Avoiding Major Hepatectomy with Oncological Clearance in Carcinoma Gallbladder with Right and Aberrant Hepatic Artery Involvement: A Case Series

Abstract

Background

Gallbladder neck cancer often presents with unique surgical challenges due to its anatomical proximity to the hilum and adjacent critical vascular structures. Aberrant vascular anatomy adds to its complexity. Achieving a complete oncological clearance while preserving liver function becomes particularly difficult when the future liver remnant is inadequate. Preoperative strategies, such as biliary drainage and innovative vascular interventions like hepatic artery (HA) embolization, can play a pivotal role in optimizing surgical outcomes and minimizing the need for major liver resections. This study highlights the effectiveness of these approaches in a series of complex cases.

Aim

To evaluate strategies to prevent major liver resection in gallbladder neck cancer patients with the involvement of the aberrant right HA (RHA) and inadequate future liver remnant.

Materials and Methods

This retrospective case series included five patients with gallbladder neck cancer and aberrant RHA involvement who underwent surgery at the Department of GI and General Surgery, Kathmandu Medical College and Teaching Hospital, from January 1, 2020, to February 1, 2025. Preoperative biliary drainage (PTBD) and vascular interventions were employed, including embolization and reconstruction. Intraoperative findings, surgical outcomes, and postoperative recovery were analyzed.

Results

Among the five patients, one underwent embolization of a replaced RHA (rRHA), two required vascular reconstruction, and the remaining two underwent ligation of the RHA. The patient with obstructive jaundice with a rRHA developed adequate collateral supply following embolization, with simultaneous PTBD. This approach prevented major liver resection despite inadequate functional liver reserve (FLR). The study included three males and two females, with a mean age of 58 ± 5 years. Complete pathological resection (R0) was achieved in all five patients. Postoperative liver function was preserved in all cases, with one patient experiencing a posthepatectomy bile leak that resolved with conservative management. The 90-day postoperative morbidity rate was 20%, with no mortality.

Conclusion

PTBD and selective vascular interventions, such as HA embolization and reconstruction, are effective strategies for managing gallbladder neck cancer with RHA involvement and inadequate FLR. These approaches optimize surgical outcomes, minimize the need for major liver resection, and preserve liver function in high-risk patients. Tailored preoperative planning and a multidisciplinary approach are critical in achieving favorable results in these complex cases.

 

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Keywords

aberrant right hepatic artery - biliary drainage - gallbladder neck cancer - hepatic artery embolization - obstructive jaundice - surgical oncology - vascular reconstruction

With advances in diagnostic modalities, hepatobiliary malignancies are being diagnosed frequently. Among extrahepatic biliary tract pathologies, gallbladder carcinoma (GBC) remains one of the most formidable cancers, particularly in advanced stages, due to its high morbidity and poor overall prognosis. It is difficult to attain ideal circumstances in such patients for curative surgery, considering oncological radicality with complete pathological resection (R0) of the tumor, which will eventually affect the postoperative morbidity. As per GLOBOCAN 2022, GBC has the 22nd highest incidence and 20th most common cause of mortality compared to all cancers, with Asia comprising 75% of the total mortalities. The observatory shows 860 mortalities due to GBC in Nepal, which is an underestimated figure, as a lot of data is not reported. It has been predicted to double in the next 20 years.[1]

GBC is a grievous disease considering its vague and nonspecific symptoms, resulting in delayed diagnosis, especially with a fundal origin. It carries a 5-year survival rate of only 5%. However, carcinoma originating at the neck of the gallbladder has a relatively earlier presentation. GBC at the neck has proximity to the hilum and the adjacent vessels with organs demanding extended surgeries like hepatopancreatoduodenectomy and major liver resections. Extensive surgeries are usually performed for complete pathological resection, although they might lead to high postoperative morbidity and poor overall survival outcomes.[2] [3] [4] [5]

Obstructive jaundice (OJ) and inadequate functional liver reserve (FLR) are some of the components that complicate liver resection, increasing the chances of posthepatectomy liver failure (PHLF). Preoperative biliary drainage (PTBD) and portal vein embolization (PVE) are key interventions that tackle these issues and aid in avoiding PHLF.[6]

