Gallbladder cancer: the role of laparoscopy and radical resection

Current management of gallbladder carcinoma

Gallbladder cancer (GBC) represents the most common and aggressive type among the biliary tree cancers (BTCs). Complete surgical resection offers the only chance for cure; however, only 10% of patients with GBC present with early-stage disease and are considered surgical candidates. Among those patients who do undergo "curative" resection, recurrence rates are high. There are no established adjuvant treatments in this setting. Patients with unresectable or metastatic GBC have a poor prognosis. There has been a paucity of randomized phase III data in this field. A recent report demonstrated longer overall survival with gemcitabine in combination with cisplatin than with gemcitabine alone in patients with advanced or metastatic BTCs. Molecularly targeted agents are under development. In this review, we attempt to discuss the current status and key issues involved in the management of GBC.

Are histological alterations observed in the gallbladder precancerous lesions?

INTRODUCTION

Gallbladder cancer, which is characterized by rapid progression and a poor prognosis, is a complex disease to treat. Unfortunately, little is known currently about its etiology or pathogenesis. A better understanding of its carcinogenesis and determining risk factors that lead to its development could help improve the available treatment options.

METHOD

Based on this better understanding, the histological alterations (such as acute cholecystitis, adenomyomatosis, xanthogranulomatous cholecystitis, polyps, pyloric metaplasia, intestinal metaplasia, dysplasia, cancer and others) in gallbladders from 1,689 patients who underwent laparoscopic cholecystectomy for cholecystolithiasis were analyzed. The association of these gallbladder histological alterations with clinical data was studied.

RESULTS

Gender analysis revealed a greater incidence of inflammatory changes in males, while dysplasia and cancer were only found in women. The incidence of cholesterolosis was greater in the patients 60 years of age and under, and the incidence of adenomyomatosis and gangrene was greater in the elderly patients. A progressive increase in the average age was observed as alterations progressed through pyloric metaplasia, intestinal metaplasia, dysplasia and then cancer, suggesting that the metaplasia-dysplasia-carcinoma sequence may occur in gallbladder cancer. Gallbladder histological alterations were also observed in asymptomatic patients.

CONCLUSION

The results of this study suggest that there could be an association between some histological alterations of gallbladder and cancer, and they also suggest that the metaplasia-dysplasia-carcinoma sequence could in fact be true in the case of gallbladder cancer. Nevertheless, further studies directed towards a perfect understanding of gallbladder carcinogenesis are required.

Differential diagnostic and staging accuracies of high resolution ultrasonography, endoscopic ultrasonography, and multidetector computed tomography for gallbladder polypoid lesions and gallbladder cancer

OBJECTIVE

The authors undertook to investigate the diagnostic performance of high-resolution ultrasound (HRUS), and to compare the differential diagnostic and staging accuracies of endoscopic ultrasonography (EUS), HRUS, and multidetector computed tomography for gallbladder (GB) polypoid lesions and GB cancer.

SUMMARY OF BACKGROUND DATA

Endoscopic ultrasonography was considered the most sensitive diagnostic modality for GB polypoid lesions. However, recent technical advancements in other image modalities including conventional sonography (US) allow the production of comparable images.

METHODS

A total of 170 patients, with a more than 1-cm sized polypoid GB lesion, and without evidence of definite local invasion to adjacent organs during primary screening, were consecutively enrolled in this prospective, blind, comparative study. After excluding 26 patients with inappropriate medical histories, 144 patients were finally enrolled. All patients underwent surgical resection. Clinical diagnoses were compared with histopathologic findings by diagnostic modality.

RESULTS

Of the 144 patients, there were 115 (79.8%) cases of benign GB polypoid lesions and 29 (20.2%) cases of GB cancers. Diagnostic sensitivities for malignancy were 90% for HRUS, 86% for EUS, and 72% for CT. When evaluating the abilities of these modalities to predict GB cancer depth of invasion, we excluded 2 unusual GB malignancies (melanoma and lymphoma), HRUS was found to have the highest diagnostic accuracy of 62.9%; EUS and CT had accuracies of 55.5% and 44.4%, respectively.

