Laparoscopic completion radical cholecystectomy for T2 gallbladder cancer

Role of Minimally Invasive Reoperation for Postoperatively Diagnosed T2 Gallbladder Cancer: Multicenter Retrospective Cohort Study

BACKGROUND

Although T2 gallbladder cancer (GBC) incidentally diagnosed after cholecystectomy requires additional resection, the surgical approaches are technically difficult due to inflammatory adhesion or fibrosis around the hepatoduodenal ligament and gallbladder bed. In this study, we sought to compare the surgical and oncologic outcomes of open and minimally invasive reoperation for postoperatively diagnosed T2 GBC.

STUDY DESIGN

Patients who underwent open (110) and laparoscopic (38) reoperation for T2 GBC between November 2004 and October 2022 at 5 tertiary referral centers were included in this multicenter retrospective cohort study. The short- and long-term outcomes were compared between the 2 groups.

RESULTS

There were no differences in clinicopathologic characteristics between the open and laparoscopic groups. Liver resection was more frequent in the open group (101 [91.8%] vs 21 [55.3%], p < 0.001). Compared with open operation, laparoscopic reoperation was associated with shorter postoperative hospital stay (9.0 [8.0 to 10.0] vs 6.0 [3.8 to 8.3] days, p < 0.001) and a lower postoperative complication rate (24 [21.8%] vs 1 [2.6%], p = 0.013). Among patients who underwent liver resection, the postoperative hospital stay was shorter in the laparoscopic group (9.0 [8.0 to 10.0] vs 6.0 [4.0 to 9.0] days, p = 0.004). The 5-year disease-free survival (66.7% vs 76.1%, p = 0.749) and overall survival (75.2% vs 73.7%, p = 0.789) rates were not significantly different between the 2 groups.

CONCLUSIONS

The results indicate that laparoscopic reoperation for postoperatively diagnosed T2 GBC has favorable postoperative outcomes and similar oncologic safety compared with open operation.

Current status and progress in laparoscopic surgery for gallbladder carcinoma

Gallbladder carcinoma (GBC) is the most common biliary tract malignancy associated with a concealed onset, high invasiveness and poor prognosis. Radical surgery remains the only curative treatment for GBC, and the optimal extent of surgery depends on the tumor stage. Radical resection can be achieved by simple cholecystectomy for Tis and T1a GBC. However, whether simple cholecystectomy or extended cholecystectomy, including regional lymph node dissection and hepatectomy, is the standard surgical extent for T1b GBC remains controversial. Extended cholecystectomy should be performed for T2 and some T3 GBC without distant metastasis. Secondary radical surgery is essential for incidental gall-bladder cancer diagnosed after cholecystectomy. For locally advanced GBC, hepatopancreatoduodenectomy may achieve R0 resection and improve long-term survival outcomes, but the extremely high risk of the surgery limits its implementation. Laparoscopic surgery has been widely used in the treatment of gastrointestinal malignancies. GBC was once regarded as a contraindication of laparoscopic surgery. However, with improvements in surgical instruments and skills, studies have shown that laparoscopic surgery will not result in a poorer prognosis for selected patients with GBC compared with open surgery. Moreover, laparoscopic surgery is associated with enhanced recovery after surgery since it is minimally invasive.

Short- and long-term outcomes of laparoscopic vs open surgery for T2 gallbladder cancer: A systematic review and meta-analysis

BACKGROUND

With the development of laparoscopic techniques, gallbladder cancer (GBC) is no longer a contraindication to laparoscopic surgery (LS). Although LS is recommended for stage T1 GBC, the value of LS for stage T2 GBC is still controversial.

AIM

To evaluate the short- and long-term outcomes of LS in comparison to those of open surgery (OS) for stage T2 GBC.

METHODS

We searched the PubMed, Embase, Cochrane Library, Ovid, Google Scholar, and Web of Science databases for published studies comparing the efficacy of LS and OS in the treatment of stage T2 GBC, with a cutoff date of September 2022. The Stata 15 statistical software was used for analysis. Relative risk (RR) and weighted mean difference (WMD) were calculated to assess binary and continuous outcome indicators, respectively. Begg’s test and Egger’s test were used for detecting publication bias.

RESULTS

A total of five studies were included, with a total of 297 patients, 153 in the LS group and 144 in the OS group. Meta-analysis results showed that the LS group was better than the OS group in terms of operative time [WMD = -41.29, 95% confidence interval (CI): -75.66 to -6.92, P = 0.02], estimated blood loss (WMD = -261.96, 95%CI: -472.60 to -51.31, P = 0.01), and hospital stay (WMD = -5.67, 95%CI: -8.53 to -2.81, P = 0.0001), whereas there was no significant difference between the two groups in terms of blood transfusion (RR = 0.60, 95%CI: 0.31-1.15, P = 0.13), complications (RR = 0.72, 95%CI: 0.39-1.33, P = 0.29), number of lymph nodes retrieved (WMD = –1.71, 95%CI: -4.27 to -0.84, P = 0.19), recurrence (RR = 0.41, 95%CI: 0.06-2.84, P = 0.36), 3-year and 5-year overall survival (RR = 0.99, 95%CI: 0.82-1.18, P = 0.89 and RR = 1.02, 95%CI: 0.68-1.53, P = 0.92; respectively), and 3-year and 5-year disease-free survival (RR = 1.01, 95%CI: 0.84-1.21, P = 0.93 and RR = 1.15, 95%CI: 0.90-1.46, P = 0.26; respectively).

CONCLUSION

The long-term outcomes of LS for T2 GBC are similar to those of OS, but LS is superior to OS in terms of operative time, intraoperative bleeding, and postoperative hospital stay. Nevertheless, these findings should be validated via high-quality randomized controlled trials and longer follow-ups.