Among the hilar structures, the hepatic artery (HA) has its anatomical variations. The largest series of 1,000 patients showed that 24.3% had an anomalous origin. Most of the practitioners follow Michel's classification, which is graded in terms of the origin of either of the HA. The origin of the right HA (RHA) is normally from the proper HA (PHA), originating from the common HA (CHA). The alternative origin can be from the superior mesenteric artery (SMA) as well. Aberrant vessels can either be an accessory vessel with a different derivation or may completely replace the normal origin and orientation.[7] [8]

There are several articles discussing strategies regarding the management of the replaced vessels during pancreatoduodenectomy (PD), where resection and reconstruction of the respective vessels have been suggested.[9] [10] In a bicentric French cohort, Marichez et al concluded that percutaneous embolization of the replaced RHA (rRHA) was safe and reproducible, which was followed by en bloc PD, limiting the risk of bilio-hepatic ischemia, and also suggested that it could facilitate oncologic resection.[11] However, similar modalities for carcinoma gallbladder, especially originating at the neck involving the hilum in similar circumstances, are scarce and need to be addressed. This series of five patients with GBC at the neck with variable involvement of the right aberrant HA (aRHA) encourages preoperative interventions of the artery, facilitating a R0 resection.

Materials and Methods

Study Design and Setting

The study was conducted as a retrospective case series of patients undergoing surgery for GBC with aRHA involvement at the Department of Gastrointestinal and General Surgery, Kathmandu Medical College and Teaching Hospital, from January 1, 2020, to February 1, 2025. All patients were managed according to institutional protocols. Data were collected under an approved institutional review board protocol, adhering to STROBE guidelines for observational studies. The team of surgeons who performed all the surgeries was constant.[12] ([Fig. 1])

Fig. 1 Consort diagram for the patients enrolled in the study.

 

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Patient Selection

All patients with postoperative pathologically confirmed GBC centered at the neck and with radiologic or intraoperative evidence of involvement of RHA were included. Patients were identified through surgical and pathology databases. Inclusion criteria were: (1) primary GBC of the neck; and (2) typical or aRHA involvement, defined as direct tumor encasement or abutment of the RHA. Exclusion criteria were distant metastases or unresectable disease found intraoperatively.

 

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Preoperative Assessment and Interventions

Each patient underwent a comprehensive preoperative evaluation. Imaging included contrast-enhanced triphasic computed tomography (CT) of the abdomen to delineate tumor extent. Preoperative CT angiography was performed to define hepatic arterial anatomy and identify RHA origin. In cases of OJ, biliary drainage (percutaneous transhepatic biliary drainage) was performed to relieve cholestasis. When a major liver resection was anticipated, volumetric analysis was performed mandatorily using CT. In selected cases, coil embolization of the involved aRHA was performed 7 days before surgery to induce arterial collateralization.

 

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Surgical Techniques

All patients were managed by open radical or extended radical cholecystectomy.[13] The procedure included en bloc resection of the gallbladder with a wedge or hepatic resection (typically segment IVb/V) and formal lymphadenectomy (porta hepatis, pericholedochal, and periportal nodes). Intraoperatively, the aRHA was carefully dissected and its tumor involvement assessed. Management of the RHA was individualized:

1. Divestment: if the aRHA could be safely dissected free of the tumor or divested with an adequate margin and was not the sole blood supply to a large liver remnant, it was preserved.

2. Embolization: if a long segment of the artery was involved that was nonreconstructable, and the lumen was intact, embolization was preferred.

3. Ligation: if the aRHA was encased by tumor and accessory supply, the artery was sacrificed. If the vessel was completely occluded with backflow, ligation was the choice of intervention.

4. Reconstruction: When the aRHA supplied a substantial portion of the liver and could not be sacrificed without risk of ischemia, arterial reconstruction was performed. If the artery had a partial occlusion, identified by no backflow or poor backflow with only a short segment (<2 cm), an end-to-end anastomosis was constructed. Hemostasis and biliary transection were performed under intermittent Pringle maneuvers as needed. Intraoperative cholangiography confirmed biliary anatomy when necessary.