CONCLUSIONS

The diagnostic accuracies of HRUS and EUS for the differential diagnosis of GB polypoid lesions were comparable. In view of patient comfort and no requirement for sedation, we consider that HRUS is likely to become an important diagnostic modality for the differential diagnosis and staging of GB polypoid lesions and early GB cancer.

Intraluminal versus infiltrating gallbladder carcinoma: Clinical presentation, ultrasound and computed tomography

AIM: To compare clinical presentation and ultrasound (US) and computed tomography (CT) sensitivity between intraluminal and infiltrating gallbladder carcinoma (GBCA).

METHODS: This retrospective study evaluated 65 cases of GBCA that were categorized morphologically into the intraluminal-GBCA (n = 37) and infiltrating-GBCA (n = 28) groups. The clinical and laboratory findings, presence of gallstones, gallbladder size, T-staging, nodal status, sensitivity of preoperative US and CT studies, and outcome were compared between the two groups.

RESULTS: There were no significant differences between the two groups with respect to female predominance, presence of abdominal pain, serum aminotransferases level, T2-T4 staging, and regional metastatic nodes. Compared with the patients with intraluminal-GBCA, those with infiltrating-GBCA were significantly older (65.49 ± 1.51 years vs 73.07 ± 1.90 years), had a higher frequency of jaundice (3/37 patients vs 13/28 patients) and fever (3/37 patients vs 10/28 patients), higher alkaline phosphatase (119.36 ± 87.80 IU/L vs 220.68 ± 164.84 IU/L) and total bilirubin (1.74 ± 2.87 mg/L vs 3.50 ± 3.51 mg/L) levels, higher frequency of gallstones (12/37 patients vs 22/28 patients), smaller gallbladder size (length, 7.47 ± 1.70 cm vs 6.47 ± 1.83 cm; width, 4.21 ± 1.43 cm vs 2.67 ± 0.93 cm), and greater proportion of patients with < 12 mo survival (16/37 patients vs 18/28 patients). The sensitivity for diagnosing intraluminal-GBCA with and without gallstones was 63.6% and 91.3% by US, and 80% and 100% by CT, respectively. The sensitivity for diagnosing infiltrating-GBCA with and without gallstones was 12.5% and 25% by US, and 71.4% and 75% by CT, respectively.

CONCLUSION: In elderly women exhibiting small gallbladder and gallstones on US, especially those with jaundice, fever, high alkaline phosphatase and bilirubin levels, CT may reveal concurrent infiltrating-GBCA.

Radical resection for T1b gallbladder cancer: a decision analysis

BACKGROUND

Gallbladder cancer is the most common malignancy of the biliary tract. Radical surgery (including liver resection and regional lymphadenectomy) is applied for some gallbladder cancers, but the benefits of these procedures are unproven. For patients with T1b cancers discovered incidentally on cholecystectomy specimens, the utility of radical surgery remains debated.

METHODS

A decision analytic Markov model was created to estimate and compare life expectancy associated with management strategies for a simulated cohort of patients with incidentally discovered T1b gallbladder cancer after routine cholecystectomy. In one strategy, patients were treated with no additional surgery; in another, patients were treated with radical resection. The primary (base-case) analysis was calculated based on a cohort of 71-year-old females and incorporated best available input estimates of survival and surgical mortality from the literature. Sensitivity analysis was performed to assess the effects of model uncertainty on outcomes.

RESULTS

In the base-case analysis, radical resection was favoured over no further surgical resection, providing a survival benefit of 3.43 years for patients undergoing radical resection vs. simple cholecystectomy alone. Sensitivity analysis on the age at diagnosis demonstrated that the greatest benefit in gained life-years was achieved for the youngest ages having radical resection, with this benefit gradually decreasing with increasing age of the patient. High peri-operative mortality rates (>/=36%) led to a change in the preferred strategy to simple cholecystectomy alone.