Comparison of the Oncological Outcomes of Open versus Laparoscopic Surgery for T2 Gallbladder Cancer: A Propensity-Score-Matched Analysis

Although laparoscopic treatment for T1 gallbladder cancer (GBC) has been described previously, the differences in oncologic outcomes between laparoscopic and conventional open surgery for T2 GBC have not been investigated. We aimed to assess the role of laparoscopic surgery using retrospectively collected data for 81 patients with T2 GBC who underwent surgical resection between January 2010 and December 2017. Eligible patients were classified into “laparoscopic” and “open” groups. Propensity-score matching was performed in a 1:1 ratio. The effects of surgery type on surgical and oncological outcomes were investigated. After propensity-score matching, 19 patients were included in the open and laparoscopic surgery groups. The median follow-up durations were 70 and 26 months in the open and laparoscopic groups, respectively. The operative time (316.8 ± 80.3 vs. 218.9 ± 145.0 min, p = 0.016) and length of postoperative hospital stay (14.4 ± 6.0 vs. 8.4 ± 5.9 days, p = 0.004) were significantly shorter in the laparoscopic group. The three-year overall (86.3% vs. 88.9%, p = 0.660) and disease-free (76.4% vs. 60.2%, p = 0.448) survival rates were similar between the groups. Propensity-score matching showed that laparoscopic surgery for T2 GBC yielded similar long-term oncological outcomes and favorable short-term outcomes in comparison with open surgery. Laparoscopic treatment should be considered in patients with T2 GBC.

Treatment of Resectable Gallbladder Cancer

Gallbladder cancer (GBC) is the most common biliary tract cancer worldwide and its incidence has significant geographic variation. A unique combination of predisposing factors includes genetic predisposition, geographic distribution, female gender, chronic inflammation, and congenital developmental abnormalities. Today, incidental GBC is the most common presentation of resectable gallbladder cancer, and surgery (minimally invasive or open) remains the only curative treatment available. Encouragingly, there is an important emerging role for systemic treatment for patients who have R1 resection or present with stage III-IV. In this article, we describe the pathogenesis, surgical and systemic treatment, and prognosis.

Laparoscopic versus open extended cholecystectomy with bi-segmentectomy (s4b and s5) in patients with gallbladder cancer

Introduction:

The outcome of laparoscopic extended cholecystectomy (EC) with wedge hepatic resection (LECW) in patients with gallbladder cancer (GBC) has been compared with that of open EC with wedge hepatic resection (OECW), but studies comparing laparoscopic EC with bi-segmentectomy (LECB) with open EC with bi-segmentectomy (OECB) are lacking.

Patients and Methods:

This retrospective study comprised of 68 patients with GBC who were offered either LECB or OECB from July 2011 to July 2018. Patients were divided into laparoscopic group (LG) and open group (OG), and appropriate statistical methods were used for comparison.

Results:

Out of the total 68 patients, 30 patients were in LG and 38 patients were in OG. Demographic, clinical and biochemical characteristics were similar except significantly higher number of male patients in OG (P = 0.01). In LG versus OG, the mean operation time was 286 versus 274 min (P = 0.565), mean blood loss was 158 versus 219 ml (P = 0.006) and mean hospital stay was 6.4 versus 9 days (P = 0.0001). The complication rate was 16.6% in LG and 31.5% in OG, but this difference was not statistically significant (P = 0.259). The median number of lymph nodes was 12 in both LG and OG (P = 0.62). Distribution of patients among American Joint Committee on Cancer stages I to IV was similar in both the groups (P = 0.5). Fifty percent of the patients in both the groups received adjuvant treatment (P = 1). In LG versus OG, the recurrence rate was 20% versus 28.9% (P = 0.4), mean recurrence-free survival was 48 months versus 44 months (P = 0.35) and overall survival was 51 months versus 46 months (P = 0.45). In LG versus OG, 1, 3 and 5-year survival was 96% versus 94%, 79% versus 72% and 79% versus 62% (P = 0.45). The median follow-up was statistically significantly shorter (24 vs. 36 months) in LG versus OG (P = 0.0001).

Conclusions:

The oncological outcome and survival after LECB in patients with resectable GBC is not inferior to that after OECB. Laparoscopic approach has a potential to improve perioperative outcome in patients with GBC.

Current status and future perspectives of minimally invasive surgery in gallbladder carcinoma

BACKGROUND

Gallbladder carcinoma (GBC) is the most common biliary tract malignancy, which is characterized by easy local invasion, lymph nodes metastasis, local vascular invasion. Hence, minimally invasive surgery (MIS) can be performed in a limited number of patients. In our study, we reviewed the current studies on laparoscopic surgery (LS) and robotic surgery (RS) for GBC and analysed the limitations and difficulties of MIS for GBC.

METHODS

Multiple electronic databases were used for a systematic literature retrieval. All studies involving MIS of GBC were included (up to August 2019).

RESULTS

A total of 24 studies were included, of which 18 studies involved LS for GBC and six studies concerned RS of GBC. For LS, 16 studies contained relevant information of T stage, and 323 patients (98.8%) had T3 or lower stage; the average rate of R0 resection, conversion, postoperative complications and mortality was 95.3% (range 80.5-100%), 1.9% (range 0-16.7%), 13.4% (range 0-33.3%) and 1.0% (range 0-10%), respectively. For RS, four studies contained relevant information of T stage, and all patients were T3 or lower stage; the average rate of R0 resection, conversion and postoperative complications was 96.8% (range 81.8-100%), 5.5% (range 0-14.8%) and11.9% (range 0-36.4%), respectively. In addition, no patient had perioperative mortality.

