Hepatopancreatoduodenectomy for advanced gallbladder carcinoma

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.

Robotic versus open extended cholecystectomy for T1a–T3 gallbladder cancer: A matched comparison

Background

The feasibility and safety of robotic extended cholecystectomy (REC) are still uncertain. This study was performed to compare the short- and long-term outcomes of REC with those of open extended cholecystectomy (OEC) for T1a–T3 gallbladder cancer.

Methods

From January 2015 to April 2022, 28 patients underwent REC in our center. To minimize any confounding factors, a 1:2 propensity score-matching analysis was conducted based on the patients’ demographics, liver function indicators, T stage, and symptoms. The data regarding demographics, perioperative outcomes, and long-term oncologic outcomes were reviewed.

Results

The visual analogue scale score was significantly lower in the REC than OEC group immediately postoperatively (3.68 ± 2.09 vs. 4.73 ± 1.85, P = 0.008), on postoperative day 1 (2.96 ± 1.75 vs. 3.69 ± 1.41, P = 0.023), and on postoperative day 2 (2.36 ± 1.55 vs. 2.92 ± 1.21, P = 0.031). In addition, the REC group exhibited a shorter time to first ambulation (P = 0.043), a shorter time to drainage tube removal (P = 0.038), and a shorter postoperative stay (P = 0.037), but hospital costs were significantly higher in the REC group (P < 0.001). However, no statistically significant difference was found in the operation time (P = 0.134), intraoperative blood loss (P = 0.467), or incidence of postoperative morbidity (P = 0.227) or mortality (P = 0.289) between the REC and OEC groups. In regard to long-term outcomes, the 3-year disease-free survival rate was comparable between the OEC and REC groups (43.1% vs. 57.2%, P = 0.684), as was the 3-year overall survival rate (62.8% vs. 75.0%, P = 0.619).

Conclusion

REC can be an effective and safe alternative to OEC for selected patients with T1a–T3 gallbladder cancer with respect to short- and long-term outcomes.

Insights From the Analysis of Clinicopathological and Prognostic Factors in Patients With Gallbladder Cancer

Aims

To investigate the clinical efficacy and prognostic factors of primary gallbladder cancer (GBC) treated by radical surgery.

Methods

The clinical and pathological data of 168 patients with primary gallbladder cancer admitted and treated in the Third Affiliated Hospital of Soochow University from January 1st, 2010 to December 31st, 2018 were analyzed retrospectively. Kaplan Meier method was used to draw the survival curve and evaluate the survival rate. Chi-square test was used for univariate analysis and binary logistic regression was used for multivariate analysis.

Results

94 cases showed symptoms of abdominal pain and abdominal distension. 7 cases showed symptoms of fatigue and weight loss. Jaundice occurred in 10 patients. Fever occurred in 6 patients. 51 patients had no symptoms at all. The median survival time of 168 patients was 35.0 (1.0 ~ 142.0) months. The overall 1-, 2- and 3-year cumulative survival rates were 69.6%, 55.4% and 48.8% respectively. The univariate analysis indicated that preoperative bilirubin, tumor size, tumor location, pathological type, degree of differentiation, liver invasion, nerve invasion, vascular invasion, surgical margin, filtration depth and N staging were significant factors influencing prognosis of patients with primary GBC (P<0.05). The results of multivariate analysis demonstrated that degree of differentiation, nerve invasion, filtration depth and N staging were independent risk factors for prognosis of patients with primary GBC (P<0.05).

Conclusion

Patients with risk factors of gallbladder cancer should be more active in early cholecystectomy to avoid the malignant transformation of benign diseases. Degree of differentiation, nerve invasion, filtration depth and N staging were important factors for poor prognosis of patients with primary GBC. For T4 staging patients, preoperative evaluation should be more comprehensive, and patients and surgeons should be more prudent in adopting appropriate clinical treatment. The primary purpose should be prolonging the survival time and improving the quality of life.

Hepatopancreatoduodenectomy With Delayed Division of the Pancreatic Parenchyma: A Novel Technique for Reducing Pancreatic Fistula

Objectives

To review our novel technique of hepatopancreatoduodenectomy (HPD) with delayed division of the pancreatic parenchyma (DDPP) for reducing postoperative pancreatic fistula (POPF).

Background

The high operative morbidity and mortality rates after HPD remains a major issue. One of the most troublesome complications is POPF, which might possibly be caused by peripancreatic saponification due to long interval between pancreas resection and reconstruction, as most surgeons prefer a caudocranial approach, performing pancreatoduodenectomy (PD) first and then hepatectomy (conventional HPD [C-HPD]).

Methods

A review of the patients undergoing C-HPD and HPD with DDPP was performed. Postoperative outcomes were compared. Multivariable analysis was conducted to evaluate the risk factors of POPF after HPD.

Results

One-hundred two patients comprised of 50 patients undergoing C-HPD and 52 patients undergoing HPD with DDPP. The interval between pancreas resection and reconstruction was significantly shorter in HPD with DDPP group than in C-HPD group (51 vs 263 minutes; P < 0.001). The incidence of POPF was significantly lower in HPD with DDPP group than in C-HPD group (32.7% vs 77.3%; P < 0.001). The postoperative hospital stay was shorter in patients undergoing HPD with DDPP than in those undergoing C-HPD (32 vs 45 days). A multivariate analysis revealed that body mass index >24 kg/m2 and conventional (PD first) procedure were significant risk factors for POPF after HPD.

Conclusions

A novel technique of HPD with DDPP is a simple procedure and the optimal treatment choice to reduce the risk of developing POPF after this extensive surgery.

Safety and Oncological Benefit of Hepatopancreatoduodenectomy for Advanced Extrahepatic Cholangiocarcinoma with Horizontal Tumor Spread: Shinshu University Experience

BACKGROUND

Although hepatopancreatoduodenectomy (HPD) is the only means of achieving R0 resection of widespread extrahepatic cholangiocarcinoma, its safety and oncological benefit remain controversial because of its inherent high risk of mortality and morbidity.

OBJECTIVE

The aim of this study was to retrospectively analyze short- and long-term outcomes and evaluate the safety and oncological benefit of this advanced procedure.

METHODS

The study cohort comprised 37 consecutive patients who had undergone major HPD. Portal vein embolization was performed before surgery in 20 (54%) patients with future remnant liver volume < 35%.

RESULTS

The median operative time and blood loss were 866 min and 1000 mL, respectively. Concomitant vascular resection was performed in five patients (14%). The overall morbidity and mortality rates were 100% and 5.4% (n = 2), respectively. Nineteen patients (51%) had major (Clavien-Dindo grade III or higher) complications, the most common being intra-abdominal infection (49%) and post-hepatectomy liver failure (46%, grade B/C: 32%/5%), followed by postoperative pancreatic fistula (30%, grade B/C). R0 resection was achieved in 31 patients (84%). The 1-, 3-, and 5-year overall survival (OS) rates were 83%, 48%, and 37%, respectively. In patients with R0 resection, 5-year OS was comparable between patients who had undergone major HPD and major hepatectomy alone (41% vs. 40%, p = non-significant).