CONCLUSIONS

Decision analysis demonstrates that radical resection is associated with increased survival for most patients with T1b gallbladder cancer.

Lymph node evaluation is associated with improved survival after surgery for early stage gallbladder cancer

BACKGROUND

Guidelines for the current National Comprehensive Cancer Network recommend radical cholecystectomy, including hepatic resection and portal lymph node (LN) dissection, for patients with early stage gallbladder (GB) cancer. We sought to determine the survival benefit conferred by adequate LN evaluation.

METHODS

We used the surveillance, epidemiology and end results (SEER) neoplasm registry to identify patients who had an operation for GB cancer between 1988 and 2004. Patients were classified by stage of disease, operative procedure performed (cholecystectomy alone or radical resection), number of LNs evaluated (0, 1, >1), and receipt of radiation (RT). We included patients with T1B, T2, and T3 neoplasms who were LN positive or negative. Patients with T4 neoplasms and those with metastatic disease were excluded. Multivariate analysis included adjustment for age, race, sex, neoplasm grade, stage, operation performed, receipt of RT, and neoplasm registry.

RESULTS

We identified 4,614 patients who underwent operative treatment for stage 1-2B GB (including T1B-T3 and LN positive or negative) cancer between 1988 and 2004. Of 4,614 patients, 9.6% (442) had radical resection, whereas 90.4% (4,172) had cholecystectomy alone. Among patients undergoing radical resection, 56% had LNs evaluated as compared with 28% of patients after cholecystectomy. For patients with T1B and T2 neoplasms who underwent radical resection, pathologic evaluation of at least 1 LN was associated with a significant improvement in median overall survival (OS) compared with those who had no LN evaluated (123 months vs 22 months; P < .0001). Radical resection with no LN evaluation provided similar OS compared with cholecystectomy alone (22 months vs 23 months; P = NS). For patients with T3 neoplasms, radical resection, including pathologic evaluation of at least 1 LN, was also associated with improved OS compared with radical resection with no LN evaluation (12 months vs 7 months; P = .0014). Again, individuals who had radical resection without LN evaluation had similar OS compared with those who had cholecystectomy alone (7 months vs 6 months; P = NS). Individuals who had radical resection with LN evaluation were more likely to receive RT than those who had radical resection without LN evaluation (33.1% vs 19.1%; P = .002). In multivariate analysis (including adjustment for RT), however, LN evaluation was still associated with a decrease in mortality compared with no LN evaluated (HR = 0.611; 95% CI = 0.484, 0.770). The pathologic evaluation of additional LN (>1) did not provide any additional benefit compared with the evaluation of a single node (HR = 0.795; 95% CI = 0.571, 1.107). Radical resection alone (without LN evaluation) did not provide any benefit over cholecystectomy alone (HR = 1.098; 95% CI = 0.971, 1.241).

CONCLUSION

LN evaluation is a critical component of radical resection for GB cancer. In the absence of LN evaluation, radical resection provides no benefit over cholecystectomy alone.

[Gallbladder cancer in a regional hospital]

OBJECTIVES

To assess the management of gallbladder cancer (GBC) in our region.

MATERIAL AND METHODS

Data on 372 patients who underwent cholecystectomy were identified from our database (January 2003 to February 2008) and 6 patients were found to have GBC.

RESULTS

Four patients had incidental carcinoma, one case was preoperatively suspected, and one patient presented with jaundice and locally advanced neoplasia. The incidence was 2 per 100,000 inhabitants per year; incidental carcinoma in 1.1% of cholecystecomies. The ultrasonography showed multilithiasis in 2 patients, sludge and neoplasia in 1, gallstones more than 3cm in 2, and tumor mass only in 1 case. T stage: 1 case of T0 (in situ), 1 of T1, 2 of T2 and one T4. Incidental carcinomas were reoperated on when a T2 was established: 2 underwent lymphadenectomy and cystic stump resection, 1 segmentectomy IVb-V and lymphadenectomy. In the preoperative suspected neoplasia a cholecystectomy, lymphadenectomy, and partial hepatic gallbladder bed resection was initially performed.