The primary endpoint was achieving an R0 resection. R0 was defined as per UICC criteria as no microscopic tumor at any resection margin.[14] Secondary endpoints included postoperative liver function (peak bilirubin and transaminases) as per Edinburgh criteria (Clichy criteria), occurrence of bile leak, and perioperative outcomes at 90 days (complications and mortality).[6] Postoperative morbidity was graded using the Clavien–Dindo classification. Bile leak was defined according to the International Study Group of Liver Surgery criteria.[15] Mortality was recorded as any death within 90 days of surgery.

 

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Data Collection and Statistical Analysis

We collected detailed data on patients' demographic variables (age and sex), clinical presentation (jaundice and performance status), anatomical variant (type of an aRHA), and preoperative interventions (drainage and embolization). Intraoperative data included the extent of hepatectomy, RHA management (ligation and reconstruction), blood loss, and operative time. Pathological data included tumor size, T stage, nodal status, differentiation, and margin status. Postoperative outcomes recorded were peak liver enzyme levels, length of stay, complications (type and grade), and 90-day mortality. Quantitative variables are reported as median or mean ± SD, and categorical variables as counts and percentages. No inferential statistics were performed. All analyses were conducted using SPSS v26.

 

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Results

Patient Characteristics

A total of 55 cases of GBC were evaluated, and five patients (three males and two females) met the inclusion criteria over the study period. The median age was 58 years (range: 35–72). One patient (20%) presented with OJ and underwent PTBD to optimize liver function. Aberrant arterial anatomy was documented preoperatively in a few cases: all patients with aRHA originated from the SMA. Two patients had a variety of aberrancies. One of the five patients (20%) underwent preoperative coil embolization of the involved rRHA (7 days before surgery) to promote collateral formation. Angiography postembolization confirmed collaterals. One patient underwent ligation of the RHA as it was completely occluded and with backflow, while the remaining two (cases 2 and 5) underwent end-to-end vascular anastomosis. All patients had adequate cardiac and pulmonary function for major surgery. No patient received neoadjuvant therapy. ([Table 1])

Table 1 Demographics, preoperative interventions, typical RHA and aRHA variant, and surgical management

Case	Sex	Age	Jaundice	aRHA variant	Preoperative drainage	Preoperative embolization	aRHA management	Resection margin	Clavien–Dindo grade
1	M	71	No	Typical RHA	No	No	Ligation	R0	I
2	F	62	No	Typical RHA	No	No	Reconstruction	R0	II
3	M	35	Yes	Replaced RHA (SMA)	PTBD	Yes	Embolization and ligation	R0	I
4	F	65	No	Replaced RHA (SMA)	No	No	Ligation	R0	I
5	M	72	No	Typical RHA	No	No	Reconstruction	R0	I

Abbreviations: F, female; M, male; PTBD, percutaneous transhepatic biliary drainage; R0, complete pathological resection; RHA, right hepatic artery; SMA, superior mesenteric artery.

 

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Surgical and Oncological Outcomes

All patients underwent an extended cholecystectomy. Hepatic resection usually involves segments 4b and 5. In the patient (case 3) who had preoperative RHA embolization, the rRHA was ligated without reconstruction; preoperative CT showed multiple collaterals, and the patient achieved R0 resection. ([Fig. 2]) In one patient (case 1), the RHA was encased by the tumor and was ligated. In the remaining two patients (cases 3 and 4), the aRHA was ligated eventually. All resections were pathologically complete. Final pathology showed one case of neuroendocrine carcinoma of the gallbladder, and the remaining four showed adenocarcinoma, with tumor sizes ranging between 2.5 and 6.0 cm, with moderate to poor differentiation. No patient required a blood transfusion. Postoperative liver function tests remained acceptable: peak bilirubin did not exceed 4 mg/dL in the majority of the cases, except for the patient (case 3), who presented with OJ, who had a preoperative total bilirubin of 10 mg/dl after PTBD, which was gradually decreasing. There was no clinically evident liver failure. ([Fig. 3])

Fig. 2 Fluoroscopy and CT images showing rRHA embolization and collateral development. (A) Before embolization of the rRHA. (B) After embolization of the rRHA. (C) rRHA encasement by the GBC. (D) Collateral development after embolization.

