Selective Histological Examination After Cholecystectomy: An Analysis of Current Daily Practice in The Netherlands

Is systematic histological examination of the cholecystectomy specimen always necessary?

INTRODUCTION

The histological examination (HE) of all cholecystectomy specimens removed for cholelithiasis is a widespread practice to rule out unrecognized gallbladder cancer. (GBC). But this dogmatic practice has been called into question by recent published data. The aim of this literature review was to answer two questions: (1) can HE be omitted in specific cases; (2) under what conditions is a selective strategy indicated?

METHODS

A review of the literature was carried out that included selected multicenter studies, registry studies, or meta-analyses. A reliable technique for the surgeon's macroscopic examination of the specimen would allow the selection of dubious cases for HE. The cost-effectiveness of selective HE was discussed. The PICO methodology (population, intervention, comparator, outcome) was used in the selection of articles that compared routine and selective histological examination.

RESULTS

If cases from countries with a high prevalence of gallbladder cancer are excluded and in the absence of high-risk situations (advanced age, female gender, calcified or porcelain gallbladder, acute cholecystitis, polyps, abnormalities noted intra-operatively), the macroscopic examination of the gallbladder in the operating room has a reliability approaching 100% in the majority of published studies. This would make it possible to omit systematic HE without compromising the diagnosis and prognosis of patients with unsuspected GBC and with a very favorable cost-effectiveness ratio.

CONCLUSION

Through a selection of patients at very low risk of incidentally-discovered cancer and a routine macroscopic examination of the opened gallbladder, the strategy of selective HE could prove useful in both clinical and economic terms.

A Dutch prediction tool to assess the risk of incidental gallbladder cancers after cholecystectomies for benign gallstone disease

BACKGROUND

Despite the increasing implementation of selective histopathologic policies for post-cholecystectomy evaluation of gallbladder specimens in low-incidence countries, the fear of missing incidental gallbladder cancer (GBC) persists. This study aimed to develop a diagnostic prediction model for selecting gallbladders that require additional histopathological examination after cholecystectomy.

METHODS

A registration-based retrospective cohort study of nine Dutch hospitals was conducted between January 2004 and December 2014. Data were collected using a secure linkage of three patient databases, and potential clinical predictors of gallbladder cancer were selected. The prediction model was validated internally by using bootstrapping. Its discriminative capacity and accuracy were tested by assessing the area under the receiver operating characteristic curve (AUC), Nagelkerke's pseudo-R², and Brier score.

RESULTS

Using a cohort of 22,025 gallbladders, including 75 GBC cases, a prediction model with the following variables was developed: age, sex, urgency, type of surgery, and indication for surgery. After correction for optimism, Nagelkerke's R² and Brier score were 0.32 and 88%, respectively, indicating a moderate model fit. The AUC was 90.3% (95% confidence interval, 86.2%-94.4%), indicating good discriminative ability.

CONCLUSION

We developed a good clinical prediction model for selecting gallbladder specimens for histopathologic examination after cholecystectomy to rule out GBC.

Should all gallbladders be examined routinely or selectively by microscopy after cholecystectomy? Population-based Dutch study over a decade

The need for routine histopathological examination of gallbladders after cholecystectomy is debated. This study suggests that selective histopathological examination of the gallbladder may be considered oncologically safe.

While the necessity of a routine histopathologic examination of gallbladders after cholecystectomy is debated. This study suggests that a selective histopathologic examination of the gallbladder may be considered as oncologically safe.

Method for adequate macroscopic gallbladder examination after cholecystectomy

BACKGROUND AND AIMS

There is no clear guideline nor protocol for macroscopic examination of the gallbladder, leaving surgeons extemporaneous in regard of gallbladder examination in selective histopathologic policy. The purpose of this article is to describe a surgical approach for adequate macroscopic inspection of the gallbladder.

MATERIALS AND METHODS

The described practical method was developed in collaboration between surgeons and pathologists. This method was introduced in 2011 and implemented in 2012. We retrospectively reviewed the number of cholecystectomies and number of histopathologic examinations between 2006 and 2017, using our own patient database. We used the Netherlands Cancer Registry (NCR) to examine the incidence of gallbladder cancer patients before and after implementation of the selective policy in our hospital. In addition to the method, we depict several frequent macroscopic abnormalities in order to provide some examples for surgical colleagues.

