Combined pancreaticoduodenectomy and hepatectomy for patients with locally advanced gallbladder carcinoma: Long term results

The role of extra-hepatic bile duct resection in the surgical management of gallbladder carcinoma. A first meta-analysis

OBJECTIVE

To systematically evaluate the clinicopathological and prognostic value of extra-hepatic bile duct resection (EHBDR) in the surgical management of patients with gallbladder carcinoma (GBC), especially in non-jaundiced patients.

METHODS

PubMed, EMBASE and the Cochrane Library were searched up to March 1^st 2021 for comparative studies between bile duct resected and non-resected groups. RevMan5.3 and Stata 13.0 software were used for the statistical analyses.

RESULTS

EHBDR did not correlate with a better overall survival (OS) (P = 0.17) or disease-free survival (P = 0.27). No survival benefit was also observed in patients with T2N1 (P = 0.4), T3N0 (P = 0.14) disease and node-positive patients (P = 0.75), rather, EHBDR was even harmful for patients with T2N0 (P = 0.01) and node-negative disease (P = 0.02). Significantly higher incidences of recurrent disease (P = 0.0007), postoperative complications (P < 0.00001) and positive margins (P = 0.02) were detected in the bile duct-resected group. The duration of postoperative hospital stay between the two groups was comparable (P = 0.58). Selection bias was also detected in our analysis that a significantly higher proportion of advanced lesions with T3-4 or III-IV disease was observed in the bile duct-resected group (P < 0.00001). EHBDR only contributed to a greater lymph yield (P = 0.01).

CONCLUSION

EHBDR has no survival advantage for patients with GBC, especially for those with non-jaundiced disease. Considering the unfairness of comparing OS between jaundiced patients receiving EHBDR with non-jaundiced patients without EHBDR, we could only conclude that routine EHBDR in non-jaundiced patients is not recommended and future well-designed studies with more specific subgroup analyses are required for further validation.

The effect of preoperative jaundice in the surgical management of gallbladder carcinoma: An updated meta-analysis

BACKGROUND

An updated meta-analysis was performed on the significance of preoperative jaundice in the surgical management of gallbladder carcinoma (GBC).

METHODS

A thorough database searching was performed in PubMed, EMBASE, and the Cochrane library for comparative studies between jaundiced and non-jaundiced GBC patients. RevMan5.3 and Stata 13.0 software were used for statistical analysis. A total of nine measured outcomes were identified: resectability, R0 resection rate, concurrent bile duct resection, major hepatectomy, vital vascular reconstruction, combined adjacent organ resections, postoperative morbidities, mortalities, and overall survival (OS).

RESULTS

A total of eight studies were finally included. Newcastle- Ottawa Quality Assessment Scale was used for evaluating the quality of all included studies and the details were recorded in Table S1. Our pooled results revealed that preoperative jaundice was associated with a significantly lower resectability (p < 0.00001), a significantly lower R0 resection rate (p < 0.00001), a significantly higher concurrent bile duct resection rate (p < 0.00001), major hepatectomy rate (≥3 segments) (p < 0.00001), and vital vascular reconstruction rate (portal vein or hepatic artery) (p < 0.00001). Moreover, jaundiced patients experienced more postoperative morbidities (p < 0.00001), mortalities (p < 0.0001), and worse OS (p < 0.00001). However, jaundice was not related to combined adjacent organ resections (p = 0.58).

CONCLUSION

Preoperative jaundice in GBC patients seems to be contraindicated to curative resection and the optimal therapeutic strategies should be identified via multidisciplinary team rather than surgery alone. Candidates for curative surgery should be highly selected and experienced centers are preferred. More significant well-designed studies are required for further exploration.

Outcome of radical surgery for gallbladder carcinoma according to TNM stage: implications for adjuvant therapeutic strategies

PURPOSE

Outcomes following surgery for advanced gallbladder carcinoma remain unsatisfactory. This study aimed to determine the surgical outcome and effectiveness of adjuvant chemotherapy according to TNM stage in patients with gallbladder carcinoma.

METHODS

A total of 200 patients undergoing surgery for gallbladder carcinoma were enrolled. Clinicopathological data were evaluated and surgical outcomes were compared between patients with and without adjuvant chemotherapy according to TNM stage.