Fig. 3 Intraoperative pictures of reconstruction of the RHA. (A) Hepatic artery after transection, during anastomosis. (B) Hepatic artery after anastomosis.

 

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Complications and Follow-Up

One patient (case 2) developed a postoperative bile leak. This was managed with antibiotics and prolonged abdominal drain placement; the leak was graded Clavien–Dindo II and resolved by the third week postoperatively. No other major complications were observed. Overall, 90-day morbidity was 20% (one of five patients). There were no cases of postoperative liver failure. All five patients survived to 90 days. Median follow-up was up to 1 year.

 

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Discussion

GBC can present variably; some present with vague abdominal pain, some present with no symptoms at all, diagnosed incidentally, and some present with OJ. Radical resection, such as major liver resection, has been proposed to achieve R0 resection. However, the extensive surgery has not been validated in the literature and poses the risk of high morbidity and poor survival benefits, especially in patients with inadequate FLR.

GBC with vascular involvement is an area of discussion, and encasement of aberrant vessels, especially replaced vessels, complicates the complete pathological resection. Considering all the drawbacks of major liver resection for GBC, interventions like ligation, arterial reconstruction, and preoperative arterial embolization can aid in achieving an R0 resection in patients with GBC.

Gallbladder neck carcinoma poses significant surgical challenges due to its anatomical proximity to the hepatic hilum and frequent involvement of critical vascular structures, such as the aRHA. The presence of an inadequate FLR further complicates achieving R0 resection while preserving liver function. Our case series of five patients with GBC and aRHA involvement demonstrates the efficacy of preoperative strategies, including biliary drainage and vascular interventions, in achieving R0 resection and minimizing major liver resection.

One patient (20%) presented with OJ, requiring preoperative PTBD to optimize liver function (preoperative bilirubin reduced from 21 to 10 mg/dL). All patients with aRHA had a replaced variant identified preoperatively via CT angiography, aligning with the reported 15 to 20% prevalence of aRHA in the general population.[16] The use of preoperative imaging to delineate vascular anatomy is consistent with recommendations by Kumaran et al, who emphasized CT angiography for planning resection in gallbladder cancer with vascular involvement.[17] One patient in our series underwent preoperative coil embolization of a rRHA 7 days before surgery, promoting collateral formation, as confirmed by postembolization angiography. This approach mirrors strategies described in PD for periampullary cancers with aRHA involvement, where preoperative embolization enhances collateral flow to prevent ischemia during ligation. Marichez et al reported a bicentric study of 16 patients undergoing preoperative aRHA embolization before PD, achieving R0 resection in 87.5% without ischemic complications, comparable to our 100% R0 resection rate. The timing of embolization aligns with their findings, where collateral development was confirmed 3 to 21 days postembolization.[10] [11]

In contrast, a case report by Takagi et al described preoperative HA embolization for locally advanced gallbladder cancer invading the RHA, achieving R0 resection via gallbladder bed resection with PD and RHA resection without reconstruction.[18] Unlike our patient, their case involved a nonaberrant RHA case, but the principle of embolization to promote collaterals was similar, with no postoperative liver ischemia observed. Optimizing jaundiced patients via biliary drainage, reducing bilirubin to safe levels (<3 mg/dL), as per the guidelines for gallbladder neck cancer requiring major resection, has been discussed in a few studies.[19]

Comparatively, PVE is more commonly reported for FLR augmentation in hepatobiliary malignancies, with studies like Yamashita et al reporting 20% FLR hypertrophy in 80% of the patients.[20] However, HA embolization, as used in our study, is less studied but shows promise in gallbladder cancer with aRHA involvement, particularly when PVE is not indicated due to hilar tumor extent. The combination of PTBD and embolization in the jaundiced patient optimized both biliary and vascular status, a strategy less emphasized in PVE-focused studies but critical for gallbladder neck tumors.[21]

Our series reported a 20% postoperative morbidity rate (Clavien–Dindo grades I and II), with one patient experiencing a self-limiting bile leak, which was comparable with the literature morbidity rates ranging from 15 to 30% in gallbladder cancer resections with vascular involvement.[22]