CONCLUSIONS

HPD is a valid treatment option for extensive cholangiocarcinoma, offering long-term survival benefit at the cost of relatively high but acceptable morbidity and mortality rates. HPD is advocated in selected patients provided that it is considered possible to achieve R0 resection.

Extended liver surgery for gallbladder cancer revisited: Is there a role for hepatopancreatoduodenectomy?

Gallbladder cancer (GBCA) is a rare and fatal disease and the majority of patients presents with advanced stage. Surgical resection associated with lymphadenectomy is the only chance for cure. For patients in stages III and IV, extended resection is the only treatment to achieve R0 margins. For GBCA invading the hepatoduodenal ligament and pancreatoduodenal region, the resection of extrahepatic bile duct and pancreas is necessary. Hepatopancreatoduodenectomy (HPD) represents the most complex and challenging procedure in the hepatopancreatobiliary region. Kuno at the Cancer Institute Hospital Tokyo performed the first HPD in Japan in 1974 and in 1980 Takasaki presented five cases and the 30-day mortality was 60%. After that, other countries started to perform the procedure including United States and Brazil. The main complications are liver failure and pancreatic fistula. Advancements in perioperative care, surgical technique, medical instruments and postoperative at intensive care unit have resulted in reduction in morbidity and mortality. The use of portal vein embolization is indicated to increase the liver volume in patients with insufficient remnant. Preoperative biliary drainage can prevent cholangitis and improve hepatic function. This procedure should be recommended before extended HPD in jaundiced patients. Operative results with mortality rates below 5% at high volume centers suggest that HPD should be performed at centers with expertise in hepatopancreatobiliary surgery.

Who benefits from R0 resection? A single-center analysis of patients with stage Ⅳ gallbladder cancer

Objectives

Most patients with gallbladder cancer (GBC) present with advanced-stage disease and have a poor prognosis. Radical resection remains the only therapeutic option to improve survival in patients with GBC. This study aimed to analyze the prognostic factors in patients with stage Ⅳ GBC and to identify a subgroup of patients who might benefit from R0 resection.

Methods

A total of 285 patients with stage Ⅳ GBC were retrospectively analyzed at our institution from January 2008 to December 2012. Factors potentially influencing the prognosis of GBC after surgery were analyzed by univariate and multivariate analyses.

Results

The 1-, 3-, and 5-year overall survival rates were 6.6% (15/229), 0.9% (2/229), and 0 (0/229), respectively. Ascites (relative risk [RR] = 1.631, 95% confidence interval [CI]: 1.221-2.180, P = 0.001), pathological grade (RR = 1.337, 95% CI: 1.050-1.702, P = 0.018), T stage (RR = 1.421, 95% CI: 1.099-1.837, P = 0.000), M stage (RR = 1.896, 95% CI: 1.409-2.552, P = 0.000), and surgery (RR = 1.542, 95% CI: 1.022-2.327, P = 0.039) were identified as independent risk factors influencing prognosis. The median survival time (MST) was significantly higher in patients undergoing R0 resection than in those undergoing R1/R2 resection (6.0 vs. 2.7 months; P < 0.001). In subgroup analyses, stage ⅣA patients benefited from R0 resection (MST for R0 vs. R1/R2, 11.0 vs. 4.0 months; P = 0.003), while R0 resection had a significant survival benefit than R1/R2 resection in patient with stage ⅣB GBC without distant metastasis (MST for R0 vs. R1/R2, 6.0 vs. 3.0 months; P = 0.007).

Conclusion

Ascites, pathological grade, T stage, M stage, and surgery were independent risk factors influencing prognosis in patients with stage IV GBC. N2 lymph node metastasis did not preclude curative resection, and radical resection should be considered in patients with stage Ⅳ GBC without distant metastasis once R0 margin was achieved.

A modified surgical approach of hepatopancreatoduodenectomy for advanced gallbladder cancer: Report of two cases and literature review

Gallbladder cancer (GBC) is the most common cancer of the biliary tract, constituting 80%-95% of malignant biliary tract tumors. Surgical resection is currently regarded as the sole curative treatment for GBC. Hepatopancreatoduodenectomy (HPD) has been adopted to remove the advanced gallbladder tumor together with the infiltrated parts within the liver, lower biliary tract and the peripancreatic region of GBC patients. However, patients who underwent HPD were reported to have a distinctly higher postoperative morbidity (71.4%, ranging from 30.8% to 100%) and mortality (13.2%, ranging from 2.4% to 46.9%) than those given pancreatoduodenectomy (PD) alone. We present two patients with advanced GBC who underwent a modified surgical approach of HPD: PD with microwave ablation (MWA) of adjacent liver tissues and the technique of intraductal cooling of major bile ducts. No serious complications like bile leakage, pancreatic fistula, hemorrhage and organ dysfunction, etc. occurred in the two patients. They had a rapid recovery with postoperative hospital stay being 14 days. Application of this approach effectively eliminated tumor-infiltrated adjacent tissues, and maximally reduced the postoperative morbidity and mortality. This modified surgical method is secure and efficacious for the treatment of locally advanced GBC.

A systematic review of safety and efficacy of hepatopancreatoduodenectomy for biliary and gallbladder cancers

OBJECTIVES

To review the evidence on the safety and efficacy of hepatopancreatoduodenectomy for biliary and gallbladder cancers.

METHODS

Medline and EMBASE were systematically searched for papers of hepatopancreatoduodenectomy in patients with biliary and gallbladder cancers.

RESULTS

Eighteen studies involving 397 patients were reviewed. Major hepatectomy was undertaken in 81.3% of the 397 patients and the R0 resection rate was 71.3%. The morbidity and mortality rates were 78.9% and 10.3%, respectively. The 5-year overall survival rate ranged from 3% to 50% (median = 31%). The 5-year survival rate in patients who underwent curative resection was 18-68.8% (median = 51.3%), and 0% in patients who received non-curative resection.

CONCLUSIONS

Hepatopancreatoduodenectomy is a challenging procedure with high morbidity and mortality rates. However, this procedure can provide a chance of long-term survival in patients in whom curative resection is feasible.

A systematic review of the safety and efficacy of hepatopancreatoduodenectomy for biliary and gallbladder cancers

OBJECTIVES

To review the evidence on the safety and efficacy of hepatopancreatoduodenectomy for biliary and gallbladder cancers.

METHODS

Medline and EMBASE were systematically searched for papers describing hepatopancreatoduodenectomy in patients with biliary and gallbladder cancers.

RESULTS

Eighteen studies involving 397 patients were reviewed. A major hepatectomy was undertaken in 81.3% of the 397 patients, and the R0 resection rate was 71.3%. The morbidity and mortality rates were 78.9% and 10.3%, respectively. The 5-year overall survival rate ranged from 3% to 50% (median = 31%). The 5-year survival rate in patients who underwent a curative resection was 18-68.8% (median = 51.3%), and 0% in patients who received a non-curative resection.

CONCLUSIONS

A hepatopancreatoduodenectomy is a challenging procedure with high morbidity and mortality rates. However, this procedure can provide a chance of long-term survival in patients in whom a curative resection is feasible.

Is combined pancreatoduodenectomy for advanced gallbladder cancer justified?

BACKGROUND

The clinical impact of combined pancreatoduodenectomy (PD) for advanced gallbladder cancer remains unclear.

