The American Journal of Surgery 194 (2007) 355361

Clinical surgeryAmerican

Extended hepatic resection for gallbladder cancer

Srinevas K. Reddy, M.D.*, Carlos E. Marroquin, M.D., Paul C. Kuo, M.D., M.B.A.,
Theodore N. Pappas, M.D., Bryan M. Clary, M.D.
Division of General Surgery, Department of Surgery, Duke University Medical Center, Box 3247, Durham, NC 27710, USA
Manuscript received January 12, 2007; revised manuscript February 1, 2007

Abstract
Background: Although radical cholecystectomy is the standard of care for gallbladder cancers that invade
perimuscular connective tissue or perforate visceral peritoneum, the role of extended right hepatectomy in
achieving negative resection margins is not clear.
Methods: Clinicopathologic, perioperative, and long-term outcome data were reviewed from patients who
underwent hepatic resection for gallbladder cancer.
Results: From 1995 to 2005, 22 consecutive patients underwent hepatic resection for gallbladder cancer,
and 11 underwent extended hepatectomy. Negative resection margins were achieved in all patients. There
were no significant differences in postoperative morbidity, mortality, and long-term survival after extended
and minor hepatectomy. T3 tumors negatively predicted overall and recurrence-free survival.
Comments: Extended hepatectomy achieves negative resection margins for patients with gallbladder
cancer and is associated with acceptable morbidity and long-term survival. 2007 Excerpta Medica Inc.
All rights reserved.
Keywords: Extended liver resection; Gallbladder cancer; Radical cholecystectomy

Traditionally, gallbladder cancer has been associated with

poor prognosis because the lack of recognized symptoms
results in advanced primary and nodal disease at presentation. The aggressive biologic nature of this tumor, coupled
with extensive lymphatic drainage of the gallbladder, often
results in rapid progression of disease. However, several
recent studies have reported long-term patient survivors
after margin negative resection of stages III and IV disease
[1 6]. Although the infrequent incidence of gallbladder
cancer likely precludes any randomized controlled trials, the
consensus from large case series is that a simple cholecystectomy is sufficient therapy for T1 (tumor that invades the
lamina propria or muscle layer) node-negative disease. A
radical cholecystectomy, involving a 4B/5 segment resection, and portal lymphadenectomy has been established as
the minimum therapy for T2 (invasion of perimuscular
connective tissue) and T3 (perforation of visceral peritoneum) tumors because of the relatively high likelihood of
direct hepatic invasion and nodal disease [1,5]. Although a
radical cholecystectomy allows for an adequate margin near
the gallbladder fundus, it results in a minimal margin at the
* Corresponding author. Tel.: 1-919-684-6553 or 919-684-3381; fax:
919-681-7508
E-mail address: reddy005@mc.duke.edu

base of the cystic plate and thus may not be sufficient for
tumors that lie near the gallbladder neck, in Hartmanns
pouch, or that extend into the triangle of Calot [1]. The role
of extended hepatectomy, where the plane of transection is
well to the left of the cystic plate, in decreasing local or
regional recurrence and prolonging long-term outcome is
not well defined. The objective of this study was to report
our experience with hepatic resection for gallbladder cancer,
with a focus on the safety and long-term outcomes of
extended hepatectomy, for patients suspected to have disease near the cystic plate.
Methods
After obtaining approval from the Institutional Review
Board at Duke University Medical Center, patients who
underwent hepatic resection for gallbladder cancer from
August 1995 to December 2005 were identified from a
prospective hepatectomy database. After 2001, patients who
were discovered to have gallbladder cancer due to an incidental finding on pathologic specimen examination after
simple cholecystectomy or on preoperative diagnostic imaging were evaluated for extended right hepatectomy as the
procedure of choice for definitive surgical resection. We
typically performed an extended hepatectomy in the following circumstances: (1) when the cystic duct margin of the

0002-9610/07/$ see front matter 2007 Excerpta Medica Inc. All rights reserved.
doi:10.1016/j.amjsurg.2007.02.013