CONCLUSIONS

GBC has a low incidence but it will be found in 1% of cholecystectomies. There is no adjuvant treatment and T-based surgical treatment is the is the only opportunity to reach cure in those patients. A national GBC database would be helpful in the publication of national guidelines for this disease.

Laparoscopic radical cholecystectomy

Controversy exists as to the role of minimally invasive techniques in the management of early gallbladder cancer. The majority of early gallbladder cancers are diagnosed upon final pathology after laparoscopic cholecystectomy. For stage pT1a tumors, no further surgery is warranted; however, for pT1b or greater lesions, patients usually undergo port-site excisions and completion of open radical cholecystectomy involving a partial hepatectomy of segments IV and V and a lymphadenectomy of the hepatoduodenal ligament. Presented in this paper is a totally laparoscopic radical cholecystectomy performed for suspected early gallbladder cancer. Despite the fact that a preoperative serum IgG4 level was within normal limits, final pathology was consistent with autoimmune cholecystitis. As a result, the laparoscopic radical cholecystectomy may be useful in select patients with a preoperative suspicion of early-stage gallbladder cancer by sparing them the necessity of a second-stage open procedure.

Gallbladder carcinoma manifesting as acute cholecystitis: clinical and computed tomographic features

BACKGROUND

Gallbladder carcinoma is uncommon and may manifest as acute cholecystitis. An accurate diagnosis is helpful for operative planning and this study attempted to explore the distinctive clinical and computed tomographic (CT) features for differentiating acute cholecystitis alone from that with contemporaneous gallbladder carcinoma.

METHODS

This 20-year, retrospective study evaluated the CT features of 26 patients with surgically proven gallbladder carcinoma with clinical presentations of acute cholecystitis (carcinoma group). Thirty elderly patients with surgically proven simple acute cholecystitis were enrolled as age-matched controls (cholecystitis group). The clinical, laboratory, and CT findings were compared between the 2 groups.

RESULTS

The carcinoma and cholecystitis groups showed no significant differences with respect to clinical symptoms (abdominal pain, fever, and jaundice), serum total bilirubin level, leukocyte count, percentage of segmented leukocytes, presence of gallstones, and CT features of pericholecystic stranding/fluid and focally increased enhancement of adjacent liver. Fifteen of the 26 (57.6%) patients in the carcinoma group exhibited diffuse gallbladder wall thickening on CT and the other 11 exhibited focal thickening or intraluminal masses. Beside female predominance, the patients in the carcinoma group had significantly higher serum aspartate/alanine aminotransferase and alkaline phosphatase levels, a thicker gallbladder wall, smaller volume, lower frequency of triple-layer gallbladder wall enhancement pattern, and a higher frequency of enlarged regional lymph nodes than those in the cholecystitis group.

CONCLUSION

For elderly patients, especially women, presenting with acute cholecystitis and abnormal liver function, CT demonstration of focal gallbladder wall thickening, intraluminal masses, small gallbladder with diffuse wall thickening, and enlarged regional lymph nodes are suggestive of concurrent gallbladder carcinoma. Triple-layer gallbladder wall enhancement is suggestive of simple acute cholecystitis.

Lymphatic invasion: an important prognostic factor for stages T1b-T3 gallbladder cancer and an indication for additional radical resection of incidental gallbladder cancer

BACKGROUND

Laparoscopic cholecystectomy is being performed with increasing frequency worldwide. This has led to more frequent discovery of incidental gallbladder cancer (IGBC) and in turn to the need for an independent prognostic factor for stages T1b-T3 gallbladder cancer so that is can be determined clinically which cases of IGBC are indicated for additional radical resection (ARR).