CONCLUSIONS

MIS for GBC is limited to highly selected patients and is considered to be technically feasible in experienced surgeons. However, improvements in technical and instrumental are needed to reduce the associated postoperative complications and implantation metastasis, and to promote MIS in the treatment of GBC.

Oncologic safety of laparoscopic radical cholecystectomy in pT2 gallbladder cancer: A propensity score matching analysis compared to open approach

The role of laparoscopic radical cholecystectomy (LRC) in the surgical management of T2 gallbladder carcinoma (GBC) is still controversial.The medical records of patients with T2 GBC treated with radical cholecystectomy were retrospectively reviewed. In this study, we compare the short- and long-term oncologic outcomes, using propensity score matching analysis, of patients with T2 GBC who underwent LRC and open radical cholecystectomy (ORC).Among 183 patients, 86 were selected by propensity score matching (LRC = 43 and ORC = 43). The ORC group underwent more extensive surgery (liver resections and extended lymph node dissections [ELND]) than the LRC group. The LRC group had less operative blood loss, shorter length of hospital stay, fewer complications, and had the earlier start of adjuvant chemotherapy. There was no significant difference between the laparoscopic and open surgery groups in terms of 5-year overall survival rate (64.6% vs 80.4%, P = .214) and disease-free survival rate (77.1% vs 82.2%, P = .641). A subgroup analyses showed that liver resection and ELND had no survival advantage compared to no liver resection and regional lymph node dissection, respectively.Our LRC approach is safe and effective, with long-term survival comparable to that of ORC.

Robotic extended cholecystectomy in gallbladder cancer

BACKGROUND

The application of minimally invasive surgery (MIS) in advanced gallbladder cancer (GBC) requiring extended cholecystectomy is challenging, in terms of achieving clinically safe and complete oncologic resection. Recently developed robotic systems, however, may provide advantages in overcoming difficulties faced by laparoscopic MIS. The purpose of this study is to investigate the feasibility and advantages of a robotic system to assist with extended cholecystectomy.

METHODS

Patients diagnosed with clinically suspected stage T2 or above, GBC (as determined by preoperative computed tomography or ultrasonography) underwent robotic extended cholecystectomy (REC) from February 2018 to January 2020. The attached video shows the detailed procedure in the following order: the positioning of the patient and the trocars, Kocher maneuver, lymph node dissection (#8, 9, 12, 13), skeletonization of hepatoduodenal ligament, ligation of the cystic duct and liver resection.

RESULTS

Of 16 patients who underwent REC, mean operation time was 198.3 min and the median estimated blood loss was 295 ml. 11 patients (68.8%) were pathologically diagnosed as stage T2 or above, and the metastatic lymph node was identified in 3 patients (18.8%). All cases had secured tumor-free resection margins, and 3 patients (18.8%) showed invasion to the hepatic parenchyma. The mean number of retrieved lymph nodes was 7.2. The median duration of hospital stay was 7 days. There were no mortality or recurrence within 90 days after the operation.

CONCLUSION

This study suggests that robotic systems can be safely utilized in advanced stage GBC, facilitating oncologically sufficient lymph node dissection and rapid recovery.

Laparoscopic surgery for early gallbladder carcinoma: A systematic review and meta-analysis

BACKGROUND

There is a controversy as to whether laparoscopic surgery leads to a poor prognosis compared to the open approach for early gallbladder carcinoma (GBC). We hypothesized that the laparoscopic approach is an alternative for early GBC.

AIM

To identify and evaluate the safety and feasibility of laparoscopic surgery in the treatment of early GBC.

METHODS

A comprehensive search of online databases, including MEDLINE (PubMed), Cochrane libraries, and Web of Science, was performed to identify non-comparative studies reporting the outcomes of laparoscopic surgery and comparative studies involving laparoscopic surgery and open surgery in early GBC from January 2009 to October 2019. A fixed-effects meta-analysis was performed for 1- and 5-year overall survival and postoperative complications, while 3-year overall survival, operation time, blood loss, the number of lymph node dissected, and postoperative hospital stay were analyzed by random-effects models.

RESULTS

The review identified 7 comparative studies and 8 non-comparative studies. 1068 patients (laparoscopic surgery: 613; open surgery: 455) were included in the meta-analysis of 1-, 3-, and 5-year overall survival with no significant differences observed [(HR = 0.54; 95%CI: 0.29-1.00; I² = 0.0%; P = 0.051), (HR = 0.75; 95%CI: 0.34-1.65; I² = 60.7%; P = 0.474), (HR = 0.71; 95%CI: 0.47-1.08; I² = 49.6%; P = 0.107), respectively]. There were no significant differences in operation time [weighted mean difference (WMD) = 18.69; 95%CI: −19.98-57.36; I² = 81.4%; P = 0.343], intraoperative blood loss (WMD = −169.14; 95%CI: −377.86-39.57; I² = 89.5%; P = 0.112), the number of lymph nodes resected (WMD = 0.12; 95%CI: −2.95-3.18; I² = 73.4%; P = 0.940), and the complication rate (OR = 0.69; 95%CI: 0.30-1.58; I² = 0.0%; P = 0.377 ) between the two groups, while patients who underwent laparoscopic surgery had a reduced length of hospital stay (WMD = −5.09; 95%CI: −8.74- −1.45; I² = 91.0%; P= 0.006).

CONCLUSION

This systematic review and meta-analysis confirms that laparoscopic surgery is a safe and feasible alternative to open surgery with comparable survival and operation-related outcomes for early GBC.