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S.K. Reddy et al. / The American Journal of Surgery 194 (2007) 355361

previous cholecystectomy specimen was positive or unknown, (2) after open cholecystectomy or when the initial
operative indication was acute cholecystitis because we
anticipated that the triangle of Calot would be obliterated by
scar tissue, (3) when node-positive disease was evident
before hepatic resection (either in the initial cholecystectomy specimen or detected on preoperative imaging), (4) for
patients presenting with preoperative jaundice because of
biliary obstruction, and/or (5) for large-mass lesions detected on preoperative imaging (usually computed axial
tomography [CAT]). Patients without any of these criteria
were offered minor hepatic resection (segment 4B/5 hepatectomy). Patients 75 years old and those with extensive
medical comorbidity were not offered extended hepatectomy. Portal vein embolization (PVE) was used when the
estimated volume of the future liver remnant was 25% of
the native liver volume or in cases of severe steatosis (as
detected by CAT scan).
A retrospective review of patient demographics, tumor
characteristics, surgical treatment, length of hospital stay, postoperative course, use of adjuvant chemotherapy or radiotherapy, and long-term outcomes was completed. Operative mortality included any death attributed to liver resection (as
determined by the operative surgeon) and all death within 30
days of partial hepatectomy. Deaths were ascertained by clinic
or hospital records, the Social Security Death Index, and the
Institutional Review Board Tumor Registry. Overall survival
reflected deaths from any cause. The last date of any clinical
correspondence was used to determine length of recurrencefree survival after hepatectomy.
Statistical analyses were performed using the Stats Di-

rect, Version 2.4.5 (StatsDirect Limited Software, Cheshire,

UK) and GraphPad Prism, Version 3.0 (GraphPad Software,
San Diego, CA) software packages. Categoric variables
were summarized with percentages. Continuous variables
were summarized with medians and corresponding ranges.
Comparisons between categoric variables were performed
with Fishers exact test. Mann-Whitney U test was used to
compare continuous variables. Survival was estimated with
Kaplan-Meier analysis and compared with the log-rank test.
Two-sided mid-P values are reported; P .05 was considered significant.
Tumor staging was reported according to the American
Joint Committee on Cancer 6th edition TNM staging guidelines [7]. Specifically, T1 tumors invade the gallbladder
lamina propria or muscle layers; T2 lesions invade perimuscular connective tissue without extension into liver; T3
tumors perforate visceral peritoneum and/or directly invade
the liver or 1 other adjacent organ; and T4 carcinomas
invade the main portal vein, hepatic artery, or multiple
extrahepatic organs. Any node-positive disease was designated as N1.
Results
From 1995 to 2005, 22 consecutive patients underwent
curative hepatic resection for gallbladder cancer. Eleven
of 22 (50%) patients underwent extended hepatectomy.
Three patients operated on after 2001 were not offered
extended hepatectomy because of old age (75 years).
Indications for extended hepatectomy included large tumor size in patients who did not undergo previous simple

Table 1
Tumor characteristics, treatments, and outcomes
Stage

Liver resection

BDE

Previous chol

Pathology

Grade

Adjuvant therapy

Status (mo)

T3N1
T3N1
T3N1
T3N1
T3N0
T3N0
T3N0
T3N0
T3N0
T3N0
T3N0
T3N0
T2N1
T2N1
T2N0
T2N0
T2N0
T2N0
T2N0
T2N0
T2N0
T1N0

Extended right hepatectomy

Extended right hepatectomy
Extended right hepatectomy
Extended right hepatectomy
Extended right hepatectomy
4B/5 bisegmentectomy
Extended right hepatectomy
Extended right hepatectomy
4B/5 bisegmentectomy
Extended right hepatectomy
4B/5 bisegmentectomy
4B/5 bisegmentectomy
4B/5 bisegmentectomy
Extended right hepatectomy
4B/5 bisegmentectomy
4B/5 bisegmentectomy
4B/5 bisegmentectomy
4B/5 bisegmentectomy
Extended right hepatectomy
Extended right hepatectomy
4B/5 bisegmentectomy
4B/5 bisegmentectomy

N
Y
Y
Y
N
N
Y
N
Y
Y
N
Y
Y
Y
Y
N
N
N
Y
Y
N
N

N
Y
Y
Y
N
Y
Y
N
Y
N
Y
Y
Y
Y
Y
Y
Y
N
Y
Y
Y
N

Adenoca
Adenoca
Adenoca
Adenoca
Adenoca
Adenoca
Adenoca
Squamous
Adenoca
Adenoca
Adenoca
Adenoca
Adenoca
Adenoca
Adenoca
Adenoca
Adenoca
Papillary
Adenoca
Papillary
Adenoca
Papillary

Poor
Well
Poor
NA
Poor
Poor
Poor
Poor
Well
Moderate
Moderate
Poor
Moderate
Well
Moderate
Well
Well
Moderate
Well
Moderate
Well
Well