METHODS

A total of 96 patients who underwent resection for stage II, III, or IV gallbladder cancer were enrolled. Patients with lower bile duct involvement, pancreatic or duodenal infiltration, or peripancreatic lymph node metastasis were considered candidates for combined PD. The operative outcomes were compared between the patients treated with PD (PD group, n = 21) and those treated without PD (non-PD group, n = 75), and between those treated with major hepatopancreatoduodenectomy (major HPD group, n = 9) and those treated with major hepatectomy (major hepatectomy group, n = 20).

RESULTS

Overall morbidity in the PD group was greater than that in the non-PD group (81% vs 23%, P < .001), whereas the overall survival (OS) was comparable between the groups (5-year OS; 39.8% vs 46.7%, P = .96). There was no in-hospital mortality in the PD group. A serum albumin <3.0 g/dL (P = .004) and tumor size ≥ 9.0 cm (P = .029) were associated independently with a poor prognosis in the PD group. Overall morbidity in the major HPD group was greater than that in the major hepatectomy group (89% vs 40%, P = .014), whereas the OS was comparable between the groups (5-year OS; 34.6% vs 21.1%, P = .57), and the OS of major HPD group was better than that of unresectable group (n = 18, P = .017).

CONCLUSION

Combined PD, including major HPD, is beneficial for selected patients of advanced gallbladder cancer; however, the indications should be carefully evaluated because of greater morbidity rates.

Review of hepatopancreatoduodenectomy for biliary cancer: an extended radical approach of Japanese origin

Cholangiocarcinomas exhibit various modes of local extension, and some tumors can only be completely resected by hepatopancreatoduodenectomy (HPD), which is defined as the resection of the whole extrahepatic biliary system with the adjacent liver and pancreatoduodenum. Since Takasaki et al. introduced HPD for locally advanced gallbladder cancer in 1980, Japanese hepatobiliary surgeons have aggressively challenged this extended procedure for advanced biliary tumors. Early experiences with HPD were frequently associated with liver failure and sequential mortality, leading to an underestimation of the survival benefit of HPD. However, with improvements in surgical techniques and perioperative patient care, including portal vein embolization, over the last two decades, the mortality rate after HPD has gradually decreased. Recent studies have demonstrated a favorable survival in cholangiocarcinoma, provided that R0 resection is achieved. In contrast, HPD for gallbladder cancer remains controversial because of the extremely poor survival, although the study populations have been limited. HPD can be performed with low mortality and offers a better probability of long-term survival in patients with cholangiocarcinoma. We should consider HPD to be a standard approach for laterally advanced cholangiocarcinomas that are otherwise unresectable.

Is extended hemihepatectomy plus pancreaticoduodenectomy justified for advanced bile duct cancer and gallbladder cancer? Surgery. 2013;153:794-800. [PMID: 23415082 DOI: 10.1016/j.surg.2012.11.024]

BACKGROUND

Major hepatopancreaticoduodenectomy (HPD) is an extensive surgical procedure offering the highest curability for patients with advanced biliary cancer. However, surgical morbidity associated with major HPD is high, and optimal indications for this procedure remain unclear.

METHODS

Between 1989 and 2010, 14 patients with widespread bile duct cancer and 5 with gallbladder cancer having biliary infiltration underwent major HPD at our hospital. Preoperative portal vein embolization was performed in 17 patients undergoing right HPD. Clinicopathologic factors and survivals following HPD were compared between patients with bile duct cancer and those with gallbladder cancer.

RESULTS

One patient who underwent right HPD for gallbladder cancer died of hepatic failure (5.3%) and 18 of the 19 patients (95%) developed postoperative pancreatic fistulas. The median hospital stay was 47 days. Depth of invasion was T3 in 1 patient and T4 in 2 patients with bile duct cancer and was T4 in all 5 patients with gallbladder cancer (P = .002). The clinical stage was IV in 3 patients (21%) with bile duct cancer and in all 5 patients with gallbladder cancer (P = .002). The 5-year survival rates and median survival rates of patients with bile duct cancer and gallbladder cancer were 45% vs 0 and 3.3 years vs 8 months, respectively (P < .001).

CONCLUSION

HPD can be an acceptable treatment option for widespread bile duct cancer. However, the indication for HPD in advanced-stage gallbladder cancer should be considered carefully, considering the high morbidity rate and the advanced stage of the disease.

Gallbladder cancer: past, present and an uncertain future

Although gallbladder cancer (GBC) is the most common malignancy of the biliary tract, its relatively low incidence and confounding symptomatology result in advanced disease at the time presentation, contributing to the poor prognosis and decreased survival associated with this disease. It is therefore increasingly important to understand its pathogenesis and risk factors to allow for the earliest possible diagnosis. To date, gallbladder cancer is poorly understood compared to other malignancies, and is still most commonly discovered incidentally after cholecystectomy. Moreover, while much is known about biliary neoplasms as a whole, understanding the clinical and molecular nuances of GBC as a separate disease process will prove a cornerstone in the development of early intervention, potential screening and overall more effective treatment strategies. The present work reviews the most current understanding of the pathogenesis, diagnosis, staging and natural history of GBC, with additional focus on surgical treatment. Further, review of current adjuvant therapies for unresectable and advanced disease as well as prognostic factors provide fertile ground for the development of future studies which will hopefully improve treatment outcomes and affect overall survival for this highly morbid, poorly understood malignancy.

Hepatopancreatoduodenectomy for cholangiocarcinoma: a single-center review of 85 consecutive patients. Ann Surg. 2012;256:297-305. [PMID: 22750757 DOI: 10.1097/sla.0b013e31826029ca]

OBJECTIVE

To outline our experience with hepatopancreatoduodenectomy (HPD) as a treatment for cholangiocarcinoma and to appraise the clinical significance of this challenging procedure.

BACKGROUND

Cholangiocarcinomas often exhibit an extensive ductal spread invading from the hepatic hilus to the lower bile duct, and such tumors can be completely resected only by HPD. Early experiences with HPD were associated with high mortality and morbidity, leading to an underestimation of the survival benefit of HPD.

METHODS

We retrospectively reviewed the medical records of 85 patients with cholangiocarcinoma who underwent HPD from 1992 to 2011. Major hepatectomy was performed in 79 patients (92.9%), and combined vascular resection was performed in 26 patients (30.6%).

RESULTS

The operating time was 762 ± 141 minutes, and blood loss was 2696 ± 1970 mL. Liver failure was the most common abdominal complication (n = 64), followed by pancreatic fistula (n = 60), wound sepsis (n = 33), intra-abdominal abscess (n = 22), refractory ascites (n = 17), bacteremia (n = 16), bile leakage (n = 13), and delayed gastric emptying (n = 12). Re-laparotomy was necessary in 9 cases (11.1%). Overall, 19 patients (22.4%) exhibited Clavien grade 0 to II complications, 58 (68.2%) exhibited grade III, 6 (7.1%) exhibited grade IV, and 2 (2.4%) exhibited grade V (mortality). The overall survival rate for the 85 patients was 79.7% after 1 year, 48.5% after 3 years, 37.4% after 5 years, and 32.1% after 10 years; 9 (10.5%) patients survived for more than 5 years. The rate of survival for the 53 patients with pM0 disease who underwent R0 resection was the most favorable, with 5- and 10-year survival rates of 54.3% and 46.6%, respectively.

