the common bile duct or port sites.


      Our findings suggest some similarities in the management of GBC internationally, but also specific areas of practice which differed from published guidelines. Transcontinental collaborative studies on GBC are necessary to establish evidence-based practice to minimise variation and optimise outcomes.
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        • Aloia T.A.
        • Járufe N.
        • Javle M.
        • Maithel S.K.
        • Roa J.C.
        • Adsay V.
        • et al.
        Gallbladder cancer: expert consensus statement.
        HPB. 2015 Aug; 17: 681-690
        • Søreide K.
        • Guest R.V.
        • Harrison E.M.
        • Kendall T.J.
        • Garden O.J.
        • Wigmore S.J.
        Systematic review of management of incidental gallbladder cancer after cholecystectomy.
        Br J Surg. 2019 Jan; 106: 32-45
        • DeSimone M.S.
        • Goodman M.
        • Pehlivanoglu B.
        • Memis B.
        • Balci S.
        • Roa J.C.
        • et al.
        T2 gallbladder cancer shows substantial survival variation between continents and this is not due to histopathologic criteria or pathologic sampling differences.
        Virchows Arch. 2021 May; 478: 875-884
        • Chen M.
        • Cao J.
        • Xiang Y.
        • Ma X.
        • Bai Y.
        • Lai Q.
        • et al.
        Hepatectomy strategy for T2 gallbladder cancer between segment IVb and V resection and wedge resection: a propensity score-matched study.
        Surgery. 2021 Jun; 169: 1304-1311
        • Nag H.H.
        • Nekarakanti P.K.
        • Sachan A.
        • Nabi P.
        • Tyagi S.
        Bi-segmentectomy versus wedge hepatic resection in extended cholecystectomy for T2 and T3 gallbladder cancer: a matched case-control study.
        Ann Hepatobiliary Pancreat Surg. 2021 Nov 30; 25: 485-491
        • Patkar S.
        • Patel S.
        • Gupta A.
        • Ramaswamy A.
        • Ostwal V.
        • Goel M.
        Revision surgery for incidental gallbladder cancer—challenging the dogma: ideal timing and real-world applicability.
        Ann Surg Oncol. 2021 Oct; 28: 6758-6766
        • Coimbra F.J.F.
        • Torres O.J.M.
        • Alikhanov R.
        • Agarwal A.
        • Pessaux P.
        • Fernandes E. de SM.
        • et al.
        BRAZILIAN consensus on incidental gallbladder carcinoma.
        Arq Bras Cir Dig. 2020; 33e1496
        • Shukla H.S.
        • Sirohi B.
        • Behari A.
        • Sharma A.
        • Majumdar J.
        • Ganguly M.
        • et al.
        Indian Council of Medical Research consensus document for the management of gall bladder cancer.
        Indian J Med Paediatr Oncol. 2015 Apr; 36: 79-84
        • Nagino M.
        • Hirano S.
        • Yoshitomi H.
        • Aoki T.
        • Uesaka K.
        • Unno M.
        • et al.
        Clinical practice guidelines for the management of biliary tract cancers 2019: the 3rd English edition.
        J Hepatobiliary Pancreat Sci. 2021 Jan; 28: 26-54
        • Anacak Y.
        • Zubizarreta E.
        • Zaghloul M.
        • Laskar S.
        • Alert J.
        • Gondhowiardjo S.
        • et al.
        The practice of paediatric radiation oncology in low- and middle-income countries: outcomes of an international atomic energy agency study.
        Clin Oncol. 2021 Apr; 33: e211-e220
        • Han H.S.
        • Yoon Y.S.
        • Agarwal A.K.
        • Belli G.
        • Itano O.
        • Gumbs A.A.
        • et al.
        Laparoscopic surgery for gallbladder cancer: an expert consensus statement.
        Dig Surg. 2019; 36: 1-6
        • Yoon Y.S.
        • Han H.S.
        • Agarwal A.
        • Belli G.
        • Itano O.
        • Gumbs A.A.
        • et al.
        Survey results of the expert meeting on laparoscopic surgery for gallbladder cancer and a review of relevant literature.
        Dig Surg. 2019; 36: 7-12
        • Sinagra E.
        • Garritano S.
        • Iacopinelli S.M.
        • Messina M.
        • Raimondo D.
        • Rossi F.
        • et al.
        Minimally invasive surgical approach for radicalization of incidental post-cholecystectomy gallbladder carcinoma: safety, feasibility and outcomes.
        Minim Invasive Ther Allied Technol. 2018 Jul 4; 27: 217-220
        • Regmi P.
        • Hu H.J.
        • Chang-Hao Y.
        • Liu F.
        • Ma W.J.
        • Ran C.D.
        • et al.
        Laparoscopic surgery for oncologic extended resection of T1b and T2 incidental gallbladder carcinoma at a high-volume center: a single-center experience in China.
        Surg Endosc. 2021 Dec; 35: 6505-6512
        • Vega E.A.
        • Sanhueza M.
        • Viñuela E.
        Minimally invasive surgery for gallbladder cancer.
        Surg Oncol Clin N Am. 2019 Apr; 28: 243-253
        • Gil L.
