The management of gallbladder cancer: before, during, and after laparoscopic cholecystectomy

Incidental Gallbladder Cancer: Routine versus Selective Histological Examination After Cholecystectomy

Background  Incidental gallbladder cancer is relatively rare, with an incidence ranging between 0.19 and 5.5% of all the cholecystectomies for benign disease, and carries a poor prognosis. Currently, in the literature, there appears to be some controversy about whether all gallbladder specimens should be sent for routine histopathology. The aim of this study was to investigate the need for either routine or selective histopathological evaluation of all gallbladder specimens following cholecystectomy in our institution.

Methods  The records of all patients who underwent a cholecystectomy (laparoscopic and open) for gallstone disease over a 5-year period (between January 2011 and January 2016) were reviewed retrospectively in a single university teaching hospital. Patients with radiological evidence of gallbladder cancer preoperatively were excluded. The notes of patients with incidental gallbladder cancer were reviewed and data were collected for clinical presentation and preoperative investigations including blood tests and radiological imaging.

Results  A total of 1,473 specimens were sent for histopathological evaluation, with two patients being diagnosed with an incidental gallbladder cancer (papillary adenocarcinoma in situ and moderately differentiated invasive adenocarcinoma [stage IIIa]). The incidence rate was 0.14%. All patients with incidental gallbladder cancer had macroscopically abnormal specimens.

Conclusion  Both patients in our study who were diagnosed with incidental gallbladder cancer had macroscopic abnormalities. A selective rather than routine approach to histological evaluation of gallbladder specimens especially in those with macroscopic abnormalities should be employed. This will reduce the burden on the pathology department with potential cost savings.

Novel strategy for laparoscopic treatment of pT2 gallbladder carcinoma

BACKGROUND

This study evaluated our new strategy for treating suspected T2 gallbladder carcinoma (GBC) using a laparoscopic approach.

METHODS

We examined 19 patients with suspected T2 GBC who were treated laparoscopically (LS group) between December 2007 and December 2013; these patients were compared with 14 patients who underwent open surgery (OS group). Laparoscopic staging was initially performed to exclude factors making the patients ineligible for curative resection. Intraoperative pathological examination of the surgical margin of the cystic duct was performed prior to laparoscopic gallbladder bed resection, and pathological examination was again performed to confirm the presence of carcinoma and the depth of tumor invasion. Surgery was completed when the pathological findings indicated that the patient was cancer free. Lymph node dissection was performed according to the depth of tumor invasion.

RESULTS

None of the patients required conversion to laparotomy. For three patients with benign lesions, only gallbladder bed resection was required. Additional regional lymph node dissection was performed in 16 patients in the LS group. The mean operative time (309 vs. 324 min, p = 0.755) and mean number of dissected lymph nodes (12.6 vs. 10.2, p = 0.361) were not significantly different between the LS and OS groups. The intraoperative blood loss was significantly lower (104 vs. 584 mL, p = 0.002) and the postoperative hospital stay was significantly shorter (9.1 vs. 21.6 days, p = 0.002) for LS patients than for those in the OS group. In the LS group, one patient developed postoperative pneumonia, but all patients survived without recurrence after a mean follow-up of 37 months.

CONCLUSION

Our strategy for suspected T2 gallbladder GBC is safe and useful, avoids unnecessary procedures, and is associated with similar oncologic outcomes as the open method.

Incidental gallbladder cancer diagnosed following laparoscopic cholecystectomy

BACKGROUND

Laparoscopic cholecystectomy (LC) is the treatment of choice for benign gallbladder disease. Gallbladder cancers have been found following LC. The aim of the present study was to evaluate the survival outcome and prognosis of incidental gallbladder cancer diagnosed after LC.

METHODS

From January 2002 to December 2007, 3,145 patients underwent LC at the Department of Surgery, Korea University Medical Center. Of these, 33 patients (1.05%) were diagnosed with gallbladder cancer after LC. Clinicopathological characteristics were retrospectively reviewed in this study.

RESULTS

Of the 33 patients studied, 9 were men and 24 were women. Laparoscopic cholecystectomy alone was performed in 26 patients, and additional radical surgery was performed in 7 others. Regarding tumor staging, there were 2 Tis, 6 T1a, 4 T1b, 17 T2, and 4 T3 tumors. Male patients had a significantly higher incidence of moderately and poorly differentiated tumors (P < 0.001), T2 and T3 tumors (P = 0.02), additional second operations (P = 0.046), and recurrence (P = 0.016). The cumulative 1-, 3-, and 5-year survival rates were 87.2, 73.1, and 47.0%, respectively. Univariate analysis revealed that significant prognostic factors for poorer survival were male gender (P = 0.026), age older than 65 years (P = 0.013), the presence of inflammation (P = 0.009), moderately or poorly differentiated tumor (P < 0.001), nonpolypoid gross type (P = 0.003), and pT stage (P < 0.001). Tumor differentiation was a significantly independent predictor of poor prognosis.

CONCLUSIONS

Male patients exhibited aggressive tumor characteristics. Laparoscopic cholecystectomy is an adequate treatment for pT1 tumors. For pT2 and pT3 patients, additional radical surgery might be needed to achieve a tumor-free surgical margin, along with lymph node dissection.

Gallbladder cancer: laparoscopic and classic cholecystectomy

BACKGROUND

Gallbladder carcinoma is an abdominal malignancy with an extraordinarily poor prognosis that depends on the stage at the time of the diagnosis.

METHODS

In the past 8 years, 3,158 laparoscopic cholecystectomies (LC), and 8 years before that, 3,083 classic cholecystectomies (CC) were performed in the authors' department.

RESULTS

In 15 LC cases and 7 CC cases, gallbladder carcinoma was found. There was preoperative or intraoperative suspicion of malignancy in 3 LC and 5 CC cases. According to the tumor-node-metastasis (TNM) classification system, these cases were categorized as stage 3 (S3) or S4, and resumption of the operation was necessary. Two LC cases and five CC cases were inoperable malignancies requiring palliative treatment. The others were managed with surgery for the completion of an extended cholecystectomy. The survival rate for all the patients was less than 1 month. In 12 LC cases and 2 CC cases, malignancy was diagnosed postoperatively. The stages for the LC group were S1(T in situ) in four cases and S1(T1) in eight cases. The stage for the CC group was S1(T1) in both cases. After simple LC or CC, the survival time was more than 2 years for eight patients and more than 3 years for four patients. Two patients were still alive, respectively, 1 and 2 years postoperatively. The difference in the numbers of diagnosed and resected gallbladder carcinoma in the earlier stages between the LC and CC groups is statistically significant ( p < 0.01).

CONCLUSIONS

With the increased use of LC for presumed gallstone disease, the diagnosis and removal of gallbladder carcinoma in the earlier stages could be more frequent.