Comparison of oncological outcomes after open and laparoscopic re-resection of incidental gallbladder cancer

BACKGROUND

The safety and oncological efficacy of laparoscopic re-resection of incidental gallbladder cancer have not been studied. This study aimed to compare laparoscopic with open re-resection of incidentally discovered gallbladder cancer while minimizing selection bias.

METHODS

This was a multicentre retrospective observational cohort study of patients with incidental gallbladder cancer who underwent re-resection with curative intent at four centres between 2000 and 2017. Overall survival (OS) and recurrence-free survival (RFS) were analysed by intention to treat. Inverse probability of surgery treatment weighting using propensity scoring was undertaken.

RESULTS

A total of 255 patients underwent re-resection (190 open, 65 laparoscopic). Nineteen laparoscopic procedures were converted to open operation. Surgery before 2011 was the only factor associated with conversion. Duration of hospital stay was shorter after laparoscopic re-resection (median 4 versus 6 days; P < 0·001). Three-year OS rates for laparoscopic and open re-resection were 87 and 62 per cent respectively (P = 0·502). Independent predictors of worse OS were residual cancer found at re-resection (hazard ratio (HR) 1·91, 95 per cent c.i. 1·17 to 3·11), blood loss of at least 500 ml (HR 1·83, 1·23 to 2·74) and at least four positive nodes (HR 3·11, 1·46 to 6·65). In competing-risks analysis, the RFS incidence was higher for laparoscopic re-resection (P = 0·038), but OS did not differ between groups. Independent predictors of worse RFS were one to three positive nodes (HR 2·16, 1·29 to 3·60), at least four positive nodes (HR 4·39, 1·96 to 9·82) and residual cancer (HR 2·42, 1·46 to 4·00).

CONCLUSION

Laparoscopic re-resection for selected patients with incidental gallbladder cancer is oncologically non-inferior to an open approach. Dissemination of advanced laparoscopic skills and timely referral of patients with incidental gallbladder cancer to specialized centres may allow more patients to benefit from this operation.

Totally Laparoscopic Radical Cholecystectomy for Gallbladder Cancer: A Single Center Experience

Background: Primary laparoscopic approach for the treatment of cancers of the biliary tract is not popular in the surgical community. The aim of this study is to report the short-term data of patients who underwent total laparoscopic radical cholecystectomy for gallbladder cancer (GBC) at a single center of specialized hepatobiliary surgery. Methods: From November 2016 to January 2019, we routinely performed a laparoscopic approach for two groups of patients: (1) patients with primary GBC (diagnosed preoperatively) and (2) patients with incidental GBC (IGBC) discovered after cholecystectomy. Results: Our retrospective study included 18 patients (7 primary GBCs, 11 IGBCs). Conversion rate from laparoscopy to laparotomy was 28.6% and 9.1%, respectively, for the two groups, but this difference was not statistically significant (P = .28). Only 3 patients had liver recurrence (27.3%) and 1 had liver invasion (14.3%). A more advanced T category and TNM stage were presented in the preoperative suspicion cases (T3-T4 18.2% versus 57.1%, P = .06, stage IVA-B 9.1% versus 71.4%, P = .017). Regional lymphadenectomy was performed in 15 patients, in 73.3% the total number of lymph nodes (total LNs) retrieved was more than 7 (7-12 LNs in 66.7% of patients and >12 LNs in 6.6% of patients). The mean postoperative long stay was 8 days excluding for cases who developed complication. Conclusions: Laparoscopy can be considered a safe treatment for IGBC or primary GBC. The T3 stage with only liver involvement was not a contraindication. The real reasons that lead to convert the laparoscopic procedure were due to oncological concerns, unrelated to the liver infiltration.

Totally Laparoscopic Radical Resection of Gallbladder Cancer: Technical Aspects and Long-Term Results

INTRODUCTION

Gallbladder cancer (GBC) is a rare tumor in developed countries. Chile has one of the highest incidences worldwide. For patients affected by resectable T1b or more advanced GBC, radical cholecystectomy (RC) is considered the standard therapy. Our aim is to describe the surgical technique and clinical-pathological results of patients undergoing totally laparoscopic radical resection of GBC.

METHODS

Patients undergo laparoscopic radical resection for primary and incidental GBC, between the years 2009 and 2016 in two centers from Chile. Patients in whom suspected bile duct invasion, frozen biopsy did not confirm cancer and para-aortic lymph node sampling was positive were excluded.

RESULTS

Eighteen patients were operated, 77.8% were female with median age of 60.5 year, and 16 patients had previous cholecystectomy with incidental cancer finding. The median operative time was 490 min (400-550). No conversion to open surgery occurred. All patients achieved a R0 resection. Postoperative complications occurred in 2 patients (11.1%), and there was not mortality. After a median follow-up of 59 months, the 5-year survival was 80.7%.

CONCLUSION

This study shows the technical feasibility of the totally laparoscopic approach for radical resection of GBC with the same principles of classical open surgery. It appears that long-term oncological findings would also be similar at least in less advanced lesions.

Comparison of Laparoscopic and Open Approach in Treating Gallbladder Cancer

BACKGROUND

Preliminary study on the feasibility and efficacy of laparoscopic cholecystectomy and radical cholecystectomy in stage Tis-T3 gallbladder cancer (GBC).

METHODS

Retrospective analysis of the clinical data of 102 patients with GBC from August 2008 to August 2017 in the Department of Hepatopancreatobiliary Surgery at the Third Affiliated Hospital of Soochow University. The clinical and pathological data of laparoscopic surgery and open surgery were compared.

