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Cavallaro A, Di Mattia P. Beyond station 16: A pathway-aware framework for gallbladder cancer lymphadenectomy after neoadjuvant therapy. World J Gastrointest Surg 2026; 18(11): 125509 [DOI: 10.4240/wjgs.125509]
World J Gastrointest Surg. Nov 27, 2026; 18(11): 125509 Published online Nov 27, 2026. doi: 10.4240/wjgs.125509
Beyond station 16: A pathway-aware framework for gallbladder cancer lymphadenectomy after neoadjuvant therapy
Andrea Cavallaro, Paolo Di Mattia
Andrea Cavallaro, Department of General Surgery and Medical Surgical Specialties, University of Catania, Catania 95123, Italy
Paolo Di Mattia, Department of Medicine and Surgery, University of Enna “Kore”, Enna 94100, Italy
Co-first authors: Andrea Cavallaro and Paolo Di Mattia.
Author contributions: Cavallaro A and Di Mattia P jointly conceived the review, developed the pathway-oriented surgical concept, and contributed to the anatomical-surgical framework of the manuscript, both authors participated in literature interpretation, surgical analysis, manuscript drafting, and critical revision of the intellectual content, qualified as the co-first authors of the paper, both authors approved the final version of the manuscript.
AI contribution statement: ChatGPT Edu was used solely for English language polishing and proofreading during manuscript preparation and revision. No AI tool was used to generate research data, perform data analysis, interpret results, select references, formulate clinical conclusions, or create the scientific content of the manuscript. All AI-assisted language edits were critically reviewed and revised by the authors, who take full responsibility for the accuracy, originality and integrity of the manuscript.
Conflict-of-interest statement: The authors declare no conflict of interest.
Corresponding author: Andrea Cavallaro, Department of General Surgery and Medical Surgical Specialties, University of Catania, Via S. Sofia 78, Catania 95123, Italy. andreacavallaro@tiscali.it
Received: July 9, 2026 Revised: August 31, 2026 Accepted: September 21, 2026 Published online: November 27, 2026 Processing time: 126 Days and 17.2 Hours
Abstract
Gallbladder cancer is an aggressive biliary tract malignancy and lymph node status is among the strongest determinants of outcome. For decades, the surgical debate has focused on the extent of lymphadenectomy and on whether para-aortic or interaortocaval nodal involvement should be regarded as regional extension or systemic disease. This binary framing is useful for staging but anatomically incomplete. Classical lymphatic studies described three drainage routes: cholecysto-celiac, cholecysto-retropancreatic and cholecysto-mesenteric. These pathways involve stations 12, 8, 9, 13, 17 and 14 before converging toward station 16, especially 16a2 and 16b1. Current Western algorithms often focus on the hepatoduodenal ligament and treat para-aortic/interaortocaval nodal disease as a contraindication to curative-intent surgery. This Opinion Review proposes a pathway-aware framework for interpreting lymphadenectomy after neoadjuvant therapy. The concept is hypothesis-generating, not a validated therapeutic recommendation. For staging, reporting and research purposes, nodal assessment may be described by both nodal yield and station distribution; a six-node harvest limited to station 12 provides different anatomical information from a six-node harvest sampled across celiac, retropancreatic, mesenteric and para-aortic convergence basins. We do not advocate indiscriminate extended lymphadenectomy. Rather, in medically fit patients with adequate physiological reserve, no systemic progression and realistic R0 resection, pathway mapping and selective clearance may be discussed as an expert-center investigational framework. The key question is whether the involved pathway remains surgically controllable after biological selection, not simply whether station 16 is regional or metastatic.
Core Tip: Station 16 is better understood as the convergence basin of three gallbladder lymphatic pathways rather than as an isolated boundary. This Opinion Review proposes that pathway-aware reporting may complement lymph-node count by documenting station distribution. The framework remains hypothesis-generating: Selective clearance of stations 13, 17, 14 and 16a2-16b1 should not be considered a standard surgical requirement, and may be discussed only in medically fit responders after neoadjuvant therapy, when systemic progression is absent, R0 resection is realistic and expert hepatobiliary surgery is available.
