Advanced gallbladder cancer: Indian "middle path".

Gallbladder cancer (GBC) is common in northern India. The western world has a pessimistic attitude towards GBC resulting in inadequate management of even early GBC. At the other extreme is the Japanese aggressivism with high mortality but very few actual long-term survivors. The Indian surgeons have adopted a Buddhist "middle path"--aggressive surgical approach for "less advanced" GBC and non-surgical palliative approach for "more advanced" GBC. We rely heavily on staging laparoscopy to detect metastatic deposits on liver, peritoneum and omentum, and upper gastrointestinal endoscopy (UGIE) to detect duodenal infiltration which indicates unresectability as we do not perform pancreatico-duodenectomy for GBC. Our favoured procedure is extended cholecystectomy (EC) which includes a 2 cm nonanatomical wedge of liver in the GB bed and the lymph nodes in hepatoduodenal ligament, behind the duodenum and head of pancreas and along the hepatic artery to the right of celiac axis. EC can achieve R0 resection in patients with T1-T2 and T3 (fundus/body--hepatic bed type) disease. For T3 (neck--hepatic hilum type) and T4 disease major hepatic resection is required. In selected patients with nodally advanced GBC, a non-curative simple cholecystectomy with post-operative chemoradiotherapy may improve survival. GBC is an "Indian disease" and Indian surgeons have to be prepared to accept the "challenge" of GBC.