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Defining surgical excellence in gallbladder cancer: A meta-analysis validating the 6-node threshold and extended D2
Manoj Pandey1, Shuchismita Chakraborty2, Dency Hansalia2
1Surgical Oncology, Institute of Medical Sciences, Banaras Hindu University, Varanasi, 211005, India; Health technology assessment India (HTAIn) nodal center, Institute of Medical Sciences, Banaras Hindu University, Varanasi, 211005, India.
Introduction:
The surgical management of gallbladder cancer (GBC) is complicated by aggressive lymphatic spread, leading to ongoing debate regarding the optimal extent of lymphadenectomy. This study aims to evaluate the stage-specific association between nodal harvest volume, anatomical templates, and survival outcomes.
Methods:
A systematic review and meta-analysis of 27 studies (1999-2025) were conducted. Utilizing random-effects models and meta-regression, we evaluated Overall Survival (OS) and Disease-Free Survival (DFS) across pathological T-stages.
Results:
Regional lymphadenectomy was associated with a significant overall survival benefit (HR 0.77, 95% CI: 0.62-0.96). Subgroup analysis and meta-regression (p = 0.768) suggested this association remains consistent across the T-stage spectrum (T1b-T4). Achieving a harvest of ≥6 nodes was identified as a critical quality benchmark (HR 0.68, 95% CI: 0.57-0.81). For T2 and T3 disease, D2 dissection (including retropancreatic and celiac stations) was associated with superior outcomes compared to D1 clearance (HR 0.68, 95% CI: 0.57-0.82). Secondary analysis of DFS similarly favored thorough nodal removal (HR 0.63, 95% CI: 0.48-0.83).
Conclusion:
Systematic lymphadenectomy of at least six nodes, incorporating the retropancreatic and celiac stations, is a critical quality metric associated with improved regional control and survival in resectable GBC. While these findings support a standardized approach, the retrospective nature of the evidence necessitates cautious application, particularly in early-stage (T1b) disease.