Correspondence to: Dr. Wissam Benhami (email: wissambenhami@gmail.com)
Department of General Surgery
RAHMOUNI Djilali Public Hospital (Les Orangers)
Faculty of Medicine
University of Algiers
16000 Algiers
Algeria
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BJS Open, https://doi.org/10.1093/bjsopen/zraf056, published 23 May 2025
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Dear Editor
We read with great interest the OMEGA study by Balakrishnan et al.
1, which presents one of the larger international cohorts of surgically treated patients with gallbladder cancer (GBC).
The OMEGA-NOPPS score is simple, pragmatic, and particularly valuable in incidental GBC (iGBC), where lymphadenectomy is often omitted, by integrating T stage, differentiation, and LVPI. It provides a structured and reproducible framework for estimating nodal risk.
Importantly, the study confirms the poor prognosis associated with ≥3 positive nodes, reinforcing the AJCC N2 threshold and the prognostic relevance of nodal burden2.
However, several points should be discussed. Among 3227 patients who underwent lymphadenectomy, only 1820 (56.3%) had ≥6 nodes retrieved, still below the recommended standards3. Nodal dissection was more frequently omitted in low-incidence countries (14 versus 8.6% in high-incidence regions), suggesting a staging bias with fewer nodes retrieved and fewer positives detected.
The indication of common bile duct resection also remains unclear. Among the 43 patients who underwent this procedure, none had nodal involvement. Given that common bile duct resection is no longer routinely recommended in this setting4, further clarification of surgical rationale would have been valuable.
The 2.6% N+ rate in T1a tumours is biologically unexpected. In selected high-risk T1a cases, should lymphadenectomy be reconsidered despite current guidelines3?
The implications of the score also deserve reflection: should high-score iGBC prompt PET-CT or neoadjuvant therapy? Conversely, is reoperation justified in low-score patients likely to be node-negative? Moreover, recent data suggest a survival benefit from extended lymphadenectomy even in histologically confirmed N0 patients, supporting a potential therapeutic lymphadenectomy’s role5.
Lastly, tumour biology remains underexplored; markers such as CA 19-9 may offer prognostic insight as demonstrated in pancreatic cancer. In conclusion, this study highlights the important role of the robotic approach in GBC, particularly its potential to enhance nodal retrieval.
References
Balakrishnan A, Barmpounakis P, Demiris N et al. Assessment of nodal staging and risk factors for nodal involvement in gallbladder cancer: an international, multicentre retrospective study. BJS Open 2025;9. doi: 10.1093/bjsopen/zraf056.
Amin MB, Greene FL, Edge SB et al. The Eighth Edition AJCC Cancer Staging Manual: Continuing to build a bridge from a population-based to a more "personalized" approach to cancer staging. CA Cancer J Clin 2017;67:93-99. doi: 10.3322/caac.21388
Palepu J, Endo I,Chaudhari VA et al. IHPBA–APHPBA clinical practice guidelines: international Delphi consensus recommendations for gallbladder cancer. HPB (Oxford) 2024;26:561–572. doi: 10.1016/j.hpb.2024.07.411
Araida T, Higuchi R, Hamano M et al. Should the extrahepatic bile duct be resected or preserved in R0 radical surgery for advanced gallbladder carcinoma? Results of a Japanese Society of Biliary Surgery Survey: a multicenter study. Surg Today 2009;39:770-779. doi: 10.1007/s00595-009-3960-6
Wu B, Shen Y, Chen X, Wang X, Zhong Z. Effect of lymphadenectomy on the prognosis for N0 gallbladder carcinoma patients: A study based on SEER database. Cancer Med 2021;10:7136-7143. doi: 10.1002/cam4.4250
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