Is Extended Lymphadenectomy in Biliary Tract Cancers Justified? A Retrospective Comparative Study of Gallbladder Cancer, Perihilar and Intrahepatic Cholangiocarcinoma

BACKGROUND: The oncologic value of lymphadenectomy (LND) in biliary tract cancers (BTC) remains controversial. While guidelines recommend retrieval of ≥ 6 lymph nodes to ensure accurate staging, evidence for a therapeutic survival benefit is limited. PATIENTS AND METHODS: We retrospectively analyzed 253 consecutive resections for intrahepatic cholangiocarcinoma (iCCA), perihilar cholangiocarcinoma (pCCA), and gallbladder carcinoma (GBC) at a high‑volume hepatobiliary center from a prospectively maintained database (2013-2023). Patients were stratified into no (0 nodes), limited (1-5 nodes), and extended (≥ 6 nodes) LND. Postoperative morbidity, recurrence-free survival (RFS), and overall survival (OS) were assessed with uni- and multivariable models. RESULTS: LND was performed in 47% of patients and extended LND in 52.9%. Clavien-Dindo grade ≥ III complications occurred in 69.8% with LND ≥ 6 compared with 46.4% with LND1-5 and 41.8% with no LND (p < 0.001), with longer ICU and hospital stays and more septic and pulmonary events. On multivariable analysis, LND ≥ 6 was not an independent predictor of morbidity in the overall cohort, but in the subgroup of major resections (OR 2.79, 95% CI 1.121-6.955, p = 0.027). LND extent had no independent impact on OS or RFS. CONCLUSIONS: Extended LND was associated with a higher rate of postoperative complications and was an independent risk factor in patients undergoing major hepatectomy. However, no clear survival benefit was observed. These findings may suggest that the role of LND in BTC may be primarily diagnostic and that more selective, biology-driven approaches should be considered. Prospective studies are needed for validation.