RESULTS

The 5-year overall survival (OS) after resection for patients with stage I (n = 27), IIA (n = 18), IIB (n = 28), IIIA (n = 25), IIIB (n = 43), IVA (n = 7), and IVB (n = 52) disease was 90.8%, 94.4%, 73.6%, 33.7%, 57.7%, 14.3%, and 11.8%, respectively (p < 0.001). R0 resection was performed in all patients with stage I or II disease, in 89.7% of those with stage III disease, and 69.5% of those with stage IV disease. For patients with stage III disease, adjuvant chemotherapy was associated with improved OS (5-year OS, 60.9% vs. 41.1%; p = 0.028) and was an independent prognostic factor (hazard ratio, 2.045; p = 0.039). For patients with stage IV disease, adjuvant chemotherapy appeared to affect OS (5-year OS, 25.1% vs. 5.3%; p = 0.041); R0 resection (hazard ratio, 1.882; p = 0.040) was the only independent prognostic factor.

CONCLUSION

TNM stage clearly predicts survival after resection of gallbladder carcinoma. R0 resection with adjuvant chemotherapy is recommended for long-term survival in the multimodal management of patients with stage III or IV gallbladder carcinoma.

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.

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.

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.

Hepatopancreatoduodenectomy for advanced hepatobiliary malignancies: a single-center experience

BACKGROUND

Hepatopancreatoduodenectomy is a complicated and challenging procedure but necessary for curative resection for advanced hepatobiliary malignancies. This retrospective study was to examine the safety and survival outcomes of hepatopancreatoduodenectomy in our center.

METHODS

Prospectively collected data of 12 patients who underwent hepatopancreatoduodenectomy for advanced hepatobiliary malignancies in our hospital from January 1998 to December 2014 were analyzed. The primary endpoints are treatment-related morbidity and mortality and the secondary endpoints are overall survival and disease-free survival.

RESULTS

Curative resection was achieved in 11 (91.7%) patients. Complications developed in 10 (83.3%) patients. Three hospital deaths resulted from multiorgan failure secondary to postoperative pancreatic fistula or hepaticojejunostomy leakage. Six of the nine remaining patients had disease recurrence. The nine patients had a median survival of 39.8 (5.3-151.8) months. The 1-, 3- and 5-year overall survival rates were 66.7%, 55.6% and 27.8%, respectively. The corresponding disease-free survival rates were 55.6%, 44.4% and 29.6%, respectively.

CONCLUSIONS

Morbidity and mortality after hepatopancreatoduodenectomy were significant. With R0 resection, the 5-year overall survival and disease-free survival rates were 27.8% and 29.6%, respectively.

THE LARGEST WESTERN EXPERIENCE WITH HEPATOPANCREATODUODENECTOMY: LESSONS LEARNED WITH 35 CASES

Background:

Hepatopancreatoduodenectomy is one of the most complex abdominal operations mainly indicated in advanced biliary carcinoma.

Aim:

To present 10-year experience performing this operation in advanced malignant tumors.

Methods:

This is a retrospective descriptive study. From 2004 to 2014, 35 hepatopancreatoduodenectomies were performed in three different institutions. The most common indication was advanced biliary carcinoma in 24 patients (68.5%).

Results:

Eighteen patients had gallbladder cancer, eight Klatskin tumors, five neuroendocrine tumors with liver metastasis, one colorectal metastasis invading the pancreatic head, one intraductal papillary mucinous neoplasm with liver metastasis, one gastric cancer recurrence with liver involvement and one ocular melanoma with pancreatic head and right liver lobe metastasis. All patients were submitted to pancreatoduodenectomy with a liver resection as follows: eight right trisectionectomies, five right lobectomies, four left lobectomies, 18 central lobectomies (IVb, V and VIII). The overall mortality was 34.2% (12/35) and the overall morbidity rate was 97.4%.

Conclusion:

Very high mortality is seen when major liver resection is performed with pancreatoduodenectomy, including right lobectomy and trisectionectomy. Liver failure in combination with a pancreatic leak is invariably lethal. Efforts to ensure a remnant liver over 40-50% of the total liver volume are the key to obtain patient survival.

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.

Hepato-pancreatectomy: how morbid? Results from the national surgical quality improvement project

BACKGROUND

Simultaneous resection of both the liver and the pancreas carries significant complexity. The objective of this study was to investigate peri-operative outcomes after a synchronous hepatectomy and pancreatectomy (SHP).