Y
Y
Y
N
N
Y
Y
Y
Y
N
N
N
Y
Y
Y
Y
Y
N
N
N
Y
N

DOD (11)
NED (27)
DOD (4)
NED (24)
DOD (5)
DOD (10)
DOD (52)
NED (48)
DOD (62)
DOD (24)
POD (1)
NED (30)
NED (52)
NED (67)
DOD (62)
DOC (45)
NED (107)
NED (37)
NED (26)
AWD (14)
NED (18)
NED (12)

Note: Numeric data in status column refers to number of months from partial hepatectomy to date of death, disease recurrence, or last date of follow-up
for patients who had NED. Adjuvant therapy refers to either chemotherapy or external beam radiation therapy.
Adenoca adenocarcinoma; AWD alive with disease; BDE bile duct excision; chol cholecystectomy; DOC dead of other causes; DOD dead
of disease; NED no evidence of disease; POD postoperative death.

S.K. Reddy et al. / The American Journal of Surgery 194 (2007) 355361

cholecystectomy (n 5), positive or unknown cystic

duct margin status after simple cholecystectomy (n 4),
preoperative biliary obstruction (n 1), known nodepositive disease before hepatic resection (n 4), and
acute cholecystitis leading to simple cholecystectomy
(n 1). The median age of all patients was 54 (range 45
to 80) years, and 15 of 22 (68%) were women. Table 1
lists tumor characteristics, treatments, and outcomes for
each patient. Most patients, ie, 16 of 22 (73%), presented
for curative treatment after previous laparoscopic cholecystectomy. Four of 11 (36%) patients underwent preoperative PVE. All patients underwent portal lymphadenectomy. Negative microscopic margins of resection (R0)
were achieved in all patients.
Table 2 lists postoperative morbidity and mortality by
liver resection. Severe postoperative complications occurred in 8 of 22 (36%) patients. These included vocal cord
paralysis (n 1), intraabdominal abscess and biloma requiring drainage (n 3), fascial dehiscence (n 2), deep
venous thrombosis (n 1), and sepsis with multisystem
organ failure resulting in death (n 1). In our small series,
5 of 11 (45%) of patients who underwent major hepatic
resection suffered severe postoperative morbidity versus 3
of 11 (27%) patients who underwent minor hepatectomy
(P .42). Severe complications were more often seen in
patients who underwent bile duct excision (8 of 12 [67%] vs
1 of 10 [10%], P .05). For patients who underwent
extended hepatic resection, median hospital stay was 9 days
(4 to 30 days) versus 7 days (3 to 28 days) for patients who
underwent minor hepatectomy (P .12).
Median follow-up for all patients was 37 months.
Kaplan-Meier curves for overall and recurrence free survival are displayed in Fig. 1. Actuarial 3-year overall and
recurrence-free survival in our small series was 72% and
68%, respectively. Of the 11 patients who underwent major
hepatic resection, 5 of 11 (45%) had no evidence of disease
(NED), 1 of 11 (9%) was alive with disease, and 5 of 11
(45%) were dead of disease at last follow-up. All cases of
first disease recurrence consisted of disseminated disease.
For patients who underwent previous laparoscopic cholecystectomy, there were no significant differences in median
overall or recurrence-free survival between patients who
underwent extended compared with minor hepatic resections (Fig. 2). Patients with T3 tumors had shorter long-term
survival than those with T2 disease (Fig. 3). Thirteen of 22
Table 2
Postoperative mortality and morbidity by hepatic resection type
Liver resection

4B/5 wedge resection/

7
bisegmentectomy
4B/5 wedge resection/
4
bisegmentectomy with
BDE
Extended right hepatectomy 3
Extended right hepatectomy 8
with BDE
Total
22
BDE bile duct excision.

Severe
Reoperation Mortality
complication
1

0
5

0
0

0
0

357

Fig. 1. Overall and recurrence-free survival after hepatic resection for all
22 patients with gallbladder cancer.