RESULTS

Of 102 patients with GBC, 41 underwent laparoscopic treatment, 12 of whom underwent laparoscopic cholecystectomy, and the others underwent laparoscopic radical cholecystectomy/extended radical cholecystectomy. Sixty-one patients underwent radical cholecystectomy/extended radical cholecystectomy. Based on the individual patient's condition, excision of the extrahepatic biliary tract and cholangioenterostomy were performed. There were no perioperative deaths. There was no significant difference in the operative blood loss (P = 0.732), operative time (P = 0.058), postoperative complications (P = 0.933), R0 margins (P = 0.679), and tumor-related death (P = 0.396) between the laparoscopic group and the laparotomy group. The postoperative activity time (P < 0.001), postoperative eating time (P < 0.001), drainage tube removal time (P < 0.001), and postoperative hospital discharge time (P < 0.001) in the laparoscopic group were all earlier than those in the laparotomy group, and the difference was statistically significant. The number of lymph nodes resected in the laparoscopic group and the laparotomy group was 1-17, average (5 ± 3) and 1-13 average (5 ± 3), respectively, with no statistically significant difference (P = 0.973). The 1-, 3-, and 5-y survival rates in the laparoscopic group were 97.1%, 69.4%, and 51.9%, respectively, and those in the laparotomy group were 94.7%, 64.9%, and 55.7%, respectively; there were no significant difference between the two groups (P = 0.453). In terms of different pathologic T stages, the 5-y survival rates of patients with stage Tis (9 cases), T1a (2 cases), T1b (8 cases), T2 (14 cases), and T3 (8 cases) disease in the laparoscopic group were 100%, 100%, 75%, 48.1%, and 12.5%, respectively, and the 5-y survival rates in patients with stage Tis (4 cases), T1b (9 cases), T2 (32 cases), and T3 (16 cases) disease in the laparotomy group were 100%, 87.5%, 64.7%, and 16%, respectively; there were no significant differences between the two groups.

CONCLUSIONS

Laparoscopic treatment of stage Tis-T3 GBC is feasible. Laparoscopic treatment of GBC does not increase the incision metastasis rate on the basis of the intact gallbladder wall. The same survival rates can be achieved with laparoscopic treatment as with open treatment of GBC. In terms of postoperative rehabilitation, laparoscopic treatment has more advantages.

Laparoscopic Surgery for Gallbladder Cancer: An Expert Consensus Statement

BACKGROUND

Despite the increasing number of reports on the favorable outcomes of laparoscopic surgery for gallbladder cancer (GBC), there is no consensus regarding this surgical procedure.

OBJECTIVE

The study aimed to develop a consensus statement on the application of laparoscopic surgery for GBC based on expert opinions.

METHODS

A consensus meeting among experts was held on September 10, 2016, in Seoul, Korea.

RESULTS

Early concerns regarding port site/peritoneal metastasis after laparoscopic surgery have been abated by improved preoperative recognition of GBC and careful manipulation to avoid bile spillage. There is no evidence that laparoscopic surgery is associated with decreased survival compared with open surgery in patients with early-stage GBC if definitive resection during/after laparoscopic cholecystectomy is performed. Although experience with laparoscopic extended cholecystectomy for GBC has been limited to a few experts, the postoperative and survival outcomes were similar between laparoscopic and open surgeries. Laparoscopic reoperation for postoperatively diagnosed GBC is technically challenging, but its feasibility has been demonstrated by a few experts.

CONCLUSIONS

Laparoscopic surgery for GBC is still in the early phase of the adoption curve, and more evidence is required to assess this procedure.

Laparoscopic Radical Cholecystectomy for Primary or Incidental Early Gallbladder Cancer: The New Rules Governing the Treatment of Gallbladder Cancer

AIM

To evaluate the technical feasibility and oncologic safety of laparoscopic radical cholecystectomy (LRC) for primary or incidental early gallbladder cancer (GBC) treatment.

METHODS

Articles reporting LRC for GBC were reviewed from the first case reported in 2010 to 2015 (129 patients). 116 patients had a preoperative diagnosis of gallbladder cancer (primary GBC). 13 patients were incidental cases (IGBC) discovered during or after a laparoscopic cholecystectomy.

RESULTS

The majority of patients who underwent LRC were pT2 (62.7% GBC and 63.6% IGBC). Parenchyma-sparing operation with wedge resection of the gallbladder bed or resection of segments IVb-V were performed principally. Laparoscopic lymphadenectomy was carried out according to the reported depth of neoplasm invasion. Lymph node retrieved ranged from 3 to 21. Some authors performed routine sampling biopsy of the inter-aorto-caval lymph nodes (16b1 station) before the radical treatment. No postoperative mortality was documented. Discharge mean day was POD 5th. 16 patients had post operative morbidities. Bile leakage was the most frequent post-operative complication. 5 y-survival rate ranged from 68.75 to 90.7 months.

CONCLUSION

Laparoscopy can not be considered as a dogmatic contraindication to GBC but a primary approach for early case (pT1b and pT2) treatment.

Laparoscopic approach to suspected T1 and T2 gallbladder carcinoma

AIM

To evaluate a laparoscopic approach to gallbladder lesions including polyps, wall-thickening lesions, and suspected T1 and T2 gallbladder cancer (GBC).

METHODS

We performed 50 cases of laparoscopic whole-layer cholecystectomy (LCWL) and 13 cases of laparoscopic gallbladder bed resection (LCGB) for those gallbladder lesions from April 2010 to November 2016. We analyzed the short-term and long-term results of our laparoscopic approach.