CONCLUSIONS

HPD is technically demanding and is associated with high morbidity. However, this surgery can be performed with low mortality and offers a better probability of long-term survival in selected patients. As hepatobiliary surgeons, we should consider HPD to be a standard procedure for laterally advanced cholangiocarcinomas that are otherwise unresectable.

Reappraisal of hepatopancreatoduodenectomy as a treatment modality for bile duct and gallbladder cancer

BACKGROUND

Hepatopancreatoduodenectomy has been performed to achieve radical resection in malignant biliary tumors. We reviewed clinical outcomes to evaluate the clinical feasibility of hepatopancreatoduodenectomy for the treatment of gallbladder and bile duct cancer.

METHODS

Twenty-three patients underwent hepatopancreatoduodenectomy from 1995 to 2007; 10 gallbladder cancer and 13 bile duct cancer. Median follow-up periods were 15.0 months.

RESULTS

R0 resection was performed in 17 of 23 patients (73.9%). Morbidity and mortality rates were 91.3% and 13.0%, respectively. Five-year survival rates were 10.0% for gallbladder cancer and 32.3% for bile duct cancer. Survival more than 3 years was possible for most patients with stage IIA or less, whereas all gallbladder cancer patients with stage III and all bile duct cancer with stage IIB or more died within 2 years. Bile duct cancer patients with pN0 survived longer than those with pN1 (p < 0.001).

CONCLUSIONS

To obtain negative proximal and distal ductal resection margins in the biliary tract cancer, R0 resection and long-term survival can be achieved by hepatopancreatoduodenectomy. However, its adoption in patients with lymph node metastasis or adjacent organ invasion cannot be recommended.

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.

Combined major hepatectomy and pancreaticoduodenectomy for locally advanced biliary carcinoma: long-term results. World J Surg. 2008;32:1067-1074. [PMID: 18231828 DOI: 10.1007/s00268-007-9393-8]

BACKGROUND

This study aimed to define the role of combined major hepatectomy and pancreaticoduodenectomy in the surgical management of biliary carcinoma and to identify potential candidates for this aggressive procedure.

METHODS

A retrospective analysis was conducted on 28 patients who underwent a combined major hepatectomy and pancreaticoduodenectomy for extrahepatic cholangiocarcinoma (n = 17) or gallbladder carcinoma (n = 11). Major hepatectomy was defined as hemihepatectomy or more extensive hepatectomy. Altogether, 11 patients underwent a Whipple procedure, and 17 had a pylorus-preserving pancreaticoduodenectomy. The median follow-up time was 169 months.

RESULTS

Morbidity and in-hospital mortality were 82% and 21%, respectively. Overall cumulative survival rates after resection were 32% at 2 years and 11% at 5 years (median survival time 9 months). The median survival time was 6 months with a 2-year survival rate of 0% in 11 patients with residual tumor, whereas the median survival time was 26 months with a 5-year survival rate of 18% in 17 patients with no residual tumor (P = 0.0012). Residual tumor status was the only independent prognostic factor of significance (relative risk 4.65; P = 0.003). There were three 5-year survivors (two with diffuse cholangiocarcinoma and one with gallbladder carcinoma with no bile duct involvement) among the patients with no residual tumor.

CONCLUSIONS

Combined major hepatectomy and pancreaticoduodenectomy provides survival benefit for some patients with locally advanced biliary carcinoma only if potentially curative (R0) resection is feasible. Patients with diffuse cholangiocarcinoma and gallbladder carcinoma with no bile duct involvement are potential candidates for this aggressive procedure.

Gallbladder cancer

BACKGROUND

Gallbladder cancer (GC) is a relatively rare but highly lethal neoplasm. We review the epidemiology, etiology, pathology, symptoms, diagnosis, staging, treatment, and prognosis of GC.

METHOD

A Pubmed database search between 1971 and February 2007 was performed. All abstracts were reviewed and articles with GC obtained; further references were extracted by hand-searching the bibliography. The database search was done in the English language.

RESULTS

The accurate etiology of GC remains unclear, while the symptoms associated with primary GC are not specific. Treatment with radical cholecystectomy is curative but possible in only 10% to 30% of patients. For patients whose cancer is an incidental finding on pathologic review, re-resection is indicated, where feasible, for all disease except T1a. Patients with advanced disease should receive palliative treatment. Laparoscopic cholecystectomy is contraindicated in the presence of GC.

CONCLUSION

Prognosis generally is extremely poor. Improvements in the outcome of surgical resection have caused this approach to be re-evaluated, while the role of chemotherapy and radiotherapy remains controversial.

Gallbladder cancer with duodenal infiltration: is it still resectable?

OBJECTIVE

To assess the resectability and the long-term survival in patients of gallbladder cancer with duodenal involvement.

BACKGROUND

Duodenal infiltration in patients of carcinoma gallbladder is generally regarded as a sign of advanced disease and an indicator of unresectable disease.

METHODS

A total of 252 patients of gallbladder cancer (GBC) who underwent surgery over a 5-year period were studied for duodenal involvement. Patients with duodenal infiltration on per-operative assessment were analyzed for resectability, postoperative morbidity, mortality and disease free survival.

RESULTS

Forty-three patients were detected to have duodenal infiltration on per-operative assessment out of which 17 had unresectable disease (39.54%), whereas the remaining 26 patients underwent R0 resection (61.9%). Of these, nine underwent distal gastrectomy with resection of the first part of the duodenum (34.62%), 16 underwent duodenal sleeve resection (61.54%), and in one patient pancreatoduodenectomy (HPD) (3.85%) was performed. With regard to the extent of liver resection, two underwent extended right hepatectomy, whereas the remaining 24 underwent segment IVB and V resection. Bile duct and adjacent viscera were resected when involved. Of the resected patients, eight underwent bile duct excision, seven had colonic resection, and three had vascular resection and reconstruction. The postoperative morbidity and mortality was 15 (34.9%) and three (6.97%), respectively, in the resected group of patients. The overall actual survival in the resected group was a mean of 15.87 months, median of 14 months (range 3 to 56 months).

CONCLUSION

Duodenal infiltration is neither an indicator of unresectability nor an indication to perform Hepato-pancreatoduodenectomy (HPD). In most of these patients, an oncologically adequate R0 resection can be performed with either a duodenal sleeve resection or distal gastrectomy with resection of the first part of the duodenum.

