Technical Aspects of Gallbladder Cancer Surgery

Robotic-assisted laparoscopy in pediatric surgical oncology: a narrative review

Background and Objective

Robotic surgical oncology in children calls for experienced surgeons in minimally invasive surgery (MIS) and a solid oncological background. The aim of this review was to analyze the current state of robotic-assisted laparoscopy in pediatric tumor resection, assess the necessary framework of minimally invasive surgical oncology and describe future developments of the robotic technology.

Methods

A literature search of the MEDLINE/PubMed database was conducted, using the terms "robotic surgery", "pediatric" or "children" and "oncology" or "tumor". All relevant English-language studies published between 2008 and 2022 were reviewed.

Key Content and Findings

Although concerns have been raised regarding the use of MIS in surgical oncology, current literature reports similar oncological outcome if surgeons comply with the oncologic principles. The benefits of MIS have been established for robotic surgery in adult studies, including a shorter time to adjuvant chemotherapy. Surgical feasibility should be assessed based on tumor characteristics, preoperative imaging focusing on vascular involvement and surgeon's experience until clear guidelines are issued. The difficulties in establishing eligibility criteria for robotic resection of pediatric tumors lie in the great variability of indications, heterogeneity in tumor histology with their own surgical specificities, and wide range of age and weight, as shown by the literature review we performed. Between 2008 and 2022, 31 studies reported 171 cases with three studies including at least ten patients. The most reported procedure was adrenalectomy (41 cases). Current research in pediatric surgical oncology focuses on intraoperative locoregional treatment, improved vision with fluorescence and dyed-loaded specific probes and the many possibilities of enhancement software using the robotic console.

Conclusions

The robotic technology allows the surgeon to push the boundaries of conventional laparoscopy. Specific surgical guidelines are necessary.

Annals of Surgical Oncology Practice Guidelines Series: Management of Primary Liver and Biliary Tract Cancers

Primary cancers of the liver and biliary tract are rare and aggressive tumors that often present with locally advanced or metastatic disease. For patients with localized disease amenable to resection, surgery typically offers the best chance at curative-intent therapy. Unfortunately, the incidence of recurrence even after curative-intent surgery remains high. In turn, patients with hepatobiliary cancers commonly require multimodality therapy including a combination of resection, systemic therapy (i.e., targeted therapy, cytotoxic chemotherapy, immunotherapy), and/or loco-regional therapies. With advancements in the field, it is crucial for surgical oncologists to remain updated on the latest guidelines and recommendations for surgical management and optimal patient selection. Given the complex and evolving nature of treatment, this report highlights the latest practice guidelines for the surgical management of hepatobiliary cancers.

Utilization of robotics in pediatric surgical oncology

Despite increasing implementation of robotic surgery and minimally invasive techniques within adult surgical oncology and pediatric general surgery, the utilization of robotic-assisted resections for pediatric tumors has been met with controversy. The robotic platform affords numerous advantages over conventional surgical techniques. However, limited data and guidelines regarding patient selection, indications for the robotic approach, and long-term oncologic outcomes have delayed the widespread adoption of robotic-assisted resection of pediatric tumors. This paper reviews the benefits, limitations, and existing guidelines and data regarding the utilization of robotics in pediatric surgical oncology.

Gallbladder cancer

Gallbladder cancer (GBC) is the most common cancer of the biliary tract, characterized by a very poor prognosis when diagnosed at advanced stages owing to its aggressive behaviour and limited therapeutic options. Early detection at a curable stage remains challenging because patients rarely exhibit symptoms; indeed, most GBCs are discovered incidentally following cholecystectomy for symptomatic gallbladder stones. Long-standing chronic inflammation is an important driver of GBC, regardless of the lithiasic or non-lithiasic origin. Advances in omics technologies have provided a deeper understanding of GBC pathogenesis, uncovering mechanisms associated with inflammation-driven tumour initiation and progression. Surgical resection is the only treatment with curative intent for GBC but very few cases are suitable for resection and most adjuvant therapy has a very low response rate. Several unmet clinical needs require to be addressed to improve GBC management, including discovery and validation of reliable biomarkers for screening, therapy selection and prognosis. Standardization of preneoplastic and neoplastic lesion nomenclature, as well as surgical specimen processing and sampling, now provides reproducible and comparable research data that provide a basis for identifying and implementing early detection strategies and improving drug discovery. Advances in the understanding of next-generation sequencing, multidisciplinary care for GBC, neoadjuvant and adjuvant strategies, and novel systemic therapies including chemotherapy and immunotherapies are gradually changing the treatment paradigm and prognosis of this recalcitrant cancer.

