Hepatoduodenal ligament invasion by gallbladder carcinoma: histologic patterns and surgical recommendation

A consensus for the optimal management of hepatoduodenal ligament (HDL) invasion by gallbladder carcinoma has yet to be reached. We retrospectively correlated the patterns of HDL invasion with the surgical outcome. From 1985 to 2000, 59 patients underwent combined resection of the extrahepatic bile duct and gallbladder and contiguous organs if required. Pathologic staging (UICC) was stage II, 4; stage III, 14; stage IVa, 10; and stage IVb, 31. Hepatoduodenal ligament invasion was subdivided into lymph node involvement (LNI) and bile duct infiltration (BDI). Patterns of HDL invasion were compared with bile duct morphology, resectability, and outcome. Bile duct infiltration ( n = 32) caused stenosis of the bile duct in all cases, whereas LNI ( n = 40) caused stenosis in only 4 cases. Resection was complete after extended cholecystectomy ( n = 22) in 36%; 4b/5 segmentectomy ( n = 10) in 90%; major hepatectomy ( n = 2) in 50%; and hepatopancreatoduodenectomy ( n = 17) in 53% of cases. Surgery was curative in 75% of patients without BDI, and was < 30% with BDI. The most common factor preventing curative resection in BDI was perineural invasion around the HDL. Perineural invasion occurred in over 70% of cases at either the cut end of the bile duct or in the margin of dissection. The 3-year survival rates, excluding patients with R2 resection (residual cancer) and death in hospital, were LNI(-)BDI(-) ( n = 8), 65.6%; LNI(+)BDI(-) ( n = 17), 35.3%; LNI(-)BDI(+) ( n = 7), 14.3%; and LNI(+)BDI(+) ( n = 17), 5.9%. There were no 5-year survivors with BDI. In conclusion, perineural invasion in BDI is an important obstacle to complete resection. Hepatopancreatoduodenectomy is a feasible strategy only for LNI(+)BDI(-) disease.