Lymph node (LN) involvement is a well‐recognized adverse prognostic factor in gallbladder cancer (GBC), and accurate preoperative nodal staging is critical for improving treatment decisions and thereby optimizing patient management. Cross-sectional imaging has limited accuracy in LN staging. Endoscopic ultrasound (EUS) with tissue acquisition (EUS-TA) offers a minimally invasive method to sample suspicious LNs (1-4). This study aimed to evaluate the impact of EUS for nodal staging in patients with presumed resectable GBC.

In this retrospective, single-center cohort study at the Asian Institute of Gastroenterology, Hyderabad, India, consecutive patients with potentially resectable GBC who underwent preoperative EUS between January 2019 and November 2024 were included. Regional LNs were identified according to the 8^th edition of the AJCC staging system as those located at the liver hilum, cystic duct, common bile duct, hepatic artery and adjacent to the gallbladder. Extraregional LN consisted of LNs located distal to the hepatoduodenal ligament. EUS-TA was performed at the discretion of the endosonographer. The primary outcome was the impact of EUS on clinical decision making, measured as the percentage of patients in whom surgical exploration was precluded due to pathologically confirmed LN metastasis identified by EUS-TA. The secondary outcome was the incidence of adverse events, classified according to the AGREE classification. 

A total of 56 patients were included (median age in years: 58.5, 51.8% female). Preoperative cross-sectional imaging was performed in 94.6% of patients with lymphadenopathy reported in 54.7%. Across 59 EUS procedures, 46 LNs were identified, and EUS-TA was performed in 24 nodes from 21 patients. LN metastases were detected by EUS-TA in 10.7% of patients, leading to the exclusion of these patients from surgical treatment. Notably, among patients who underwent surgical exploration after a median period of 18 days [IQR: 7.3 – 34.5], regional LN metastases were identified in nine of 31 patients and extraregional LN metastases in one patient. There were no complications reported related to the EUS or EUS-TA. 

Preoperative EUS significantly influenced clinical decision making in patients with presumed resectable GBC by identifying LN metastases and thereby altering patient management. Notably, multiple LN metastases were missed at preoperative screening. Future prospective studies employing standardized EUS protocols or integrating advanced imaging modalities are warranted to improve preoperative nodal staging and optimize management strategies in GBC.