RESULTS

The median operation time was 108 min for LCWL and 211 min for LCGB. The median blood loss was minimal for LCWL and 28 ml for LCGB. No severe morbidity occurred in either procedure. Nine patients who underwent LCWL and 7 who underwent LCGB were postoperatively diagnosed with GBC. One of these patients had undergone LCGB for pathologically diagnosed T2 GBC after LCWL. All of the final surgical margins were negative. Three of these 15 patients underwent additional open surgery. The mean follow-up period was 26 mo, and only one patient developed recurrence.

CONCLUSION

LCWL and LCGB are safe and useful procedures that allow complete resection of highly suspected or early-stage cancer and achieve good short-term and long-term results.

Current Role of Minimally Invasive Radical Cholecystectomy for Gallbladder Cancer

Background. For Tis and T1a gallbladder cancer (GbC), laparoscopic cholecystectomy can provide similar survival outcomes compared to open cholecystectomy. However, for patients affected by resectable T1b or more advanced GbC, open approach radical cholecystectomy (RC), consisting in gallbladder liver bed resection or segment 4b-5 bisegmentectomy, with locoregional lymphadenectomy, is considered the gold standard while minimally invasive RC (MiRC) is skeptically considered. Aim. To analyze current literature on perioperative and oncologic outcomes of MiRC for patients affected by GbC. Methods. A Medline review of published articles until June 2016 concerning MiRC for GbC was performed. Results. Data relevant for this review were presented in 13 articles, including 152 patients undergoing an attempt of MiRC for GbC. No randomized clinical trial was found. The approach was laparoscopic in 147 patients and robotic in five. Conversion was required in 15 (10%) patients. Postoperative complications rate was 10% with no mortality. Long-term survival outcomes were reported by 11 studies, two of them showing similar oncologic results when comparing MiRC with matched open RC. Conclusions. Although randomized clinical trials are still lacking and only descriptive studies reporting on limited number of patients are available, current literature seems suggesting that when performed at highly specialized centers, MiRC for GbC is safe and feasible and has oncologic outcomes comparable to open RC.

Technical Aspects of Gallbladder Cancer Surgery

In this review, the authors present an updated description of gallbladder cancer in 2 sections based on presentation: disease that presents incidentally following laparoscopic cholecystectomy and malignancy that is suspected preoperatively. Elements pertaining to technical aspects of surgical resection provide the critical focus of this review and are discussed in the context of evidence-based literature on gallbladder cancer today.

Optimal assessment of lymph node status in gallbladder cancer

BACKGROUND

Lymph node (LN) metastasis is an important prognostic factor in gallbladder cancer (GBCA). LN status has been adopted as a critical element of staging systems. However, the influence of total lymph node count (TLNC) remains unclear. We determined the optimal minimum TLNC and compared the prognostic significance of LN status indices in GBCA.

METHODS

We retrospectively reviewed medical records of 128 patients with T2 or greater GBCA who underwent LN dissection. We analyzed overall survival (OS) and relevance of the number of metastatic LNs, ratio of metastatic LNs to retrieved LNs (LNR), and TLNC in predicting OS.

RESULTS

The median OS durations were 120, 35, and 18 months in T2, T3, and T4 GBCA. Five-year OS rates were 73%, 43%, and 0% in T2, T3, and T4 GBCA. LN status did not significantly impact OS in T2 or T4 GBCA. However, all LN indices were significantly correlated with OS in T3 GBCA. Furthermore, multivariate analysis revealed that a metastatic LN count of more than four and a TLNC of more than eight were independent prognostic factors of OS in T3 GBCA.

CONCLUSIONS

TLNC and the number of positive LNs may be more important prognostic factors than LNR in T3 GBCA. Additionally, accurate staging may not be achieved in cases of T3 GBCA if the total number of retrieved LNs is less than eight. Thus, to ensure proper staging, we recommend that surgeons harvest more than eight LNs in patients with T3 GBCA.

Totally Laparoscopic Hepatic Bisegmentectomy (s4b+s5) and Hilar Lymphadenectomy for Incidental Gallbladder Cancer

BACKGROUND

Gallbladder cancer is suspected preoperatively in only 30 % of all patients, while the remaining 70 % of cases are discovered incidentally by the pathologist. The increasing rate of cholecystectomies via laparoscopy has led to the detection of more gallbladder cancers in an early stage, and extended resection with regional lymph node dissection has been suggested. We present a video of a totally laparoscopic liver resection (segments 5 and 4b) with regional lymphadenectomy in a patient with an incidental gallbladder cancer.

METHODS

A 50-year-old woman underwent laparoscopic cholecystectomy, and pathology revealed a T1b gallbladder carcinoma. The patient was referred for further treatment. Contact with the primary surgeon revealed that no intraoperative cholangiogram was performed, and the gallbladder was removed intact, with no perforation, and inside a plastic retrieval bag. Pathology revision confirmed T1b, and positron emission tomography/computed tomography was negative. The multidisciplinary tumor board recommended radical re-resection, and a decision was made to perform a laparoscopic extended hilar lymphadenectomy, along the resection of segments 5 and 4b.

RESULTS

Operative time was 5 h, with an estimated blood loss of 240 mL. Recovery was uneventful and the patient was discharged on the fourth postoperative day. Final pathology showed no residual disease and no lymph node metastasis.

CONCLUSIONS

Laparoscopic resection of liver segments 5 and 4b combined with a locoregional lymphadenectomy of the hepatoduodenal ligament is an oncologically appropriate technique, provided it is performed in a specialized center with experience in hepatobiliary surgery and advanced laparoscopic surgery. This video may help oncological surgeons to perform this complex procedure.

Minimally invasive versus the conventional open surgical approach of a radical cholecystectomy for gallbladder cancer: a retrospective comparative study

BACKGROUND

Laparoscopic surgery has traditionally been contraindicated for the management of gall bladder cancer (GBC). This study was undertaken to determine the safety and feasibility of a laparoscopic radical cholecystectomy (LRC) for GBC and compare it with an open radical cholecystectomy (ORC).