A curative resection improves the postoperative survival rate even in patients with advanced gallbladder carcinoma

The aim of this study was to evaluate the results of our series of 90 operations for gallbladder carcinoma according to the Japanese Society of Biliary Surgery (JSBS) classification system and to clarify the appropriate surgical strategy for advanced gallbladder carcinoma based on the depth of primary tumor invasion and lymph node metastasis. Generally, only a surgical resection can achieve a prognostic improvement of the advanced gallbladder carcinoma. The survival of patients with this neoplasm depends strictly on the depth of histological primary tumor invasion and lymph node metastasis. A retrospective analysis was conducted on 90 patients from 1990 to 2004 who underwent a surgical resection of gallbladder carcinoma. The factors influencing survival were examined. Thirty-nine patients with palliative treatment (not resected cases), which was diagnosed as T3 or T4 by preoperative imagings, were also included in this study. The significance of the variables for survival was examined by the Kaplan-Meier method and the log-rank test followed by multivariate analyses using Cox's proportional hazard model. Portal invasion, lymph node metastasis, the surgical margin (+ vs. -) and the final curability (fCurA, B vs. C) were all found to be independent prognostic factors in the multivariate analysis. In pT2 gallbladder carcinoma, a better survival was achieved in an aggressive surgical approach, in order of a S4a+S5 hepatic resection, an extended cholecystectomy and a cholecystectomy. In pT3 and pT4, although radical extended surgery did not provide the opportunity for good survival even after lobectomy of the liver, the survival of patients with curative surgery was statistically better than in those without curative surgery. In addition, the nodal involvement of pN1 to pN2 was better than that with pN3. A S4a+S5 hepatectomy, therefore, appears to be adequate for the treatment of pT2 gallbladder carcinoma. Even in patients with pT3 and pT4 gallbladder carcinoma, long-term survival can be expected by an operation with a tumor-free surgical margin. The role of radical surgery, however, is considered to be limited in patients with pN3 lymph node metastasis.

Radical lymph node dissection for gallbladder cancer: indications and limitations

Radical lymph node dissection provides survival benefit for patients with pT2 or more advanced gallbladder carcinoma tumors only if potentially curative resection is feasible; it must always be considered when planning a resection or re-resection for robust patients with pT2 or more advanced gallbladder carcinoma tumors. The degree of radical lymphadenectomy depends on clinically assessed nodal status: portal lymph node dissection is limited to cN0 disease; extended portal nodal dissection is indicated for cN0 and a modest degree of cN1 disease; peripancreatic lymph node dissection with pancreaticoduodenectomy is indicated for selected cases of evident peripancreatic nodal disease and/or direct organ involvement. Extended resection with extensive lymphadenectomy should be limited to expert surgeons because it may cause serious morbidity and mortality.

Feasibility of en-bloc wedge resection of the pancreas and/or the duodenum as an alternative to pancreatoduodenectomy for advanced gallbladder cancer

Pancreatoduodenectomy has been described as a possible treatment for gallbladder cancer that presents with evidence of direct invasion to the pancreas and/or the duodenum. This procedure does, however, carry a significantly higher morbidity and mortality if performed with a hepatectomy. An alternative procedure, therefore, of wedge resection of the invaded organ(s) was investigated in this study. On recognition of infiltration of the tumor into the pancreas and/or the duodenum, an en-bloc wedge resection of the organ(s) combined with the original tumor was the intended procedure. However, a pancreatoduodenectomy was performed if the tumor was not resectable by an attempted wedge resection. Operative and long-term outcomes were compared between patients who underwent wedge resection (n = 9) and pancreatoduodenectomy (n = 8). One patient in each group was incorrectly diagnosed preoperatively as having cancer invasion, as opposed to inflammatory changes, as recognized by subsequent histology. All tumors were excised with tumor-free pancreatic and duodenal margins. Postoperative complications occurred in one patient with wedge resection and four with pancreatoduodenectomy. One in-hospital death occurred in each group; one patient died with wedge resection of sepsis and one patient with pancreatoduodenectomy died of a pancreatic leak. No local recurrence occurred in either group. There was no difference in cumulative survival rates between the groups. Wedge resection was considered to be a feasible surgical procedure, in terms of morbidity, respectability, and long-term outcome.

Right hepatopancreatoduodenectomy: improvements over 23 years to attain acceptability

BACKGROUND/PURPOSE

Right hepatopancreatoduodenectomy (rt-HPD), a demanding procedure associated with high morbidity and mortality, remains the only curative option for some patients with biliary cancer. We retrospectively analyzed our progress over 23 years in making this operation safer.

METHODS

Fifty-eight patients who had undergone rt-HPD were enrolled. Gallbladder cancer was present in 33 patients and bile duct cancer in 25 patients. Comparisons of short-term results after surgery were made between the 1980s (16 patients), 1990s (28 patients), and 2000 to 2004 (14 patients).

RESULTS

Intraoperative blood loss decreased progressively and significantly. The incidence of pancreatic fistula, and leakage of pancreatojejunostomy and hepaticojejunostomy also decreased, as did the occurrence of liver failure. Infection varied little by decade, but some recent progress may be underway. Mortality decreased, although not significantly.

CONCLUSIONS

Refinements in techniques, imaging, and perioperative management have improved the outlook for patients requiring HPD for cure, but much more remains to be achieved. Our results are not satisfactory, but they may be acceptable, considering the lack of alternative curative treatment.

Retrospective analysis of outcome in 63 gallbladder carcinoma patients after radical resection

BACKGROUND/PURPOSE

The aim of this study was to evaluate factors influencing outcome in gallbladder carcinoma after radical resection, in order to identify those patients benefiting from radical surgery.

METHODS

Sixty-three patients (13 pT1, 28 pT2, 14 pT3, and 8 pT4) who underwent surgical resection for gallbladder carcinoma were retrospectively reviewed. Correlations were sought between survival and factors such as the depth of invasion (pT) including the status of infiltration of the hepatoduodenal ligament (pBinf) and liver bed (pHinf), the extent of lymph node metastasis, and other pathologic factors.

RESULTS

Multivariate analysis showed that pBinf, pHinf, and lymph node metastasis were significant prognostic factors. We also analyzed survival rates for each operative procedure. There was no difference in survival between patients with or without bile duct resection for lymph node metastasis. The 5-year survival rates of pHinf-negative patients with stage 1B or more advanced disease after gallbladder bed resection or bisegmentectomy 4a,5 versus those without liver resection were 66% and 0%, respectively. Twelve patients survived for more than 5 years after surgery, including one patient undergoing HPD (liver resection with pancreatoduodenectomy) with positive lymph node metastasis; none was pBinf-positive.

CONCLUSIONS

Several factyors were identified as having prognostic significance for survival in patients with gallbladder carcinomas, and we suggest that radical surgery may be indicated for selected patients with advanced disease.

Surgical strategies in patients with gallbladder cancer: nihilism to optimism

INTRODUCTION

Gallbladder cancer is an aggressive disease with dismal results of surgical treatment and a poor prognosis. However, over the last few decades selected groups have reported improved results with aggressive surgery for gallbladder cancer.

METHODS

Review of recent world literature was done to provide an update on the current concepts of surgical treatment of this disease.

RESULTS

Long-term survival is possible in early stage gallbladder carcinoma. Tis and T1a gallbladder carcinoma can be treated with simple cholecystectomy only. However, in T1b and beyond cancers, aggressive surgery (extended cholecystectomy) is important in improving the long-term prognosis. Laparoscopic cholecystectomy should not be performed where there is a high index of suspicion of malignancy due to the frequent association with factors (such as gallbladder perforation and bile spill) which may lead to implantation of cancer cells and dissemination. Surgical resection for advanced carcinoma gallbladder is recommended only if a potentially curative R0 resection is possible. Aggressive surgery with vascular and multivisceral resection has been shown to be feasible albeit with an increase in mortality and morbidity. However, the true benefit of these radical resections is yet to be realized, as the actual number of long-term survivors of advanced gallbladder carcinoma is few.