RESULTS

Since implementation of the selective policy, 2271 surgical macroscopic gallbladder examinations were performed. As a result, we observed a significant decrease from 83% in 2012 to 38% in 2017, in histopathologic examination of the gallbladder following cholecystectomy. We observed a stable trend of gallbladder carcinoma in the same period (0.17%, n = 4 during 2006-2011 and 0.26%, n = 6 during 2012-2017).

CONCLUSION

A simple, valid and easy method is described for future macroscopic analysis by the surgeon following a cholecystectomy.

Safe, selective histopathological examination of gallbladder specimens: a systematic review

Background

Routine histopathological examination after cholecystectomy is costly, but the prevalence of unsuspected gallbladder cancer (incidental GBC) is low. This study determined whether selective histopathological examination is safe.

Methods

A comprehensive search of PubMed, Embase, Web of Science and the Cochrane Library was performed. Pooled incidences of incidental and truly incidental GBC (GBC detected during histopathological examination without preoperative or intraoperative suspicion) were estimated using a random‐effects model. The clinical consequences of truly incidental GBC were assessed.

Results

Seventy‐three studies (232 155 patients) were included. In low‐incidence countries, the pooled incidence was 0·32 (95 per cent c.i. 0·25 to 0·42) per cent for incidental GBC and 0·18 (0·10 to 0·35) per cent for truly incidental GBC. Subgroup analysis of studies in which surgeons systematically examined the gallbladder revealed a pooled incidence of 0·04 (0·01 to 0·14) per cent. In high‐incidence countries, corresponding pooled incidences were 0·83 (0·58 to 1·18), 0·44 (0·21 to 0·91) and 0·08 (0·02 to 0·39) per cent respectively. Clinical consequences were reported for 176 (39·3 per cent) of 448 patients with truly incidental GBC. Thirty‐three patients (18·8 per cent) underwent secondary surgery. Subgroup analysis showed that at least half of GBC not detected during the surgeon's systematic examination of the gallbladder was early stage (T1a status or below) and of no clinical consequence.

Conclusion

Selective histopathological examination of the gallbladder after initial macroscopic assessment by the surgeon seems safe and could reduce costs.

Safety and cost analysis of selective histopathological examination following appendicectomy and cholecystectomy (FANCY study): protocol and statistical analysis plan of a prospective observational multicentre study

INTRODUCTION

Routine histopathological examination following appendicectomy and cholecystectomy has significant financial implications and comprises a substantial portion of the pathologists' workload, while the incidence of unexpected pathology is low. The aim of the selective histopathological examination Following AppeNdicectomy and CholecystectomY (FANCY) study is to investigate the oncological safety and potential cost savings of selective histopathological examination based on macroscopic assessment performed by the surgeon.

METHODS AND ANALYSIS

This is a Dutch multicentre prospective observational study, in which removed appendices and gallbladders will be systematically assessed by the operating surgeon for macroscopic abnormalities suspicious for malignant neoplasms. After visual inspection and digital palpation of the removed specimen, the operating surgeon will report whether macroscopic abnormalities suspicious for a malignant neoplasm are present, and if he or she believes additional microscopic examination by the pathologist is indicated. Regardless of the surgeon's assessment, all specimens will be sent for histopathological examination. In this way, routine histopathological examination can be compared with a hypothetical situation in which specimens are routinely examined by surgeons and only sent to the pathologist on indication. The two main outcomes are oncological safety and potential cost savings of a selective policy. Oncological safety of selective histopathological examination will be assessed by calculating the number of patients in whom a histopathological diagnosis of an appendiceal neoplasm or gallbladder cancer with clinical consequences benefitting the patient would have been missed. A cost analysis will be performed to quantify the potential cost savings.

ETHICS AND DISSEMINATION

The study protocol was reviewed by the Institutional Review Board of the Amsterdam UMC, location AMC, which decided that the Dutch Medical Research Involving Human Subjects Act is not applicable. In all participating centres, approval for execution of the FANCY study has been obtained from the local Institutional Review Board before the start of inclusion of patients. The study results will be disseminated through peer-reviewed publications and conference presentations. Guidelines will be revised according to the findings of the study.

TRIAL REGISTRATION NUMBER

NCT03510923.