METHODS

A retrospective study was conducted that included 72 patients who underwent macroscopically curative surgical resection (R0, R1) at our center for stages T1b-T3 GBC. Survival analysis was performed, and the usefulness of ARR was analyzed in 15 patients with IGBC.

RESULTS

Univariate analysis of disease-specific survival showed stage T3, histologic grade II-IV, lymphatic invasion, vessel invasion, perineural invasion, lymph node metastasis, and a positive resection margin to be factors indicative of poor prognosis. Independent predictors of poor disease-specific survival were stage T3 (hazard ratio, 2.33 [95% CI, 1.10-4.95]), lymphatic invasion (5.97 [1.29-27.6]), and a positive resection margin (3.17 [1.51-6.63]). Among the 15 IGBC patients, 4 of 5 patients without lymphatic invasion were cured, 2 of whom underwent cholecystectomy alone; 4 of 10 patients with lymphatic invasion did not undergo ARR, and the cancer recurred in all 4 patients; the other 6 patients underwent ARR, and 4 of them were cured by reoperation.

CONCLUSIONS

Lymphatic invasion well reflects the malignant phenotype of stages T1b-T3 GBC. We advocate ARR for IGBC patients with lymphatic invasion.

Evolving treatment strategies for gallbladder cancer

Gallbladder cancer is an uncommon cancer that has traditionally been associated with a poor prognosis. In the era of laparoscopic cholecystectomy, incidental gallbladder cancer has dramatically increased and now constitutes the major way patients present with gallbladder cancer. While patients with incidental gallbladder cancer have a better survival than patients with nonincidental gallbladder cancer, incidental gallbladder cancer can be associated with a varied prognosis. Imaging with computed tomography (CT), magnetic resonance imaging (MRI), and [18]F-fluorodeoxyglucose (FDG) positron emission tomography (PET), as well as diagnostic laparoscopy, all have varying roles in the workup of patients with incidental gallbladder cancer. For patients with T1b, T2, and T3 incidental gallbladder cancer re-resection is generally recommended. At re-exploration, many patients with incidental gallbladder cancer will have residual disease. Definitive oncologic management requires re-resection of the liver, portal lymphadenectomy, and attention to the common bile duct. The extent of the hepatic resection should be dictated by the ability to achieve a microscopically negative (R0) margin. Routine resection of the common bile duct is unnecessary but should be undertaken in the setting of a positive cystic duct margin. If an incidental gallbladder cancer is discovered at the time of surgery, whether the surgeon should directly proceed with a more definitive oncologic operation should depend on the surgeon's skill-set and experience. Gallbladder cancer has a propensity to recur. Although data for adjuvant therapy following resection are limited, some data do suggest a survival benefit for adjuvant chemoradiation therapy. Management of patients with gallbladder cancer requires a multidisciplinary approach with input from a surgeon skilled in hepatobiliary surgery.

Framing family conversation after early diagnosis of iatrogenic injury and incidental findings

BACKGROUND

Surgeons are rarely formally trained in giving bad news to patients. The aim of our study was to examine and compare techniques of disclosure of iatrogenic and incidental operative findings among surgical residents.

METHODS

General surgery residents performed a laparoscopic cholecystectomy on the SurgicalSIM device in a mock operating room. Half (n = 8) were presented with a common bile duct injury, and half (n = 7) encountered metastatic gallbladder cancer during the operation. Both groups disclosed this information to a patient's scripted family member and completed a questionnaire. All encounters were videotaped and independently rated using a modified SPIKES protocol, a validated tool for delivering bad news. We compared disclosure of iatrogenic versus unexpected findings by year of training. Analysis was performed using the Mann-Whitney test.

RESULTS

Regardless of the year of training, more residents were comfortable with disclosure of an incidental finding than disclosure of an iatrogenic injury (47 vs. 33%). Senior residents (PGY4-PGY5) had better ratings by SPIKES (p < 0.05), most notably for tailoring disclosure to what patient and family understand, exploring patient and family expectations, and offering to answer any questions (p < 0.05). Even though all residents felt more comfortable with disclosure of an incidental finding, the quality of the disclosure by SPIKES score was the same for iatrogenic and incidental operative findings (p = NS).