CONCLUSIONS

Surgery for gallbladder carcinoma, like other malignancies, has the potential to be curative only in local or regional disease. Pattern of loco-regional spread of disease dictates the surgical procedure. Radical surgery improves survival in early gallbladder carcinoma. The long-term benefit of aggressive surgery for advanced disease is unclear and may be offset by the high mortality and morbidity.

Significance of extensive surgery including resection of the pancreas head for the treatment of gallbladder cancer--from the perspective of mode of lymph node involvement and surgical outcome

The present study aimed to clarify the efficacy of extensive surgery, including pancreas head resection, for more complete lymphadenectomy in the treatment of gallbladder carcinoma. The study involved retrospective analyses of 65 consecutive patients with gallbladder carcinoma who underwent surgical resection between 1982 and 2003. Of these 65 patients, 41.5% displayed node-positive disease and among them 23.1% had positive para-aortic nodes. Of six node-positive 5-year survivors, five underwent pancreatoduodenectomy combined with S4aS5 hepatic subsegmentectomy. The 5-year survival rates were 76.2% for pN0, 30.0% for pN1, 45.8% for pN2, and 0% for pM1[lymph], respectively. Significant differences existed in survival rates. Postoperative recurrence was observed in 24.1% (13/54) of patients who underwent R0 resection. Of the four patients who displayed lymph node recurrence, two had pericholedocal and/or posterior pancreatoduodenal lymph node metastasis at the time of surgery and underwent pancreas-preserving regional lymphadenectomy. These results suggest that extensive resection, including resection of the pancreatic head, is effective in selected patients with up to pN2 lymph node metastasis, as long as complete removal of the cancer can be achieved. Pancreatoduodenectomy combined with S4aS5 hepatic subsegmentectomy should be considered when lymph node metastasis is obvious and the patient is in good condition.

Gallbladder Carcinoma with Biliary Invasion: Clinical Analysis of the Differences from Nonbiliary Invasion

Gallbladder carcinoma is the most common malignancy of the biliary tract. Because of a lack of specific presentations, this condition frequently is diagnosed only at an advanced stage. The clinical difference between gallbladder carcinoma with and without biliary involvement remains uncertain. This study recruited all patients with gallbladder carcinoma treated at Chang Gung Memorial Hospital (Taoyuan, Taiwan) from 1987 to 2002. The sample included 120 patients aged 28 to 91 years (mean 65.5 +/- 12.3 years) (39 men, 81 women), whose medical records were reviewed retrospectively. Based on the 2002 newly revised TNM classification, 25, 38, 28, and 29 patients had stage I, II, III, and IV disease, respectively. After we excluded patients with stage I, the other patients were classified into two groups as follows: group I, gallbladder carcinoma with biliary invasion (n = 41); group II, carcinoma without biliary involvement (n = 54). The clinical presentations, laboratory data, operative methods, and outcome of these two groups were compared. The two groups did not differ in terms of age, sex distribution, cholelithiasis, and most clinical presentations. Chemistry laboratory data also identified patients in group I with significantly elevated liver function tests. Group II had a borderline tendency toward better curative resectability than group I (p = 0.09). Survival was significantly better for group I patients who underwent curative resection (n = 5) via cholecystectomy, partial hepatectomy, and bile duct resection than for those with noncurative resection (p < 0.05). However, long-term survival demonstrated that gallbladder carcinoma had the same poor prognosis in the two groups. In conclusion, gallbladder carcinoma with biliary invasion has been found to a more overt clinical presentation and abnormal laboratory data, which might alert clinicians to consider gallbladder carcinoma at an advanced stage or biliary invasion and examine the underlying disease. Generally, the outcome of gallbladder carcinoma is dismal, and radical curative resection combined with cholecystectomy, partial hepatectomy, and bile duct resection perhaps may offer good benefits for advanced gallbladder carcinoma. Furthermore, surgical resection should be performed whenever possible in patients with gallbladder carcinoma to increase life expectancy.

Appraisal of surgical treatment for pT2 gallbladder carcinomas

This retrospective study was designed to appraise the surgical procedures for pT2 gallbladder (GB) carcinomas. Twenty patients with pT2 GB carcinomas underwent surgical resection. Hepatectomy of segments 4b and 5 was performed in 19 patients, and an extended right hepatic lobectomy was performed in 1. The extrahepatic bile duct was preserved in 8 patients in whom the disease was limited to the GB fundus and/or body. Regional lymphadenectomy was performed in 18 patients. A separate radical second operation was performed in 8 patients after cholecystectomy. Final pathological staging was stage IB in 15 patients, IIB in 4, and IV in 1. Overall 5-year survival rate in those 20 patients was 77% without operative deaths. The 5-year survival rate in 5 patients with nodal metastasis and in 8 patients without extrahepatic biliary resection was 80% and 100%, respectively. A separate radical second operation in 8 patients yielded 75% survival after 5 years. Perineural invasion as a prognostic determinant was closely associated with tumor extending to the neck or the cystic duct. Partial hepatectomy, usually with extrahepatic biliary resection and regional lymphadenectomy, was appropriate as a standard radical operation for pT2 GB carcinoma, but preservation of extrahepatic bile duct is advocated for disease limited to the GB fundus and/or body. Radical second operation enhanced the chance for cure in patients with pT2 GB carcinoma.

A 10-year experience in the management of gallbladder cancer

BACKGROUND

The aim of this retrospective study was to review all patients diagnosed with gallbladder cancer over a 10-year period to assess variables affecting survival.

METHODS

Patients diagnosed with gallbladder cancer from January 1990 to December 1999 were identified from the Lothian Surgical Audit database and a case-note review was performed.

RESULTS

The 44 patients who were studied (33 women, 11 men) had a mean age of 66 years (range 42-90 years). The diagnosis was established preoperatively in 25 patients (57%), intraoperatively in 5 patients (11%) and incidentally following pathological examination of cholecystectomy specimens in 14 patients (32%). None of the 25 patients diagnosed preoperatively underwent curative operations (median survival 4 months). All five patients diagnosed at the time of attempted cholecystectomy had advanced irresectable disease (median survival 1 month). The overall median survival in 14 patients with an incidental diagnosis of gallbladder cancer was 16 months; however, in eight of these patients who were considered to have had a potentially curative resection, the median survival was 38 months.

DISCUSSION

The prognosis for patients diagnosed preoperatively or at the time of cholecystectomy is very poor. Patients with an incidental finding of gallbladder cancer have a significantly better prognosis and should be considered for further radical re-resection.

Longterm survival after extended resections in patients with gallbladder cancer

BACKGROUND

Surgery is the treatment of choice for gallbladder cancer, but the extent of resection and its benefits remain unclear.

STUDY DESIGN

Survival analysis of 42 patients who underwent extended resections for gallbladder cancer was performed. Resections were labeled R0 (curative) or R1 (noncurative) based on histopathologic evaluation. Survival curves were constructed using the Kaplan-Meier method, and survival data were analyzed by univariate and multivariate analyses to identify factors associated with longterm (>2 years) survival.