METHODS

Retrospective analysis of primary GBC patients (with limited liver infiltration) and incidental GBC (IGBC) patients (detected after a laparoscopic cholecystectomy) who underwent LRC between June 2011 and October 2013. Patients who fulfilled the study criteria and underwent ORC during the same period formed the control group.

RESULTS

During the study period, 147 patients with GBC underwent a radical cholecystectomy. Of these, 24 patients (primary GBC- 20, IGBC - 4) who underwent a LRC formed the study group (Group A). Of the remaining 123 patients who underwent ORC, 46 matched patients formed the control group (Group B). The median operating time was higher in Group A (270 versus 240 mins, P = 0.021) and the median blood loss (ml) was lower (200 versus 275 ml, P = 0.034). The post-operative morbidity and mortality were similar (P = 1.0). The pathological stage of the tumour in Group A was T1b (n = 1), T2 (n = 11) and T3 (n = 8), respectively. The median lymph node yield was 10 (4-31) and was comparable between the two groups (P = 0.642). During a median follow-up of 18 (6-34) months, 1 patient in Group A and 3 in Group B developed recurrence. No patient developed a recurrence at a port site.

CONCLUSION

LRC is safe and feasible in selected patients with GBC, and the results were comparable to ORC in this retrospective comparison.

Surgical treatment of gall-bladder cancer

Despite the aggressive nature and poor prognosis of gall-bladder cancer there is a group of patients who can achieve significant benefits from a radical surgical treatment. The possibility of obtaining long-term survival, even in case of patients with locally advanced cancer and metastases to regional lymph nodes, prompts to verify nihilistic approach to the treatment of this disease. Obviously such therapy can and should be performed only in centers specializing in hepatobiliary surgery. Due to the high recurrence rate, most of which are systemic, the hope of improving treatment outcomes should be sought in the use of combination therapy, based on a new chemotherapy and chemoradiotherapy regimens with the addition of targeted therapy. Unfortunately, the current application of these methods did not bring the expected benefits.

Surgical treatment of gallbladder cancer: Strategy and optimization

Gallbladder cancer is the most common malignant tumor of the biliary tract. It is difficult to diagnose early due to the lack of special symptoms and physical signs. Most cases are diagnosed in advanced stages and the response to traditional chemotherapy and radiotherapy is extremely limited, with modest impact on overall survival. Despite improvements in outcome associated with extended resections, selection of patients for such extensive surgery remains controversial. In this article, we analyze and discuss the key issues about the surgical management of gallbladder cancer, with the hope of a more comprehensive recognition of this malignancy.

Outcomes in biliary malignancy

The biliary malignancies that are reviewed here are gallbladder cancer (GBC), intrahepatic cholangiocarcinoma (IHC), and perihilar cholangiocarcinoma (PHC). The focus is on outcomes after potentially curative resection of biliary malignancies. Key outcomes are postoperative mortality, median and 5-year overall survival (OS), recurrence-free survival, and recurrence patterns. Poor prognostic factors for recurrence and survival as well as prognostic models are also discussed. The incidence of biliary malignancies in the United States is about 5 in 100,000. Postoperative mortality for resection of GBC and IHC is similar to that of liver resections for other indications. However, 90 day postoperative mortality after liver resection for PHC is about 10%. For GBC, median OS depends strongly on the T-stage and ranges from 8 months (pT3) to 79 months (pT1b). Median OS after resection for IHC is about 30 months, and for PHC about 38 months. The majority of patients with biliary malignancies develop a recurrence after resection. Patients with GBC recur early with a median time to recurrence of 12 months, versus about 20 months for IHC and PHC. In patients with resected IHC or PHC locoregional recurrence was the only site of recurrence in about 60% of patients, versus 15% in patients with GBC. Poor prognostic factors after resection of all biliary malignancies include the presence of lymph node metastasis, a positive surgical resection margin, and moderate or poor tumor differentiation. Several prognostic nomograms have been developed to predict long-term outcomes of biliary cancer resection.

Selective laparoscopic approach in suspected gallbladder malignancy

More than half of patients in this study with findings concerning for gallbladder malignancy were found to have benign disease, suggesting that an initial laparoscopic approach may be appropriate in selected patients.

Background and Objectives:

We examined patients with clinical findings that are concerning for gallbladder malignancy to determine the incidence of pathology-confirmed malignancy and to discover factors that may be used to determine which patients may be initially treated with a laparoscopic approach.

Methods:

All patients referred to a surgical oncologist with preoperative findings that are concerning for gallbladder malignancy who had not undergone previous surgical resection from 2005 to 2011 were reviewed. Variables collected included demographics, imaging, operative findings, and final pathology. Patients were grouped into 3 categories based on preoperative findings: gallbladder mass, irregular wall thickening, and abnormal intraoperative findings on previous diagnostic laparoscopy.

Results:

Twenty-nine of 4474 patients evaluated for gallbladder pathology during the study period met the inclusion criteria. Preoperative imaging included computed tomography, ultrasonography, and magnetic resonance imaging. Twelve patients had multiple imaging studies. Eight patients were initially treated with a laparoscopic approach with 3 conversions to an open procedure. Forty-eight percent of patients had pathology-confirmed malignancy. Patients without a discrete mass on imaging were more likely to have benign disease (P = .04).

Conclusions:

Our results demonstrate that >50% of patients with suspicious preoperative findings had benign pathology, suggesting that the initial laparoscopic approach in selected patients may be appropriate.