CONCLUSION

In general, trainees are ill prepared for delivering bad news. Disclosure of iatrogenic injuries was more challenging compared to that of incidental findings. Senior residents do better than junior residents at delivering bad news.

A critical analysis of the surgical management of early-stage gallbladder cancer in the United States

BACKGROUND

Radical resection is recommended for selected patients with gallbladder (GB) cancer. We sought to determine whether radical resection improves survival for patients with early-stage cancer and to evaluate surgeon compliance with current treatment recommendations.

PATIENTS AND METHODS

Patients with stage 0, I, or II GB cancer who underwent surgical resection were identified from the Surveillance, Epidemiology, and End Results (SEER) tumor registry from 1988 through 2004. Patients were classified by surgical procedure performed (simple vs. radical resection) and adjuvant treatment given (radiation therapy [RT] vs. no RT). Unadjusted and adjusted overall survival (OS) and cancer-specific survival (CSS) were compared.

RESULTS

Of the 4,631 patients who underwent surgery for early-stage GB cancer from 1988 through 2004, 4,188 (90.4%) underwent cholecystectomy alone and 443 (9.6%) underwent radical surgery including hepatic resection. The proportion of patients having radical surgery for T1b, T2, and T3 cancers was 4.5%, 5.6%, and 16.3%, respectively. For patients with T1b/T2 cancer, radical resection was associated with significant improvement in adjusted CSS (p = 0.01) and OS (p = 0.03). For patients with T3 cancers, we noted no improvement in CSS or OS. Survival for patients with node-positive disease (stage 2b) was universally poor and not improved by radical resection. For all patients who underwent radical resection, node negativity, female sex, age <70, low grade, and RT predicted improved CSS and OS.

CONCLUSIONS

Despite a significant survival advantage for patients with T1b/T2 GB cancer who undergo radical resection, this treatment is significantly underutilized. Ensuring delivery of recommended surgical treatment is vital to improving outcomes for patients with this disease.

Consideration of anatomical structures relevant to the surgical strategy for managing gallbladder carcinoma

AIMS

Gallbladder carcinoma usually presents late with advanced disease. It develops in an anatomically complex area. Consideration is given to resection of relevant local structures with respect to outcome.

METHODS

A comprehensive literature review was performed, searching Medline for articles published since 2000, using the MeSH heading of 'gallbladder cancer' and 'surgery'. Abstracts were reviewed and articles retrieved if the main focus of the article centred on the surgical management of gallbladder carcinoma.

OBSERVATIONS

Hepatic resection is advocated and tailored to pathological T stage. Lymph node dissection and bile duct resection, as well as en bloc resection of other viscera, remain areas of controversy.

CONCLUSIONS

Eastern and Western practice standards of care differ, but hepatic resection with some lymph node dissection is present in both approaches. Philosophy regarding aggression with respect to en bloc resection of adjacent organs and actual extent of lymphatic resection remains disparate.

A review of the surgical strategies for the management of gallbladder carcinoma based on T stage and growth type of the tumour

AIMS

Surgery for gallbladder carcinoma is a technically challenging exercise. The extent of resection varies based on a number of factors, and controversy exists regarding what constitutes an acceptable resection. A review of current recommendations and practice was undertaken.

METHODS

A comprehensive literature review was performed, searching Medline for articles published since 2000, using the MeSH heading of 'gallbladder cancer' and 'surgery'. Abstracts were reviewed and articles retrieved if the main focus of the article centred on the surgical management of gallbladder carcinoma.

OBSERVATIONS

The extent of hepatic resection and lymph node dissection required varies in particular with T stage. Growth pattern and anatomical location of the tumour within the gallbladder also influence surgical management.

CONCLUSIONS

Discrepancy exists between the Eastern and Western literature in terms of what constitutes an acceptable limit of resection, and these issues are discussed.