RESULTS

R0 status was achieved in 18 patients (43%): 100%, 100%, 45%, and 0% in stages I, II, III, and IV, respectively. Patients with R0 resections had a significantly better survival than those with R1 resections (median 25.8 months versus 17.0 months; p = 0.03). R0 status was achieved in only 3 of 20 patients (15%) with node positive (N1) disease compared with 14 of 17 patients (82%) with node negative (N0) disease. Patients with N0 disease had a significantly better survival than those with N1 disease (median not reached versus 17 months; p = 0.01). None of the patients with N1 disease survived 5 years; 5-year survival for N0 patients was 58%. Adjuvant therapy did not have a significant effect on survival.

CONCLUSIONS

In patients with gallbladder cancer, R0 status could be achieved in only 43% of patients undergoing extended resections. R0 status and N0 disease were associated with better longterm survival.

Extensive surgery for carcinoma of the gallbladder

Background

The purpose of this study was to clarify the efficacy of, and define the indications for, extensive surgery for gallbladder carcinoma.

Methods

Between 1979 and 1994, 116 patients with gallbladder carcinoma underwent operation. Radical resection was performed in 80 patients.

Results

In 68 patients with stage III or IV disease, extensive resection including extended right hepatectomy (n = 40), pancreaticoduodenectomy (n = 23) and/or portal vein resection (n = 23) was employed to achieve complete tumour excision. The hospital mortality rate was 18 per cent. The postoperative 3- and 5-year survival rates were 44 and 33 per cent respectively in the patients with stage III disease (n = 9), and 24 and 17 per cent respectively in patients with stage IV (M0) disease (n = 29). In contrast, the postoperative survival rate for the 30 patients with stage IV (M1) disease (7 per cent at 3 years and 3 per cent at 5 years) was worse than that for patients with stage III and stage IV (M0) disease (P = 0·009 and P = 0·062 respectively).

Conclusion

Radical resection should be undertaken for stage III and stage IV (M0) gallbladder cancer. Although portal vein resection and/or pancreaticoduodenectomy did not contribute to long-term survival, better survival was obtained than that for the unresected patients.

Surgical indications and extent of resection in gallbladder cancer

Gallbladder cancer often is diagnosed at an advanced stage when the prognosis is dismal. Early tumors (T1) that are recognized incidentally are curable with simple cholecystectomy alone. All other tumors should be resected with an extended cholecystectomy (T2) or with an extensive liver resection that obtains the negative margins. Patients with tumors greater than T1 should undergo lymphadenectomy that includes the porta hepatis and superior pancreatic nodes. Long-term survival with this approach is possible, even with T3 and T4 tumors. The role of extended lymphadenectomy, including the retropancreatic and aortocaval basins, is unclear and should be attempted only in selected cases.

Perineural invasion has a negative impact on survival of patients with gallbladder carcinoma

BACKGROUND

The clinical significance of perineural invasion of gallbladder carcinoma remains unclear. The aim of this study was to elucidate the incidence and mode of perineural invasion of gallbladder carcinoma and clarify its prognostic significance.

METHODS

A clinicopathological study was conducted on 68 patients who underwent attempted curative resection for gallbladder carcinoma. According to the pathological tumour node metastasis (pTNM) classification of the Union Internacional Contra la Cancrum, there were five (7 per cent), nine (13 per cent), 20 (29 per cent) and 34 (50 per cent) patients with pT1, pT2, pT3 and pT4 disease respectively. Twenty patients (29 per cent) had pM1 disease, including involved para-aortic nodes, liver metastases and localized dissemination.

RESULTS

The overall incidence of perineural invasion was 71 per cent (48 of 68 patients). Forty-four (96 per cent) of 46 patients with extrahepatic bile duct invasion had perineural invasion. Although several histological factors were associated with perineural invasion, multivariate analysis demonstrated that extrahepatic bile duct invasion was the only significant factor correlated with perineural invasion (odds ratio 99.0, P < 0.001). The perineural invasion index, defined as the ratio of the number of involved nerves to the total number of nerves examined, was significantly higher at the centre than in the proximal and distal parts of the tumour in the 46 patients with extrahepatic bile duct invasion (P < 0.001). The 5-year survival rate for patients with perineural invasion was significantly lower than that for patients with no invasion (7 versus 72 per cent; P < 0.001). Cox proportional hazard analysis identified perineural invasion (relative risk (RR) 5.3, P < 0.001) and lymph node metastasis (RR 2.5, P = 0.008) as significant independent prognostic factors.

CONCLUSION

Perineural invasion is common in advanced gallbladder carcinoma and has a significant negative impact on patient survival.

Liver regeneration after major hepatectomy for biliary cancer

BACKGROUND

The aim of this study was to evaluate serial changes in liver volume after major hepatectomy for biliary cancer and to elucidate clinical factors influencing liver regeneration.

METHODS

Serial changes in liver volume were determined, using computed tomography, in 81 patients with biliary cancer who underwent right hepatic lobectomy or more extensive liver resection with or without portal vein resection and/or pancreatoduodenectomy. Possible factors influencing liver regeneration were evaluated by univariate and multivariate analyses.

RESULTS

The remnant mean(s.d.) liver volume was 41(8) per cent straight after hepatectomy. This increased rapidly to 59(9) per cent within 2 weeks, then increased more slowly, finally reaching a plateau at 74(12) per cent about 1 year after hepatectomy. The regeneration rate within the first 2 weeks was 16(8) cm3/day and was not related to the extent of posthepatectomy liver dysfunction. On multivariate analysis, the extent of liver resection (P < 0.001), body surface area (P = 0.02), combined portal vein resection (P = 0.024) and preoperative portal vein embolization (P = 0.047) were significantly associated with the liver regeneration rate within the first 2 weeks. In addition, body surface area (P < 0.001) and liver function expressed as plasma clearance rate of indocyanine green (P = 0.01) were significant determinants of final liver volume 1 year after hepatectomy.

CONCLUSION

The liver regenerates rapidly in the first 2 weeks after major hepatectomy for biliary cancer. This early regeneration is influenced by four clinical factors. Thereafter, liver regeneration progresses slowly and stops when the liver is three-quarters of its original volume, approximately 6 months to 1 year after hepatectomy.

Trimodality Therapy for Advanced Gallbladder Cancer

We conducted a retrospective review of all patients who underwent surgical extirpation for stage IN, stage IV, or recurrent carcinoma of the gallbladder. Between 1991 and 1999 ten patients underwent surgical resection for advanced gallbladder cancer. All patients received adjuvant therapy either pre- or postoperatively. Radiotherapy was used in all patients and chemotherapy in 90 per cent of patients. Two patients subsequently underwent resection for locally recurrent disease. An additional patient with stage II disease initially was also treated surgically for a local recurrence. Surgical management involved cholecystectomy and resection of various amounts of liver surrounding the gallbladder bed and regional lymphadenectomy. Contiguously involved structures were resected en bloc. Resection of recurrent disease included excision of all gross tumor. The median overall survival excluding the one 30-day mortality was 53.6 months (range 8–73 months). Four patients have survived 4 or more years, and currently four patients are alive and disease free at 73, 49, 33, and 8 months. Median disease-free interval after each resection of recurrent disease was 13.8 months (range 4–28 months). We conclude that trimodality therapy in selected patients with stage III, IV, or recurrent carcinoma of the gallbladder is possible and may result in prolonged survival.