METHODS

The American College of Surgeons National Surgical Quality Improvement Project database was queried to identify patients who underwent SHP. Resections were categorized as '< hemihepatectomy', '≥ hemihepatectomy' (hemihepatectomy and trisectionectomy), 'PD' (pancreaticoduodenectomy and total pancreatectomy) and 'distal' (distal pancreatectomy and enucleation).

RESULTS

From 2005 to 2013, 480 patients underwent SHP. Patients were stratified based on the extent of resection: '< hemihepatectomy + distal (n = 224)', '≥ hemihepatectomy + distal' (n = 49), '< hemihepatectomy + PD' (n = 83) and '≥ hemihepatectomy + PD' (n = 24). Although the first three groups had a reasonable and comparable safety profile (morbidity 33-51% and mortality 0-6.6%), the '≥ hemihepatectomy + PD' group was associated with an 87.5% morbidity (organ space infection 58.3%, re-intubation 12.5%, reoperation 25% and septic shock 25%), 8.3% 30-day mortality and 18.2% in-hospital mortality.

CONCLUSIONS

A synchronous hemihepatectomy (or trisectionectomy) with PD remains a highly morbid combination and should be reserved for patients who have undergone extremely cautious selection.

Lymph node metastases in patients undergoing surgery for a gallbladder cancer. Extension of the lymph node dissection and prognostic value of the lymph node ratio

BACKGROUND

Lymph node (LN) status is one of the strongest prognostic factors after gallbladder cancer (GBC) resection. The adequate extension of LN dissection and the stratification of the prognosis in N+ patients have been debated. The present study aims to clarify these issues.

METHODS

A total of 112 consecutive patients who underwent operations for GBC with LN dissection were analyzed. Twenty-five patients (22.3%) had D1 dissection (hepatic pedicle), and 87 (77.7%) had D2 dissection (hepatic pedicle, celiac and retro-pancreatic area). The LN ratio (LNR) was computed as follows: number of metastatic LNs/number of retrieved LNs.

RESULTS

The median number of retrieved LNs was 7 (1-35). Fifty-nine patients (52.7%) had LN metastases (22 N2). D2 dissection allowed the retrieval of more LNs (8 vs. 3, p = 0.0007), with similar short-term outcomes. Common bile duct (CBD) resection (n = 41) did not increase the number of retrieved LNs. In five patients, D2 dissection identified skip LN metastases that otherwise would have been missed. LN metastases negatively impacted survival (5-years survival 57.2% if N0 vs. 12.4% if N+, p < 0.0001), but N1 and N2 patients had similar survival rates. The number of LN+ (1-3 vs. ≥4) did not impact prognosis. An LNR = 0.15 stratified the prognosis of N+ patients: 5-years survival 32.7% if LNR ≤ 0.15 vs. 10.3% if LNR > 0.15 (multivariate analysis p = 0.007).

CONCLUSIONS

A D2 LN dissection is recommended in all patients, because it allows for better staging. CBD resection does not improve LN dissection. An LNR = 0.15, not the site of metastatic LNs, stratified the prognoses of N+ patients.

Managing the incidentally detected gallbladder cancer: algorithms and controversies

INTRODUCTION

Gallbladder cancer (GBC) is the fifth most common neoplasm of the gastrointestinal tract and the most common cancer of the biliary tract. GBC is suspected preoperatively in only 30-40% of patients. The other 60-70% are discovered incidentally (IGBC) by the pathologist on a gallbladder specimen following cholecystectomy for benign diseases such as polyps, gallstones, and cholecystitis.

MATERIALS AND METHODS

Between 1995 and 2011, 30 cases of GBC, who underwent resection with curative intent in our institutions, were retrospectively reviewed. They were analyzed for demographic data, and type of operation, surgical morbidity and mortality, histopathological classification, and survival. Incidental GBC was compared with suspected or preoperatively diagnosed GBC. Overall survival, disease-free survival (DFS) and the difference in DFS between patients previously treated with laparoscopic cholecystectomy and those who had oncological resection as first intervention were analyzed. The authors also present a systematic review to evaluate the role of extended surgery in the treatment of the incidental GBC.