Minimally invasive approaches to extrapancreatic cholangiocarcinoma

BACKGROUND

Due to the perceived difficulty in dissecting gallbladder cancers and extrapancreatic cholangiocarcinomas off of the portal structures and in performing complex biliary reconstructions, very few centers have used minimally invasive techniques to remove these tumors. Furthermore, due to the relative rarity of these tumors when compared to hepatocellular carcinoma, only a few reports have focused on short- and long-term results.

METHODS

We performed a review by combining the experience of three international centers with expertise in complex minimally invasive hepatobiliary surgery. Patients were entered into a database prospectively. All patients with gallbladder cancer and cholangiocarcinoma were analyzed; patients with distal cholangiocarcinomas who underwent laparoscopic pancreatoduodenectomies were excluded. Patients were divided according to if they had gallbladder cancer, hilar cholangiocarcinoma, or intrahepatic cholangiocarcinoma.

RESULTS

A total of 15 patients underwent laparoscopic resection for gallbladder cancer and 10 for preoperatively suspected gallbladder cancer, and 5 underwent laparoscopic completion procedures. An average of four lymph nodes (range = 1-11) were retrieved and all patients had an R0 resection. One patient (7 %) required conversion to an open procedure. No patients developed a biliary fistula, required percutaneous drainage, or had endoscopic stent placement. One patient had a recurrence at 3 months despite a negative final pathological margin, and a second patient had a distant recurrence at 20 months with a mean follow-up of 23 months. Nine patients underwent laparoscopic hepatectomy for intrahepatic cholangiocarcinoma. All anastomoses were completed laparoscopically. Biliary fistula was seen in two patients, one of which died after a transhepatic percutaneous biliary drain resulted in uncontrollable intra-abdominal hemorrhage despite reoperation. A third patient developed a pulmonary embolism. Thus, the morbidity and mortality rates were 33 and 11 %, respectively. One patient was converted to open and six patients (66 %) are alive with a median follow-up of 22 months. Five patients underwent minimally invasive resection for hilar cholangiocarcinoma; of these, two also required laparoscopic major hepatectomy. The mean estimated blood loss (EBL) was 240 mL (range = 0-400 mL) and the median length of stay (LOS) was 15 days (range = 11-21 days). All patients are alive with a median follow-up of 11 months (range = 3-18 months). None of the 29 patients developed port site recurrences.

CONCLUSION

Minimally invasive approaches to gallbladder cancer and intrahepatic and extrahepatic cholangiocarcinoma seem feasible and safe in the short term. Larger series with longer follow-up are needed to see if there are any long-term disadvantages or advantages to laparoscopic resection of extrapancreatic cholangiocarcinoma.

Adopting Gayet's Techniques of Totally Laparoscopic Liver Surgery in the United States

Professor Brice Gayet of the Institut Mutualiste Montsouris in Paris, France, has developed totally laparoscopic techniques for all segments of the liver. As a pioneer in the field of minimally invasive hepato-pancreato-biliary surgery, he started a Minimally Invasive Hepato-Pancreato-Biliary Fellowship in 2006. A retrospective review of all hepatic cases performed by a single surgeon since completing this Fellowship was undertaken. From November 2007 to October 2012, a total of 80 liver resections were done, of which 73 were begun with the intention of completing the case laparoscopically. Of these, more than 90% were completed laparoscopically and 88% were for malignant disease. One of the foundations of Professor Gayet's techniques is the low lithotomy or 'French' position and the utilization of a small robotically controlled laparoscope holder that is sterilizeable and considerably more economic than complete surgical systems. Prototypes exist of robotically controlled hand-held laparoscopic instruments that, unlike the complete surgical system, enable surgeons to maintain a sense of touch (haptics). Proper training in minimally invasive hepato-pancreato-biliary techniques can be obtained with surgeons able to independently perform laparoscopic major hepatectomies without senior minimally invasive backup. Furthermore, miniature and more affordable robotics may enable more surgeons to enjoy the benefits of minimally invasive surgery while maintaining patient safety and minimizing the rising burden of health-care costs worldwide.

Radical resection of gallbladder cancer: could it be robotic?

BACKGROUND

The only potentially curative option for patients with gallbladder cancer is radical resection. This is the first report that describes the successful application of a minimally invasive, robot-assisted radical resection, including lymphadenectomy, in five gallbladder cancer patients.

METHODS

Medical records of patients who underwent radical resection of gallbladder cancer via the da Vinci robotic surgical system in the Hepato-Bilio-Pancreatic Surgical Department of the Shanghai Ruijin Hospital, China, between March 2010 and July 2011 were reviewed and analyzed.

RESULTS

Robot-assisted radical resection was successful in all five patients. The mean number of excised lymph nodes was 9 (range = 3-11), mean operative time was 200 min (range = 120-300 min), mean intraoperative blood loss was 210 ml (range = 50-400 ml), and mean length of hospital stay was 7.4 days (range = 7-8 days). All patients were discharged with no reported complications. Mean postoperative follow-up was 11 months (range = 1-17 months). One patient died due to tumor recurrence 10 months postsurgically, but there was no recurrence in the remaining four patients during the follow-up period.

CONCLUSIONS

Robot-assisted radical resection for gallbladder cancer is both feasible and safe. Compared to laparoscopic surgery, the robotic surgery system is better suited for subtle dissection in a narrow, deep space. This is advantageous for both the removal of lymph nodes near the pancreas and hepatoduodenal ligament and the skeletonization of the hepatoduodenal ligament, the hepatic artery, and the celiac axis. The long-term outcome and direct comparisons to laparotomy in a larger patient cohort are needed to provide more clinical data supporting the superiority of this approach.