The use of embolization to avoid major hepatectomy is less commonly reported in gallbladder cancer compared to pancreatic or hepatocellular carcinoma, where PVE and arterial embolization are more established. Features of extrahepatic collateral arteries related to HA occlusion and benefits in transarterial management of liver tumors described by Yang et al highlight the collateral pathways from the SMA and left gastric artery for CHA embolization, while gastroduodenal artery branches for PHA embolization. Early literature from Mays ET and Wheeler CS from 1974 evaluated 20 of 50 patients who had therapeutic ligation of various hepatic arteries, who were assessed by angiography and radionuclide scanning. Dydynski et al discussed two cases of liver transplantation with subacute HA compromise with collateral artery vessel formation in 2007, which was confirmed by angiography and termed as collateral transformation. Although Michels described 26 potential collateral pathways for the arterial supply to the liver, Charnsangavej et al simplified these collaterals into intrahepatic and extrahepatic collaterals, ranging from the phrenic arteries to the epigastric arteries.[23] [24] [25]

Unlike our study, some reports emphasize neoadjuvant chemotherapy to downstage tumors before resection, as seen in a case by Nakachi et al, where cisplatin plus gemcitabine enabled conversion surgery for advanced gallbladder cancer, achieving R0 resection. The ABC-02 trial has recognized the use of gemcitabine-platinum as the choice of treatment in advanced GBC. Sirohi et al conducted the first published study of neoadjuvant chemotherapy in locally advanced GBC, where the authors concluded 48.6% downstaging and better R0 resection rates compared to upfront surgery; however, the study sample size is lower compared to other studies, but it has opened an area of discussion in GBC. On the contrary, larger studies from Dixon et al, Rossi et al, Sikora and Singh, and Foster et al have consistently favored radical resection in GBC. Our study parallels these studies, as the motive of the surgery was an R0 resection following RHA interventions in a resectable GBC with comparable morbidity and mortality benefits. The concept of collateralization after embolization and reconstruction in selective cases could form the basis of future studies in GBC management. The authors of the study fully comply with prioritizing the biology of the malignancy and use of neoadjuvant therapy whenever indicated.[26] [27] [28] [29] [30] [31] [32]

The study's small sample size and retrospective design limit generalizability, a common challenge in rare entities. However, the quality of the cases and the concept of R0 resection in a locally advanced GBC, where vascular interventions provide an opportunity for the patients to Future research should focus on standardizing embolization protocols and assessing long-term oncological outcomes. The integration of molecular profiling and advanced imaging could further refine preoperative planning. Multidisciplinary approaches, combining embolization, chemotherapy, and surgery, may improve resectability and survival in this aggressive disease.

We got an opportunity to discuss the case series with Professor Heaton from King's College in London, who expressed his positive responses about the embolization of replaced HA to achieve an R0 resection in patients with GBC. He emphasized the need to understand the arteries we anticipate might collateralize before the intervention, and the level of embolization is crucial, as it generally impacts the collateral pathway. He explained that a higher embolization level may encourage collateralization through the bile duct, which could potentially bring challenges if excision of the extrahepatic bile duct is required. Conversely, he also pointed out that excessively low embolization levels could lead to peripheral collateralization. Professor Heaton shared his experiences with some cases developing robust collateral supply from the phrenic arteries to the liver as well, but he expressed his uncertainty about it being sufficient for the bile ducts.

 

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Conclusion

Managing GBC with RHA involvement demands precise preoperative planning, expert surgical execution, and a nuanced multidisciplinary approach. Resection remains the only curative option, but RHA involvement creates difficulty in achieving R0 margins without compromising liver perfusion. Various modalities like embolization optimize surgical outcomes, minimize the need for major liver resection, and preserve liver function in high-risk patients.

 

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Conflict of Interest

None declared.

Acknowledgement

The authors would like to acknowledge Dr. Yugal Limbu, MCh, MRCS, Senior Liver Transplant Fellow at King's College, London, for his unwavering support and valuable contributions in helping to bring out the best in this series.

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Publication History

Received: 04 July 2025

Accepted: 01 August 2025

Article published online:
14 August 2025