        • de Aretxabala X.
        • Lendoire J.
        • Duek F.
        • Hepp J.
        • Imventarza O.
        Incidental gallbladder cancer: how residual disease affects outcome in two referral HPB centers from South America.
        World J Surg. 2019 Jan; 43: 214-220
        • Horiguchi A.
        • Miyakawa S.
        • Ishihara S.
        • Miyazaki M.
        • Ohtsuka M.
        • Shimizu H.
        • et al.
        Gallbladder bed resection or hepatectomy of segments 4a and 5 for pT2 gallbladder carcinoma: analysis of Japanese registration cases by the study group for biliary surgery of the Japanese Society of Hepato-Biliary-Pancreatic Surgery.
        J Hepatobiliary Pancreat Sci. 2013 Jun; 20: 518-524
        • Widmann B.
        • Warschkow R.
        • Beutner U.
        • Weitzendorfer M.
        • Ukegjini K.
        • Schmied B.M.
        • et al.
        Effect of lymphadenectomy in curative gallbladder cancer treatment: a systematic review and meta-analysis.
        Langenbecks Arch Surg. 2020 Aug; 405: 573-584
        • Kemp Bohan P.M.
        • O'Shea A.E.
        • Ellis O.V.
        • Chick R.C.
        • Clem A.M.
        • Kirby D.T.
        • et al.
        Rates, predictors, and outcomes of portal lymphadenectomy for resectable gallbladder cancer.
        Ann Surg Oncol. 2021 Jun; 28: 2960-2972
        • Papageorge M.V.
        • de Geus S.W.L.
        • Woods A.P.
        • Ng S.C.
        • Drake F.T.
        • Merrill A.
        • et al.
        Lymphadenectomy in gallbladder adenocarcinoma: are we doing enough?.
        Am J Surg. 2022 Jul; 224: 423-428
        • Sahara K.
        • Tsilimigras D.I.
        • Maithel S.K.
        • Abbott D.E.
        • Poultsides G.A.
        • Hatzaras I.
        • et al.
        Survival benefit of lymphadenectomy for gallbladder cancer based on the therapeutic index: an analysis of the US extrahepatic biliary malignancy consortium.
        J Surg Oncol. 2020 Mar; 121: 503-510
        • Maegawa F.B.
        • Ashouri Y.
        • Hamidi M.
        • Hsu C.H.
        • Riall T.S.
        Gallbladder cancer surgery in the United States: lymphadenectomy trends and impact on survival.
        J Surg Res. 2021 Feb; 258: 54-63
        • Leigh N.L.
        • Solomon D.
        • Feingold D.
        • Hiotis S.P.
        • Labow D.M.
        • Magge D.R.
        • et al.
        Staging gallbladder cancer with lymphadenectomy: the practical application of new AHPBA and AJCC guidelines.
        HPB. 2019 Nov; 21: 1563-1569
        • Köhn N.
        • Maubach J.
        • Warschkow R.
        • Tsai C.
        • Nussbaum D.P.
        • Candinas D.
        • et al.
        High rate of positive lymph nodes in T1a gallbladder cancer does not translate to decreased survival: a population-based, propensity score adjusted analysis.
        HPB. 2018 Nov; 20: 1073-1081
        • Sternby Eilard M.
        • Lundgren L.
        • Cahlin C.
        • Strandell A.
        • Svanberg T.
        • Sandström P.
        Surgical treatment for gallbladder cancer – a systematic literature review.
        Scand J Gastroenterol. 2017 May 4; 52: 505-514
        • Kurahara H.
        • Maemura K.
        • Mataki Y.
        • Sakoda M.
        • Iino S.
        • Kawasaki Y.
        • et al.
        Indication of extrahepatic bile duct resection for gallbladder cancer.
        Langenbecks Arch Surg. 2018 Feb; 403: 45-51
        • Fujii Y.
        • Nanashima A.
        • Hiyoshi M.
        • Imamura N.
        • Yano K.
        • Hamada T.
        Significance of bile duct resection for advanced gallbladder cancer without biliary infiltration.
        Am J Surg. 2018 Dec; 216: 1122-1126
        • Berger-Richardson D.
        • Chesney T.R.
        • Englesakis M.
        • Govindarajan A.
        • Cleary S.P.
        • Swallow C.J.
        Trends in port-site metastasis after laparoscopic resection of incidental gallbladder cancer: a systematic review.
        Surgery. 2017 Mar; 161: 618-627
        • Ethun C.G.
        • Postlewait L.M.
        • Le N.
        • Pawlik T.M.
        • Poultsides G.
        • Tran T.
        • et al.
        Routine port-site excision in incidentally discovered gallbladder cancer is not associated with improved survival: a multi-institution analysis from the US Extrahepatic Biliary Malignancy Consortium.
        J Surg Oncol. 2017 Jun; 115: 805-811
        • Shroff R.T.
        • Kennedy E.B.
        • Bachini M.
        • Bekaii-Saab T.
        • Crane C.
        • Edeline J.
        • et al.
        Adjuvant therapy for resected biliary tract cancer: ASCO clinical practice guideline.
        J Clin Oncol. 2019 Apr 20; 37: 1015-1027