RESULTS

GBC was diagnosed in 30 patients, 16 women and 14 men. The M/F ratio was 1:1.14 and the mean age was 69.4 years (range 45-83 years). A preoperative diagnosis was possible only in 14 cases; fourteen of the incidental cases were diagnosed postoperatively after the pathological examination; two were suspected intraoperatively at the opening of the surgical specimen and then confirmed by frozen sections. The ratio between incidental and nonincidental cases was 1, 14/1, with twelve cases discovered after laparoscopic cholecystectomy. Eighty-one per cent of the incidental cases were discovered at an early stage (≤II). The preoperative diagnosis of the 30 patients with GBC was: GBC with liver invasion diagnosed by preoperative CT (nine cases); gallbladder abscess perforated into hepatic parenchyma and involving the transversal mesocolon and hepatic hilum (one case); porcelain gallbladder (three cases); gallbladder adenoma (four cases); and chronic cholecystolithiasis (thirteen cases). Every case, except one, with a T1b or more advanced invasion underwent IVb + V wedge liver resection and pericholedochic/hepatoduodenal lymphoadenectomy. One patient refused further surgery. Cases with Tis and T1a involvement were treated with cholecystectomy alone. Nine of the sixteen patients with incidental diagnosis reached 5-year DFS (56.25%) and eight of them are recurrence free. Surprisingly, one patient reached 38 mo survival despite a port-site recurrence (the only one in our experience) 2 years after the original surgery requiring further resection. Cases with non incidental diagnosis were more locally advanced and only two patients experienced 5 years DFS (Tables 2 and 3).

CONCLUSION

Laparoscopic cholecystectomy does not affect survival if implemented properly. Reoperation should have two objectives: R0 resection and clearance of the lymph nodes.

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.

Prognostic significance of the highest peripancreatic lymph node in biliary tract adenocarcinoma

BACKGROUND

Patients with biliary tract adenocarcinoma with nodal involvement have a poor prognosis. There is currently no standardized method for intraoperative lymph node assessment. The current study aimed to determine the prognostic significance of the highest peripancreatic lymph node (HPLN) in biliary tract malignancy.

METHODS

This was a retrospective study of patients undergoing potential curative resection of biliary tract adenocarcinoma from January 1995 through December 2010 who prospectively had intraoperative sampling of the HPLN. The median follow-up was 72.8 months. The primary end points were recurrence-free survival (RFS) and disease-specific survival (DSS).

RESULTS

The rate of HPLN positivity in 110 patients undergoing exploration for potential curative resection was 30 % and did not vary with histologic subtype (gallbladder vs. cholangiocarcinoma). Eighty-five patients underwent complete gross resection. In this subset, median RFS and DSS were 34.3 months (95 % confidence interval [CI] 23.6-not reached [NR]) and 62.4 months (95 % CI 40.8-NR) for HPLN-negative patients, and 9.6 months (95 % CI 4.76-NR) and 20.5 months (95 % CI 7.4-NR) for HPLN-positive patients (p < 0.01), respectively. Median DSS was 14.6 months (95 % CI 9.6-25.4) for patients with unresectable disease. On multivariate analysis, HPLN status was an independent predictor of RFS (hazard ratio 3.73, 95 % CI 1.86-7.45; p < 0.01) and DSS (hazard ratio 3.98, 95 % CI 1.89-8.38; p < 0.01).

CONCLUSIONS

HPLN status is prognostic of RFS and DSS in biliary tract adenocarcinoma. Intraoperative nodal staging by HPLN sampling warrants further investigation in a prospective trial.

Locally advanced gallbladder cancer: which patients benefit from resection?

OBJECTIVES

Patients with T3-4 gallbladder cancers (GBCs) often require extended surgical procedures, and up to 30% of patients have N2 metastases. This study investigated which patients with T3-4 GBC benefit from resection.

METHODS

Consecutive patients (n = 78) with T3-4 GBC who underwent resection between 1990 and 2011 were analysed (38 before 2003, 40 in 2003-2011). Forty patients required common bile duct (CBD) resection, 10 pancreatoduodenectomy, 4 right colectomy and 2 gastric resection. Fifty-two (67%) patients had LN metastases, including 22 with N2 metastases.