(59%) of patients received adjuvant chemotherapy or radiotherapy. Administration of adjuvant therapy did not
affect overall or recurrence-free survival. Table 3 lists
stages and treatments for 5-year survivors after partial
hepatectomy. All but 1 of these patients were treated with
adjuvant therapy.
Comments
Extended hepatectomy may provide long-term oncologic
survival in selected patients with gallbladder cancer by
ensuring a negative margin of resection, which many investigators have shown is a key positive predictor of long-term
survival [1,4,8 10]. Because radical cholecystectomy is often associated with a minimal margin at the base of the
cystic plate (because of the relatively thin liver parenchyma
interposed between the gallbladder and the main right or
sectoral bile ducts), extended hepatic resection may be necessary to achieve negative margins, particularly for large
cancers located in the infidibulum or in Hartmanns pouch
or that extend into the triangle of Calot. This point is
especially important for patients who (1) present for definitive surgical resection after previous simple cholecystectomy for acute cholecystitis, (2) who underwent previous
open cholecystectomy, (3) who have a positive cystic duct
margin after simple cholecystectomy, (4) who have known
node-positive disease, and/or (5) who present with preoperative jaundice caused by biliary obstruction. In these patients, the triangle of Calot is often obliterated by tumor or
scar, thus making it difficult to distinguish cancer from
benign inflammatory tissue. Extended hepatic resection may
be especially useful in these patients as a sure method to
achieve an oncologically negative resection margin by staying outside the plane of previous surgery. Other groups have
also recognized the potential of extended resection in patients with gallbladder cancer. Kondo et al [11] stated that
extended right hepatectomy was necessary for curative resection in cases of hepatic hilum gallbladder carcinomas.
Furthermore, Shiari et al [12] demonstrated that the extent
of hepatic microscopic angiolymphatic portal tract invasion
correlates with gross tumor depth. Therefore, a greater resection may be needed for thicker tumors to achieve microscopically negative margins. However, despite recent decreases in the incidence of complications after liver
resection, several large studies have noted extended hepatectomy to be a predictor of postoperative morbidity and

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S.K. Reddy et al. / The American Journal of Surgery 194 (2007) 355361

Fig. 2. Overall and recurrence-free survival by extent of resection for patients who underwent previous laparoscopic cholecystectomy.

mortality [13-15]. Given this setting, we evaluated our series of hepatic resection for gallbladder cancer where extended hepatectomy was performed in patients suspected to
have disease near the cystic plate.
The lack of differences in postoperative mortality and
median length of hospital stay between major and minor
hepatectomy suggests that extensive hepatic resection can
be done safely in patients with gallbladder cancer (Table 2).
None of the patients who underwent major hepatectomy
experienced postoperative mortality or required reoperation.
Although this absence of postoperative mortality rate is
likely due to small patient numbers, several other studies
have reported low (10% to 30%) mortality rates (Table 4).
Extended hepatectomy was associated with a higher frequency of severe postoperative complications than with
minor resections in our study (45% vs 27%); however, small
patient numbers precluded an adequate analysis of significance. Our morbidity rate is consistent with that found in
other studies (Table 4). Common bile duct excision was
associated with postoperative morbidity (67% vs 10%), a
finding confirmed by others [3].
In this small series, extended hepatectomy achieved a
negative resection margin in those patients with high likelihood of disease and/or inflammation near the cystic plate.
Long-term survival after major hepatectomy in these selected patients was similar to those patients not likely to
have cancer or inflammation near the cystic plate and who
consequently underwent minor hepatectomy (Fig. 2). Extended hepatectomy is also associated with good long-term
outcomes in patients with advanced primary (T3) and nodal
disease. Five of eleven (45%) patients who underwent major
resection were NED at last follow-up, and two of seven
5-year survivors underwent extended right hepatectomy

(Table 3). The two 5-year survivors who underwent major

hepatectomy were either afflicted with thick tumors (T3) or
regional nodal disease, and all of these long-term survivors
were treated with adjuvant chemoradiotherapy. This finding
of long-term survivors after extensive hepatic resection is in
agreement with several other reports (Table 4). As expected,
patients with T2 tumors had longer overall survival than
those with T3 cancers (Fig. 3). However, our 62-month
overall and 51-month recurrence-free survival are greater
than those reported by other investigators [1 6,8,16 19].
Several differences exist between our study and other reports that may portend a more favorable outcome in our
series. Most patients in other studies had stage III or stage
IV disease, whereas the majority of patients in our series
who underwent major hepatic resection had stage II disease.
All of our patients underwent microscopically negative margin of resection (which increases the likelihood of long-term
survival) compared with most studies in which only a subset
of patients underwent curative resection. Also, many other
series included patients who underwent concomitant other
major procedures, such as pancreaticoduodenectomy or major vein reconstruction.
PVE is performed before extended hepatectomy to induce hypertrophy of the future liver remnant (and by correlation an increase in synthetic function) to minimize postoperative complications caused by hepatic insufficiency.
Four of 11 patients in our series received PVE before
undergoing extended right hepatectomy due to a small liver
remnant as estimated by CAT scan. Although all 4 patients
experienced posthepatectomy complications, none of these
complications were caused by hepatic insufficiency, and
there was no postoperative mortality. The most extensive
experience with PVE before extended hepatectomy for gall-

Fig. 3. Overall and recurrence-free survival by tumor stage.