Total laparoscopic resection of the gallbladder together with the gallbladder bed

Patients with carcinoma of the gallbladder that is preoperatively diagnosed by radiology do not undergo laparoscopic resection, because such surgery is thought to worsen the prognosis of gallbladder carcinoma. However, the prognosis for patients with incidental T2 gallbladder carcinoma who are treated laparoscopically is reportedly no worse than that for patients undergoing conventional surgery. We successfully performed total laparoscopic resection of the gallbladder together with the gallbladder bed without any complications. We believe that this procedure represents a valid therapeutic option for carefully selected patients with T2 carcinoma of the gallbladder.

Laparoscopic liver resection for cancer

The field of laparoscopic liver resection surgery has rapidly evolved, with more than 1000 cases now reported. Laparoscopic hepatic resection was initially described for small, peripheral, benign lesions. Experienced teams are now performing laparoscopic anatomic resections for cancer. Operative times improved with experience. When compared with open cases, blood loss was less in most laparoscopic series, but was the main indication for conversion to an open procedure. Patients undergoing laparoscopic resection had shorter length of hospital stay and quicker recovery. Perioperative complications were comparable between the two approaches. Importantly, basic oncologic principles were maintained in the laparoscopic liver resections. The purpose of this review is to summarize the data available on outcomes for laparoscopic hepatic resection for cancer. This includes primary hepatocellular carcinoma, as well as metastatic colorectal cancer to the liver. The evidence to date suggests that laparoscopic results are comparable with the open approach in cancer patients.

Revision surgery for incidental gallbladder cancer: factors influencing operability and further evidence for T1b tumours

BACKGROUND AND AIM

There is a need to increase the available data on revision radical surgery for incidental gallbladder cancer and to determine factors influencing operability. We aimed to assess the impact of stage of disease (pT) and the type of primary surgery (laparoscopy versus open) on resectability rates.

MATERIAL AND METHODS

The data of 90 consecutive patients referred to the Tata Memorial Hospital between 1 January 2003 and 30 April 2007 for revision radical surgery for incidental gallbladder cancer were reviewed retrospectively.

RESULTS

Of the 90 patients who underwent revision surgery, accurate data on T-stage was available in 76, and of these 76 patients, 44 (57.8%) had prior laparoscopic simple cholecystectomy, while 32 (42.2%) had undergone open surgery. The median time interval between the two surgeries was 2 months (range 4 weeks to 11 months). By T-stage, 23 patients had T1b disease, while 33 and 20 patients had T2 and T3 disease, respectively. Successful revision surgery could be undertaken in 71% of patients (54/76) and 29.6% of these had residual disease confirmed by histopathological examination.

CONCLUSIONS

T-stage is an important factor in determining operability as confirmed by our study. As the T-stage of the disease increased, the chances of finding residual disease increased, while operability decreased. Furthermore, the case for revision surgery is strengthened because the incidence of lymph nodal disease is high even for pT1b cancers. The type of primary surgery does not affect operability in patients undergoing revision radical surgery for incidental gallbladder cancer.

Operative approach to gallbladder cancer

In most Western countries gallbladder cancer is a rare tumor with a poor prognosis. The majority of patients present with advanced-stage tumors (stage IV) that are not amenable to surgical resection. At the other end of the spectrum a small percentage of patients present with stage I disease that may be cured by cholecystectomy. The role for surgery in patients with stage II and III disease remains controversial, but most hepatobiliary surgeons believe that an aggressive surgical approach improves survival for these patients. However, the extent of hepatic and lymph node resection, the need for resection of the extrahepatic ducts in nonjaundiced patients, the role of vascular resection, and the advisability of hepatopancreatoduodenectomy remain a matter of debate. Although no data from prospective, randomized studies are available, resection of the gallbladder and adjacent liver with or without the extrahepatic bile ducts and with a regional lymph node dissection is the operative approach recommended for selected patients with gallbladder cancer.