Current management of incidental gallbladder cancer: A review

Early-stage gallbladder cancer (GBC) is mostly discovered incidentally by the pathologist after cholecystectomy for a presumed benign disease. It is the most common malignancy of the biliary tract with a variable incidence rate all over the World. The majority of patients with GBC remain asymptomatic for a long time and diagnosis is usually late when the disease is at an advanced stage. Radical surgery consisting in resection of the gallbladder liver bed and regional lymph nodes seems to be the best treatment option for incidental GBC. However, recurrence rates after salvage surgery are still high and the addition of neoadjuvant/adjuvant chemotherapy may improve outcomes. The aim of the present review is to evaluate current literature for advances in management of incidental GBC, with particular focus on staging techniques and surgical options.

Robotics-Assisted Pediatric Oncology Surgery-A Preliminary Single-Center Report and a Systematic Review of Published Studies

AIM

The use of robotics-assisted surgery in oncology has been proved effective and safe in adults. Despite these results, the use of robotics has been rarely reported for pediatric oncology. Our review aims to evaluate the safety and feasibility of robotics-assisted surgery in this field, analyzing our experience and performing a systematic review of the most recent studies.

METHODS

We reviewed all patients affected by an oncological disease who underwent a robotics-assisted procedure at our institute. We performed a systematic review of the literature from 2012 to 2021 on the subjects.

FINDINGS

A total of 14 patients underwent robotics-assisted tumor resection. Eleven procedures (median age 13.2-years old) were carried out in children with adnexal lesions (seven tumor excision and four ovariectomies). Histological diagnosis was mature teratoma (six), serous papillary cystadenofibromas of the fallopian tube (two), ovarian serous cystadenoma (one), ovarian mucinous cystadenoma (one), and ovarian seromucinous cystadenoma. The median length of stay was 2 days. No recurrences or complications at a median follow-up of 2.1-years were observed. A 5-year-old girl underwent a complete posterior resection of a type 3 sacrococcygeal tumor with a robotics-assisted approach for the dissection of a possible intraabdominal residual component of the lesion. No intra- and postoperative complications were recorded. Complete excision of a recurrent differentiating neuroblastoma of the left para-renal region was performed on a 9-year-old girl. An idiopathic anaphylactic shock occurred 1 day after the procedure. At 9 months' follow-up, no local recurrences of the lesion were observed. Overall, we reported no conversion to open surgery. Lastly, a robotic excision of a growing left superior mediastinal intermixed ganglioneuroblastoma was performed on an 8-year-old girl with no postoperative complications. Follow-up was uneventful (7 months). In the literature, the rate of complications ranges from 0 to 28%, mainly related to difficult dissection and impaired anatomy. Conversion is reported in 5% of all oncological procedures, due to more invading tumors and altered anatomical features. No robotics-related complications were reported.

CONCLUSION

Robotics-assisted surgery in pediatric oncology has proven to be feasible. Nevertheless, its use should be limited to selected cases and performed by highly trained oncological surgeons. Preparation and patient positioning, alongside a correct port placement, are crucial to carrying out these procedures. Further innovations in robotics may allow a wider application of this technology in pediatric oncology.

Port-site metastasis and atypical recurrences after robotic-assisted radical cystectomy (RARC): an updated comprehensive and systematic review of current evidences

The objective of this systematic review is to evaluate the current evidence regarding atypical metastases in patients undergoing robotic-assisted radical cystectomy (RARC). A review of the current literature was conducted through the Medline and NCBI PubMed, Cochrane Central Register of Controlled Trials (CENTRAL) and Google Scholar databases in October 2019. From the literature search using the cited keys and after a careful evaluation of the full texts, we included 31 articles in the study. Fourteen studies (45.2%) reported at least an atypical recurrence during the follow-up period with a rate between 4 and 40% of all the recurrences. Overall, 105 (1.63%) of the 6720 patients who have been evaluated in the included studies developed an atypical recurrence. Sixty-three (60%) of these atypical metastases were peritoneal carcinomatosis, 16 (15.2%) extrapelvic lymph nodes metastases, 11 (10.5%) port-site metastases, 10 (9.5%) retroperitoneal nodal metastases, while 5 (3.8%) patients developed more than one type of atypical recurrence. In literature, there is a low but not negligible incidence of atypical recurrences after RARC. However, publication bias and retrospective design of most studies could influence the evidences. Further prospective randomized studies are needed to clarify the real risk of patients undergoing RARC to develop atypical metastases.