Radical surgery for gallbladder cancer: current options

Gallbladder carcinoma is the most common malignancy of the biliary tract. There are still many controversies regarding the type of curative surgical treatment for each stage of the disease. The staging system used is the TNM classification of the International Union Against Cancer. Different patterns of spread characterize gallbladder cancer but the two main types are direct invasion and lymph node metastases; since only the depth of invasion can be easily recognized by imaging techniques, it becomes the main variable in choosing the appropriate surgical treatment. Most Tis and T1 tumours are incidentally discovered after cholecystectomy for cholelithiasis and no further therapy is requested; for pT1b tumours, relaparotomy with hepatic resection and N1 dissection is associated with a better survival. For T2 tumours, cholecystectomy with hepatic resection and dissection of N1-2 lymph nodes is the standard treatment, with a 5-year survival of 60-80%. The only chance of long-term survival for patients with a T3-T4 tumour is an extended operation combining an hepatic resection with an N1-2 dissection with or without excision of the common bile duct. A subset of patients with peripancreatic positive nodes or invasion of adjacent organs seems to benefit from a synchronous pancreaticoduodenectomy.

Intraoperative evaluation of the depth of invasion of gallbladder cancer

BACKGROUND

It is sometimes very difficult to diagnose the depth of invasion of gallbladder cancer preoperatively. Therefore, we investigated intraoperative examinations to diagnose the depth of invasion.

METHODS

A total of 104 patients were included in this study. The relation between macroscopic morphology and the depth of invasion and evaluation of the depth of invasion by intraoperative ultrasonography and frozen section examination were investigated.

RESULTS

In all cases of a pedunculated type and a subpedunculated type with thin base, invasion remained within the mucosa. In other types, the depth of invasion was various. The accuracy of diagnosing the depth of invasion by intraoperative ultrasonography and frozen section examination was 73.9% and 85.7%, respectively.

CONCLUSIONS

The cancer classified as a pedunculated type or a subpedunculated type with thin base can be diagnosed to remain within the mucosa. In other types, intraoperative ultrasonography and frozen section examination are useful in the diagnosis of the depth of invasion.

Treatment of gallbladder cancer by radical resection

BACKGROUND

The use of radical resection for gallbladder cancer is controversial. This study evaluated results of resection for gallbladder cancer and analysed prognostic factors.

METHODS

A retrospective review of 135 patients who underwent surgical resection for gallbladder cancer between 1976 and 1998 was performed. Of these, 123 patients underwent radical resection and the remaining 12 had palliative resection. The resections included 32 hepatopancreatoduodenectomies and 57 with adjuvant radiotherapy. Twelve prognostic factors were analysed. A subset of 96 patients with stage IV disease was analysed separately with respect to residual tumour level and adjuvant radiotherapy.

RESULTS

Surgical resection was associated with a 5-year survival rate of 36 per cent, with a mean follow-up time of 870 days. Twenty-two patients have survived more than 5 years including three with stage IV disease. Overall operative morbidity and mortality rates were 13 and 4 per cent respectively. The 5-year survival rate decreased with disease stage: 100, 78, 69 and 11 per cent for stages I (n = 13), II (n = 19), III (n = 7) and IV (n = 96) respectively. Performance status, jaundice, histopathological type and grade, primary tumour, lymph node, distant metastasis, stage grouping, residual tumour level and adjuvant radiotherapy were significant prognostic factors.

CONCLUSION

With careful patient selection, radical resection for gallbladder cancer improves the prognosis with acceptable operative mortality and morbidity rates, even for stage IV disease, provided that complete gross tumour resection is combined with radiotherapy.

The National Cancer Data Base report on carcinoma of the gallbladder, 1989-1995

BACKGROUND

Reports utilizing data from the Commission on Cancer's National Cancer Data Base (NCDB) have previously contained evaluations of time trends for stage of disease at diagnosis, treatment, and survival for multiple tumor sites. Data collected from 1989, 1990, 1994, and 1995 for carcinoma of the gallbladder are presented herein.

METHODS

The data presented in this review were collected from hospital cancer registries from across the U.S. Seven calls for data yielded a total of 5,850,000 cases for the years 1985-1995, including 2574 gallbladder carcinoma cases from 1989-1990 and 2914 cases from 1994-1995 from hospital cancer registries across the U.S. These data represent approximately 8.8% and 8.4% of the estimated cases of liver and biliary track cancers diagnosed in the U.S. during the two respective time periods.

RESULTS

There were no changes in patient demographics between 1989-1990 and 1994-1995. Most gallbladder carcinoma patients were white women. The documentation of tumor stage improved noticeably between the two study periods. There was no increased frequency in the occurrence of early stage tumors between the two reporting times, an era that saw the development and widespread application of laparoscopic cholecystectomy. Treatment differed according to stage of disease. Surgery alone, particularly nonradical surgery, was performed more frequently in the initial treatment of gallbladder carcinoma. A large percentage of gallbladder carcinoma patients received no definitive therapeutic intervention because of the advanced stage of disease at presentation and the lack of effective treatments for these cancers. Multimodality treatment was utilized more often for young patients. Survival was closely related to tumor stage, with 60% 5-year survival for Stage 0 patients, 39% for Stage I patients, and 15% for Stage II patients, but only 5% for Stage III patients and 1% for Stage IV patients. Patient outcome was not demonstrably affected by more aggressive therapy, nor was an adverse effect in results seen in early stage cancers between 1989-1990 and 1994-1995.

CONCLUSIONS

The NCDB data are valuable in the evaluation of trends in malignant diseases, treatments, and patient survival. No substantial differences were apparent in the diagnosis, treatment, and survival of patients during this 7-year study period. The data do not support any adverse effect on outcome results with the introduction of laparoscopic cholecystectomy in the U.S.

Gall bladder cancer: proposal for a modification of the TNM classification

Gall bladder cancer is the commonest biliary tract malignancy. The TNM classification of AJCC-UICC is the most widely accepted and most commonly used system for staging. We propose some modifications in the existing classification and recommend guidelines for management based on the stage of the disease.

Biliary malignancies

Biliary malignancies, including cancers of the intrahepatic and extrahepatic bile ducts, gallbladder and ampulla, should be considered in the differential diagnosis of patients with obstructive jaundice. Cancers of the intrahepatic bile ducts and ampulla are managed as liver and peri-ampullary tumours respectively. Extrahepatic bile duct cancers are diagnosed by cholangiography and evaluated for resectability by imaging and angiography. Vascular infiltration is the main contra-indication for resection, which may also involve the liver. Every attempt must be made to achieve curative resection, but local resection may be justified even if non-curative. Gallbladder cancers are usually advanced at the time of diagnosis and are unresectable--surgical palliation improves the quality of life by relieving biliary and gastric outlet obstruction. Long-term survival is possible after curative resection in early lesions that are usually diagnosed as an incidental finding after cholecystectomy for presumed gallstone disease. The role of adjuvant therapy in biliary malignancies needs further evaluation.