S.K. Reddy et al. / The American Journal of Surgery 194 (2007) 355361

359

Table 3
Tumor characteristics and treatment of 5-year survivors after partial hepatectomy*
Stage

Liver resection

BDE

Time since resection (mo)

Adjuvant therapy

Status

T2N0
T2N0
T3N0
T2N0
T3N0
T2N1
T2N1

4B/5 wedge
4B/5 bisegmentectomy
Extended right hepatectomy
4B/5 wedge
4B/5 bisegmentectomy
4B/5 wedge
Extended right hepatectomy

N
N
N
Y
Y
Y
Y

122
76
71
62
62
68
67

Y
N
Y
Y
Y
Y
Y

NED
NED
NED
DOD
DOD
NED
NED

Disease status reported as of last follow-up.

BDE bile duct excision; DOD dead of disease; NED no evidence of disease.
* Months since hepatic resection was calculated from date of death or date of analysis for living patients.

bladder cancer was reported by Nagino et al [19]. In this

study, PVE was performed if the size of the future liver
remnant was expected to be 40% of the total liver volume,
a more liberal guideline for noncirrhotic patients than we
and others have used [20,21]. Sixty-one patients with gallbladder cancer underwent major hepatic resection with bile
duct excision and hepaticojejunostomy after PVE. Postoperative mortality was 18%, and poor functional reserve of
the future liver remnant predicted mortality. In these patients with advanced disease who often underwent concomitant other major procedures, the 3-year and 5-year survival
rates were 25.3% and 17.1%, respectively. In addition to
improving postoperative liver function, another advantage
to PVE is that it may spare patients with aggressive disease
an unnecessary liver resection because disease progression
would be noted on the CAT scan after PVE but before

planned partial hepatectomy. We observed this aggressive

tumor biology in 3 of 7 patients not treated with PVE who
experienced disease recurrence within 6 months after extended hepatectomy. Although we did not see any difference in tumor burden after PVE by CAT scan, Nagino et al
[19] noted that the incidence of unresectability after PVE
caused by tumor progression was 32.2%. What is not clear,
however, is the role PVE itself plays in leading to this
unresectability by promoting tumor growth through stimulating cell division of not only benign hepatocytes but of
tumor cells as well. More studies on the use of PVE specifically with gallbladder cancer need to be performed to
shed light on this important issue. We concur with other
investigators [20,22] that PVE should be performed when
the left lateral section is 25% of liver volume (in noncirrhotic livers) or 40% of liver volume (in cases of cirrhosis

Table 4
Review of series with 10 extended hepatic resections for gallbladder cancer
Study

Year

Mortality
(%)

Morbidity
(%)

Survival

Ogura et al [16]

1991 302

Matsumoto et al [18]

1992

Bloechle et al [8]

18

48

10

10

20

1995

10

10

30

Bartlett et al [3]
Tsukada et al [4]
Fong et al [5]

1996
1996
2000

12
18
42

0
0
10

42
34

Major hepatic resection associated with greater mortality

than smaller resections
Mean 30 21 mo for ERH 6 of 10 curative resections; 1 stage III patient and 9 stage
BDE curative resections
IV patients;
3-y survivors: 3
9 of 10 curative resections; 4 stage III and 6 stage IV
5-y survivors: 0
patients; type of resection did not impact survival
Median hospital stay was 21 days

Endo et al [17]

2001

10

Kondo et al [2]

2002

40

30

Kondo et al [11]

2002

56

19

Kondo et al [6]

2003

51

20

Nagino et al [19]

2006

61

18

This study

2006

11

3-y survivors: 2

67

45

3-y survivors: 7
5-y survivors: 4
14% 3- and 5-y survivors
18% 3- and 5-y survivors

3-y survivors: 10
5-y survivors: 5
3-y survivors: 3

Comments

Lobectomy or greater resection predicted mortality and

morbidity; obstructive jaundice predicted mortality
Lobectomy positively predicted survival with
hepatoduodenal ligament invasion
All with stage III/IV disease; hepatic failure most common
cause of death; obstructive jaundice predicted mortality
All curative resections; survival summarized for bed and
hilum and hepatic hilum type cancers; 1 stage III and 45
stage IV patients
ERH in a cholestatic liver predicted mortality, resection
type did not predict survival
All received PVE, all curative resections, poor hepatic
function of future liver remnant predicted mortality
All curative resections

Note. Data specified are for lobectomy or extended hepatectomy only. Mortality and morbidity refer to postoperative events, and survival refers to
long-term outcome.
BDE bile duct excision; ERH extended right hepatectomy; PVE portal vein embolization.