Robotic Biliary Surgery

Robotic cholecystectomy is safe and feasible approach and can be combined with common bile duct exploration to address complicated pathology in a single setting. This article summarizes reported outcomes after robotic biliary surgery. A technical overview of robotic multiport and single port cholecystectomy is provided. Last, the approach to benign bile duct disease during robotic cholecystectomy, including reconstruction of the biliary tree, is described.

Relationship between clinical and histopathological features of patients undergoing cholecystectomy

INTRODUCTION

Cholelithiasis is most common disease of the gallbladder and cholecystectomy is the one of the most performed surgical procedure worldwide.

AIM

To assess the relationship between the demographic, biochemical, and histopathological variables of patients who underwent cholecystectomy.

MATERIAL AND METHODS

Demographic, biochemical, and histopathological data of 5077 patients undergoing cholecystectomy were compared in terms of two different aspects: open cholecystectomy (OC group; n = 2090) versus laparoscopic cholecystectomy (LC group; n = 2987), and an elective group (n = 4814) versus an emergency group (n = 263).

RESULTS

A total of 5077 patients aged between 13 and 97 years were included in the study. Aspartate aminotransferase (AST) levels, alanine aminotransferase (ALT) levels, mean platelet volume, and prevalence of acute/chronic cholecystitis were significantly higher in the LC group than in the OC group. On the other hand, age, direct bilirubin level, thrombocyte count, and prevalence of gallbladder cancer/gangrenous cholecystitis were significantly higher in the OC group than in the LC group. Levels of AST, ALT, white blood cells, neutrophils, and some prevalence of acute/chronic active cholecystitis were higher in the emergency group than in the elective group. On the other hand, the lymphocyte count and prevalence of chronic cholecystitis/hyperplastic polyps were higher in the elective group than in the emergency group. Histopathological analysis identified 32 patients with malignant gallbladder cancer as follows: adenocarcinoma (n = 21), mucinous adenocarcinoma (n = 3), papillary adenocarcinoma (n = 3), adenosquamous carcinoma (n = 1), clear cell adenocarcinoma (n = 2), squamous carcinoma (n = 1), and hepatocellular carcinoma metastasis (n = 1).

CONCLUSIONS

Even when the appearance of gallbladder specimens is normal, histopathological assessment allows for early diagnosis of many unusual findings such as gallbladder cancer.

Outcomes of surgical resection of gallbladder cancer in patients presenting with jaundice: A systematic review and meta-analysis

INTRODUCTION

Preoperative jaundice is considered a relative contraindication to radical gallbladder cancer (GBC) resection due to poor prognosis and high postoperative morbidity. Recent reports have indicated that aggressive surgery may improve long-term survival for patients with advanced GBC who present with obstructive jaundice. The current systematic review and meta-analysis aimed to compare postoperative outcomes among jaundiced and non-jaundiced patients with resectable GBC.

METHODS

An electronic search was performed using several Medical Subject Headings terms: cholecyst, gallbladder, tumor, cancer, carcinoma, adenocarcinoma, neoplasia, neoplasm, jaundice, and icterus. Overall survival after surgery was the primary outcome; resectability and postoperative morbidity were the secondary outcomes.

RESULTS

Overall survival was shorter among patients who presented with jaundice (Hazard ratio [HR]: 2.21, 95% confidence interval [CI], 1.64-2.97; P < 0.001). Patients with jaundice were less likely to have resectable disease (odds ratio: 0.27, 95% CI, 0.17-0.43; P < 0.001). The jaundice group had higher odds of postoperative morbidity, bile-leak, and posthepatectomy failure versus the non-jaundiced control group.

CONCLUSIONS

Radical surgery for GBC resection for patients presenting with obstructive jaundice was associated with reduced overall survival and increased postoperative morbidity. Jaundiced patients with advanced GBC should be considered for surgical resection but need careful evaluation and counseling before undertaking extensive surgical resection.

