Primary gallbladder cancer is a highly invasive and metastatic malignant tumor, and is the most common malignant tumor of the biliary tract system, accounting for the 5th to 6th incidence rate of gastrointestinal malignant tumors, with an increasing trend in recent years. With the advancement of diagnosis of gallbladder cancer and the improvement of surgical techniques such as hepatic resection combined with lymphatic dissection, the efficacy of radical resection has once again attracted widespread attention and attention. At present, more attention is paid to the staging and treatment of gallbladder cancer, the treatment of early and unexpected gallbladder cancer and the standard of extended radical resection for gallbladder cancer at home and abroad, which are reviewed in this paper as follows. I. Gallbladder cancer staging and treatment Currently, the following three staging methods are commonly used: TNM staging, Nevin staging and JSBS staging. Nevin staging and TNM staging are mostly used at home and abroad, and most authors believe that TNM staging is a better staging method to compare surgical results and judge prognosis [1], which is also supported by relevant comparative statistical analysis at home and abroad [2]. T-stage in TNM staging mainly describes the extent of tumor infiltration into the gallbladder wall and invasion of adjacent organs, which is the main factor in selecting the appropriate surgical approach and affecting prognosis. The wall of gallbladder from inside to outside mainly consists of mucosal layer, submucosal layer, muscular layer, connective tissue layer and plasma layer, and the part of gallbladder adjacent to liver lacks plasma layer, and connective tissue layer is directly connected with connective tissue of liver. Gallbladder cancer confined within the gallbladder wall is stage T1 and T2, and beyond the gallbladder wall is stage T3 and T4. N-stage requires histological examination of at least three regional lymph nodes, including the hilar, abdominal trunk, peri-duodenal, peri-pancreatic head, and superior mesenteric lymph nodes, and lymph node metastasis beyond the hepatoduodenal ligament is generally considered to have distant metastasis. The most common distant metastases of gallbladder cancer are abdominal and liver metastases. At present, most scholars of hepatobiliary surgery in China and abroad believe [3] that simple cholecystectomy is feasible for TNM stage I gallbladder cancer; radical cholecystectomy for stage II-III gallbladder cancer; and extended radical cholecystectomy for some stage IV patients. However, up to now, there are still differences on whether it is necessary to perform extended radical resection for gallbladder cancer, and reports show that most scholars in China and Japan believe that radical resection can improve patients’ prognosis and survival, and there are more data reports [4-5] showing good surgical results. With the continuous standardization of gallbladder cancer treatment and improvement of statistical data, reports [6] showed that the median survival and 1, 3, and 5-year survival rates (including cumulative and tumor-free survival rates) of patients after radical resection of gallbladder cancer were significantly higher than those of patients undergoing simple cholecystectomy and palliative surgery, both overall and at each different stage level, respectively. Comprehensive information on the current surgical treatment of gallbladder cancer in China shows that there are still some surgical protocols for gallbladder cancer surgery that do not conform to the treatment norms, such as some scholars still perform simple cholecystectomy for stage II patients and blindly perform extended radical cholecystectomy for patients who cannot complete R0 radical resection. Early and unexpected gallbladder cancer Stage T1a is probably the most common after laparoscopic cholecystectomy, and lymph node metastasis rarely occurs in this group of patients, and the 5-year survival rate of patients with simple cholecystectomy is as high as 85-100% if the cut margin is negative. Therefore, simple cholecystectomy for stage T1a gallbladder cancer is a treatment strategy that is not controversial among scholars at home and abroad. Stage T1b tumor invades mucosal muscle layer and metastasis is rare, but most scholars still advocate that regional lymph node dissection should be added for two reasons: firstly, there is no plasma membrane on the bed surface of gallbladder; secondly, the lymphatic network of gallbladder wall is rich and cancer cells may have very early lymphatic metastasis leading to recurrence after surgery. Of course, a few scholars insist that as long as the pathology of the gallbladder margin is negative, no further surgery is needed, and the survival rate of reoperation is not statistically significant compared with that of simple cholecystectomy. There are fewer analyses in the domestic literature involving patients with T1b stage gallbladder cancer, but most experts believe that patients with suspiciously positive postoperative incisional margins should undergo secondary surgery as early as possible [1.7]. This part of the patients is commonly seen after laparoscopic cholecystectomy, more often in patients with a long history of cholecystitis, thickened gallbladder wall, and larger stones and gallbladder polyps. Due to intraoperative gallbladder disruption, some patients may have postoperative tumor implantation and metastasis in the abdominal cavity and puncture tract, which is quite difficult to manage and has poor prognosis. Therefore, preoperative examination of gallbladder resection should be as complete as possible, and patients with suspected gallbladder cancer should be treated with open surgery. It has been reported that laparoscopic resection has a facilitating effect on the development of postoperative abdominal implant metastasis in patients with gallbladder cancer [8-12]. Both in terms of the need for reoperation for unexpected gallbladder cancer and the possibility that laparoscopic surgery may promote gallbladder cancer implant metastasis, there are reasons to support that open surgical resection should be chosen for this group of patients with a tendency to gallbladder cancer. Patients with gallbladder cancer found after laparoscopy should be managed according to the pathological stage of the postoperative lesion. At present, most scholars support that patients before stage T1a may not undergo secondary surgery after complete gallbladder resection; patients with stage T1b and above should still undergo radical resection as soon as