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S.K. Reddy et al. / The American Journal of Surgery 194 (2007) 355361

or cholestasis) by CAT scan. However, there are presently

no clear data from large retrospective case series or prospective randomized trials to support these guidelines. PVE
should not be considered in patients with tumor invasion
into the portal vein because benefits to the procedure are
likely to be minimal.
Whether the extent of resection itself influences longterm survival is not well defined because larger studies
reveal conflicting results [6,8,17]. In our smaller series, the
extent of hepatic resection did not influence long-term outcome in patients who underwent previous laparoscopic cholecystectomy (Fig. 2). We believe that extended hepatectomy can be used to ensure a margin-negative resection in
those patients likely to have inflammation or tumor near the
cystic plate. PVE should be used to make this option available to patients with small future liver remnants. Patient
contraindications to extended hepatectomy should consist of
characteristics that we and others have shown to predict
morbidity or mortality in large institutional series, including
increased creatinine, thrombocytopenia, jaundice, old age,
severe chronic obstructive pulmonary disease, presence of
preoperative infection, and high American Society of Anesthesiology and Child-Turcotte-Pugh scores [1315,23].
The role of adjuvant chemotherapy and radiotherapy in
the treatment of gallbladder cancer is controversial. Although the use of adjuvant therapy did not predict overall or
recurrence-free survival, six of seven 5-year survivors received adjuvant therapy. This suggests that adjuvant therapy
may improve long-term outcome in patients who undergo
liver resection for gallbladder cancer. This is in agreement
with our previous report, which revealed a median overall
survival of 3.7 years, 5-year overall survival of 51%, and
5-year recurrence-free survival of 39% among 13 patients
who underwent radical cholecystectomy [24]. In addition to
external-beam radiotherapy, most of these patients also received 5-fluorouracil. Kresl et al [22] also demonstrated
benefit from adjuvant external beam radiotherapy and 5-fluorouracil with 5-year survival of 33% and median survival
of 2.6 years. A key justification for the use of adjuvant
radiotherapy in particular is improvement of local and regional disease control. These studies have reported a 5-year
local and regional control rates of 64% [24] and 73% [22],
respectively. In our small case series, which only included
patients who underwent hepatic resection, 3-year local control was 75% and 5-year local control was 66% for adjuvant
chemotherapy and radiotherapy. However, in patients not
given adjuvant therapy, all disease recurrences (3 of 9 patients) were systemic, thus questioning the role of local and
regional therapies. This highlights the need for larger retrospective studies and prospective clinical trials that evaluate the efficacy of adjuvant therapy for gallbladder cancer.
There are several limitations to our study. The retrospective nature, along with the absence of a true control group
(patients likely to have disease near the cystic plate who
underwent minor hepatectomy) hampered our ability to
make definitive conclusions about the benefits of extended
hepatic resection for gallbladder cancer. The relative small
number of patients in our series increased the possibility
that we did not detect an outcome difference between patients who underwent major and minor hepatic resections
(type II error). Although postoperative morbidity, mortality,

and long-term survival in this study were similar to those of

larger series, small study size, frequent use of adjuvant
chemotherapy (which is not the standard of care), and few
cases of preoperative jaundice may hinder comparison of
these results with those of most large centers.
We conclude that extended hepatic resection may be
useful in providing negative resection margins for patients
that likely to have inflammation or tumor near the cystic
plate. Although we cannot make definitive conclusions
about whether extended hepatectomy portends a better oncologic outcome than standard radical cholecystectomy,
data from our small series in conjunction with those of other
reports show that long-term survival is possible in patients
with thick primary tumors and/or regional nodal disease.
Because of increased risk of postoperative morbidity, we
believe that extended hepatectomy should not be routinely
considered for all patients with gallbladder cancer nor in
frail elderly patients with major medical comorbidity. Extended resection may require preoperative PVE in some
patients, which may play a role in enhancing tumor growth.
Given the paramount importance of a margin negative resection, extended hepatectomy should be considered in selected patients with gallbladder cancer.
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