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Gallbladder cancer

What's new

Updated 2024 ASGE guidelines for endoscopic ultrasound-guided procedures in malignant biliary obstruction .

Guidelines

Key sources

The following summarized guidelines for the evaluation and management of gallbladder cancer are prepared by our editorial team based on guidelines from the European Society of Medical Oncology (ESMO 2025,2023,2016), the American Society for Gastrointestinal Endoscopy (ASGE 2024,2021), the Surgical Infection Society (SIS 2024), the Enhanced Recovery After Surgery Society (ERASS 2023), the Society for Immunotherapy of Cancer (SITC 2023), ...
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Screening and diagnosis

Indications for screening: as per EASL 2022 guidelines, consider obtaining screening for gallbladder cancer with ultrasound and/or MRI/MRCP at least annually in patients with large-duct PSC, regardless of disease stage.
C
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Classification and risk stratification

Staging: as per ESMO 2023 guidelines, classify biliary tract cancer according to the ICD-11 criteria.
B
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  • Prognosis

Diagnostic investigations

Diagnostic imaging: as per ESMO 2023 guidelines, obtain radiological imaging before ERCP or percutaneous transhepatic cholangiography in patients with jaundice.
B
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Diagnostic procedures

Biopsy and histopathology
As per ESMO 2023 guidelines:
Perform a core biopsy for diagnostic pathology and molecular profiling before any nonsurgical treatment.
B
Consider performing EUS-guided FNA or fine needle biopsy, depending on location, as an option to obtain biopsies of enlarged regional nodes and a tumor biopsy if ERCP-guided biopsies are negative or inconclusive.
C
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  • Molecular testing

Medical management

General principles
As per ESMO 2016 guidelines:
Provide patients with biliary tract cancer with a designated point of contact within the multidisciplinary team for advice and support (such as a nurse specialist).
E
Ensure full access to palliative care and symptom management (including pain control) for patients with biliary tract cancer.
E
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  • Adjuvant chemotherapy

  • Definitive systemic therapy (first-line therapy)

  • Definitive systemic therapy (second- and later-line therapy)

Therapeutic procedures

Radiotherapy: as per ESMO 2023 guidelines, consider offering radiotherapy after completion of adjuvant capecitabine in selected patients (R1 resection of gallbladder carcinoma).
C
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  • Management of biliary obstruction (drainage and stenting)

  • Management of biliary obstruction (EUS-guided procedures)

Perioperative care

Preoperative care, counseling
As per ERASS 2023 guidelines:
Provide preoperative information and counseling regarding the upcoming liver surgery. Consider using brochures and multimedia support to improve verbal counseling.
B
Advise preoperative smoking cessation at least 4 weeks before hepatectomy. Advise alcohol cessation in heavy drinkers (> 24 g/day for females or > 36 g/day for males) 4-8 weeks before surgery.
A
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  • Preoperative care (nutrition)

  • Preoperative care (rehabilitation)

  • Preoperative care (biliary drainage)

  • Preoperative care (antibiotic prophylaxis)

  • Preoperative care (corticosteroids)

  • Preoperative care (preanesthetic medication)

  • Intraoperative care (anesthesia and analgesia)

  • Intraoperative care (temperature management)

  • Intraoperative care (fluid management)

  • Postoperative care (thromboprophylaxis)

  • Postoperative care (early mobilization)

  • Postoperative care (nutrition)

  • Postoperative care (antiemetics)

  • Postoperative care (laxatives)

Surgical interventions

Surgical resection, indications: as per ESMO 2023 guidelines, perform radical surgery (including lymphadenectomy) as the only curative-intent treatment for biliary tract cancers. Decide on the exact nature and extent of surgery depending on tumor subtype and location agreed at a specialist hepatobiliary multidisciplinary tumor board meeting.
B
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  • Surgical resection (technical considerations)

Specific circumstances

Patients with gastric outlet obstruction: as per ASGE 2021 guidelines, consider placing self-expandable metallic stents or performing surgical gastrojejunostomy in patients with incurable malignant gastric outlet obstruction undergoing palliative intervention. Decide between these approaches based on patient characteristics and preferences, multidisciplinary input, and local expertise.
C
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Follow-up and surveillance

Assessment of treatment response
As per ESMO 2023 guidelines:
Consider obtaining CA 19-9 for the assessment of treatment response.
C
Re-assess patients by a multidisciplinary team to discuss surgery in case of response following locoregional or systemic treatment of locally advanced tumors.
B
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  • Follow-up

  • Rehabilitation