Staging, Treatment, and Future Approaches of Gallbladder Carcinoma

BACKGROUND

Gallbladder cancer is the most common malignant cancer of the bile ducts and third most common gastrointestinal malignant in the world for public health. Its relatively low incidence and confused symptoms result in advanced disease at the time of presentation, contributing to poor prognosis and reduced survival associated with this disease. The main function of the gallbladder is to store excreted bile acids from the liver in preparation for a meal. Its main risk factor is prolonged exposure to biliary calculations, although bacterial infections and other inflammatory conditions are associated. Chronic inflammatory bowel conditions are associated with gallbladder cancer. T stage translates to identifying residual disease at reoperation for incidental gallbladder cancer and residual disease negatively affects survival.

CONCLUSION

It is the most common cancer of gallbladder, gallbladder cancer remains a rare disease. Gallbladder cancer is a rare disease that can be accidentally diagnosed after cholecystectomy or accidentally, often with more advanced disease. The prognosis is generally extremely poor and improvements in surgical resection of this approach have to be re-evaluated, while the role of chemotherapy and radiotherapy remains controversial.

Minimally invasive and open gallbladder cancer resections: 30- vs 90-day mortality

BACKGROUND

Minimally invasive surgery is increasingly used for gallbladder cancer resection. Postoperative mortality at 30 days is low, but 90-day mortality is underreported.

METHODS

Using National Cancer Database (1998-2012), all resection patients were included. Thirty- and 90-day mortality rates were compared.

RESULTS

A total of 36 067 patients were identified, 19 139 (53%) of whom underwent resection. Median age was 71 years and 70.7% were female. Ninety-day mortality following surgical resection was 2.3-fold higher than 30-mortality (17.1% vs 7.4%). There was a statistically significant increase in 30- and 90-day mortality with poorly differentiated tumors, presence of lymphovascular invasion, tumor stage, incomplete surgical resection and low-volume centers (P<0.001 for all). Even for the 1885 patients who underwent minimally invasive resection between 2010 and 2012, the 90-day mortality was 2.8-fold higher than the 30-day mortality (12.0% vs 4.3%).

CONCLUSIONS

Ninety-day mortality following gallbladder cancer resection is significantly higher than 30-day mortality. Postoperative mortality is associated with tumor grade, lymphovascular invasion, tumor stage, type and completeness of surgical resection as well as type and volume of facility.

Rates and patterns of recurrence after curative intent resection for gallbladder cancer: a multi-institution analysis from the US Extra-hepatic Biliary Malignancy Consortium

BACKGROUND

Gallbladder cancer is a relatively rare malignancy. The current study aimed to define the incidence and patterns of recurrence following gallbladder cancer resection.

METHODS

Using a multi-institutional cohort we identified 217 patient undergoing curative intent surgery for gallbladder cancer. Patterns of recurrence were classified as locoregional and distant recurrence.

RESULTS

At last follow-up, 76 patients (35.0%) had experienced a recurrence (locoregional only, n = 12, 15.8%; distant only, n = 50, 65.8%; locoregional and distant, n = 14, 18.4%). Median time to recurrence was 9.5 months (IQR 4.7-17.6) and was not associated with recurrence site (all p > 0.05). On multivariable analysis, T3 disease (HR = 8.44, p = 0.014), lymphovascular invasion (HR = 4.24, p < 0.001) and residual disease (HR = 2.04, p = 0.042) were associated with an increased risk of recurrence. Patients who recurred demonstrated a worse 1-, 3- and 5-year OS (1-year OS: 91.3% vs. 68.6%, p = 0.001, 3-year OS: 79.3% vs. 28.7%, p < 0.001, and 5-year OS: 75.9% vs. 16.0%, p < 0.001). After adjusting for other risk factors, recurrence was independently associated with a decreased OS (HR = 3.71, p = 0.006). Of note, receipt of adjuvant therapy was associated with improved OS (HR = 0.56, p = 0.027) among those patients who developed a tumor recurrence.

DISCUSSION

Over one-third of patients experienced a recurrence after gallbladder cancer surgery. While chemotherapy did not decrease the rate of recurrence, patients who experienced recurrence after administration of adjuvant treatment faired better than patients who did not receive adjuvant therapy.