possible. However, some scholars believe that gallbladder cancer located on the free plasma surface does not require radical debulking again as long as it does not invade the surrounding organs, regardless of whether it invades the whole layer or not [12]. Most scholars believe that the resection scope of simple cholecystectomy for early-stage gallbladder cancer is insufficient, and Chen Fei et al. reported [13] that the 1-, 3-, 5-, and 8-year survival rates (85.7%, 57.1%, 14-3%, 14.3%) of seven patients with early-stage unexpected gallbladder cancer who underwent simple cholecystectomy (five with Nevin stage I and two with Nevin stage II) were higher than those of 17 patients who underwent radical surgery ( One patient with Nevin stage I developed jaundice 3 months after surgery, and reoperation was not curative. Lu Junhua et al. reported [14] also held the same view. In a study by Tian Hua et al [15], the resection rate of radical surgery in the accidental gallbladder cancer group was 72.2%, while the resection rate of radical surgery in the preoperatively diagnosed gallbladder cancer group was only 39.5%, and the cumulative 5-year survival rates after radical surgery in the two groups were 54.6% and 23.5%, respectively; the median survival times after radical surgery and palliative surgery for 61 gallbladder malignancies in the two groups were 43.3 and 10.5 months, respectively. The median survival time after radical surgery and palliative surgery for 61 gallbladder malignancies in the two groups was 43.3 months and 10.5 months, respectively. At present, the overall diagnosis rate of gallbladder cancer does need to be further improved, and one hospital reported [16] that 83 gallbladder cancer patients were admitted in 18 years, among which the misdiagnosis rate was 54 cases, accounting for 65.1%. In view of the low early diagnosis rate, rapid progression, poor overall outcome and high misdiagnosis rate of gallbladder cancer, in order to reduce its incidence and improve the long-term survival rate of gallbladder cancer patients, more and more scholars advocate appropriately relaxing the indications for cholecystectomy in high-risk groups and selectively performing prophylactic cholecystectomy [17-18]. Radical surgery for progressive gallbladder cancer Stage T2 gallbladder tumor has invaded the muscular layer and surrounding connective tissue, at this time, simple cholecystectomy cannot ensure that R0 resection can be obtained, and whole block resection including liver and hepatoduodenal lymph node dissection is required. The 5-year survival rate can reach up to 80% with radical resection. It has been reported that although stage T2 patients have not invaded the gallbladder plasma membrane, there is still a chance of lymphatic metastasis, and Peng Chenghong reported that liver metastases in hepatic segments IV and V occurred in 2 out of 8 cases of stage T2 patients, suggesting that even in the absence of direct infiltration of the liver, early liver metastases in the gallbladder bed may occur. A standard radical surgery including wedge resection of the liver bed is recommended. For stage T3 gallbladder cancer, at least whole-block resection including liver and regional lymph node dissection should be performed. If the gallbladder cancer invades the liver, a major hepatectomy is required; if the bile duct is invaded, resection and reconstruction of extrahepatic bile duct is also required; if the adjacent organs (duodenum, stomach or colon) are directly invaded, the whole block should also be removed; the 5-year survival rate after radical surgery for stage T3 patients can still reach 30-50%. Expanded radical surgery for gallbladder cancer Expanded radical surgery includes: major hepatectomy, pancreaticoduodenectomy, hilar vascular resection and reconstruction, transverse colectomy, and expanded regional lymph node dissection, etc. Stage T4 gallbladder cancer was previously considered almost impossible to be radically resected, and only palliative treatment was generally considered. In contrast, Pang Shuk-i Ran-xian sewerage is the most important type of treatment. Today, most scholars have recognized that not all patients with advanced gallbladder cancer have the possibility of surgical resection, and many reports [20-22] have found significant benefits for patients with advanced gallbladder cancer after extended radical surgery. partial intestinal wall invasion or invasion of the duodenal bulb can be done by partial resection of the intestinal wall or distal gastrectomy. Although extended radical surgery for gallbladder cancer can improve the survival rate of some patients, it also has greater risks and serious complications, so it should be strictly selected considering the patient’s general condition and the local condition of the tumor. The main problem is how to minimize postoperative complications and achieve better lymphatic clearance by removing the organ tissue within the established range, and many experts have suggested that such surgery should be performed by an experienced hepatobiliary surgery team to standardize the perioperative treatment [23.24]. However, the greatest difficulty in extended radical surgery is the thoroughness of lymph node dissection of the involved lymph nodes, and the radical effect cannot be achieved if there are distant lymph node metastases, so the indications for surgery and the surgical approach should be carefully chosen. As an important concomitant symptom of gallbladder cancer patients, obstructive jaundice is often mistakenly thought that patients have lost the chance of radical treatment by surgery. A study on the relationship between jaundice and gallbladder cancer reported that in patients with the same stage III and IV, the radical rate was lower in the jaundiced group (30.8%) than in the stage III and IV non-jaundiced group (62.2%), while there was no difference in survival between the jaundiced and non-jaundiced groups that underwent radical surgery. This suggests that patients with gallbladder cancer should strive for the opportunity and condition to undergo radical surgery even if they have jaundice. Comprehensive literature on the surgical treatment of gallbladder cancer reported in recent years has shown that the clinical concepts and surgical modalities of gallbladder cancer treatment have changed and improved greatly. Although controversies still exist in some treatment modalities, the effect of radical surgical resection has been unanimously recognized clinically, and there has been considerable progress and improvement in surgical resection rate and survival rate.