RESULTS

The in-hospital mortality rate was 8%, 11% before 2003 vs. 5% in 2003-2011. The morbidity rate (47%) remained stable during the study. Undergoing liver and pancreatic resection did not increase severe morbidity (0%) or mortality (10%). Sixty-seven (86%) patients had R0 resection. The 5-year survival rate was 17% (median follow-up, 65 months). Survival improved after 2002 (26% vs. 9%, p = 0.04). R1 patients had poor 3-year survival (0% vs. 32%, p = 0.001). N+ patients also had low survival (5-year survival, 10% vs. 32% in N0, p = 0.019), but N1 and N2 patients had similar outcomes. CBD resection and major hepatectomy did not worsen prognosis. Patients requiring pancreatoduodenectomy, gastric or colonic resection had 0% 3-year survival (p = 0.036 in multivariate analysis).

CONCLUSIONS

Resection of T3-4 GBC is worthwhile only if R0 surgery is achievable. Outcomes improved in most recent years. N2 metastases should not preclude surgery. Good results are possible even with CBD resection or major hepatectomy, while benefits from surgery are doubtful if pancreatoduodenectomy or other organ resection is needed.

Simultaneous resection of abdominal cancer and synchronous pancreaticoduodenal metastasis: indications and literature review

OBJECTIVE

This study was aimed to identify the potential indications for simultaneous resection of abdominal cancer and synchronous pancreaticoduodenal metastasis (SRAPM) and improve the efficacy of SRAPM.

METHODS

The data of 34 patients who underwent SRAPM were retrospectively reviewed. The intraoperative findings, morbidity and mortality, patterns of tumor invasion in the pancreas and duodenum, lymph node metastases, long-term outcomes and causes of death were evaluated.

RESULTS

Fourteen patients (41.2%) developed complications, and 2 died of pancreatic fistulas with abdominal bleeding. The in-hospital mortality was 5.9%. The overall 1-year, 2-year and 3-year survival rates were 52.9%, 32.3% and 21.8%, respectively. The survival rates depended on the primary tumor, the invasion pattern, the presence of metastatic lymph nodes at the paraaortic site and the presence of residual tumor. The follow-up outcomes revealed that the main causes of death were as follows: systemic metastasis (n = 7), peritoneal metastasis (n = 6) and intrahepatic metastasis (n = 6).

CONCLUSIONS

SRAPM is indicated for low-grade malignant tumors and in cases with direct invasion of the pancreaticoduodenum. The presence of metastatic lymph nodes at the paraaortic site, intrahepatic metastasis, micro-peritoneal metastasis, and distinct metastasis should be contraindications for the surgical procedure.

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.

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.

Clinicopathologic analysis of adenosquamous/squamous cell carcinoma of the gallbladder

BACKGROUNDS AND OBJECTIVES

Adenosquamous/squamous cell carcinoma (AS/SCC) of the gallbladder is rarely encountered and accounts for 1.4-10.6% of all gallbladder carcinomas (GBCs). This study was conducted to investigate the clinicopathologic features of AS/SCC of gallbladder.

METHODS

The authors retrospectively reviewed 16 cases of pathologically proven AS/SCC of the gallbladder among 404 patients who underwent surgery for GBC from October 1994 to March 2009. Forty-eight conventional GBC patients were selected as controls after matching for age and gender.

RESULTS

Mean patient age was 60.2 years and half were male. Tumor stages in the case group were significantly more advanced than the control group (P < 0.001). R0 resection rates in cases and controls were 50% and 81.2% (P = 0.022). Overall 1-year survival in the case group was significantly poorer than in the control group (18.8% vs. 87.3%, P < 0.001). However, no significant difference in disease-free survival rates was found between cases and controls after R0 resection (P = 0.072).

CONCLUSIONS

AS/SCC of the gallbladder is often diagnosed at an advanced stage, which results in non-curative surgical resection and a poorer prognosis than conventional GBC. However, curative surgical resection of AS/SCC of the gallbladder might result in disease-free survival rates that are comparable with those of conventional GBC.

Number of positive lymph nodes independently determines the prognosis after resection in patients with gallbladder carcinoma

BACKGROUND

This study was designed to compare the prognostic power of the location of positive lymph nodes with that of the number of positive lymph nodes in gallbladder carcinoma.

METHODS

A retrospective analysis was conducted of 116 consecutive patients who underwent an R0 radical resection for gallbladder carcinoma. A total of 2,406 lymph nodes taken from the patients were examined histologically. The location of positive regional nodes was classified according to the Japanese staging system. The number of positive regional nodes was recorded for each patient.

RESULTS

Nodal disease was found in 49 patients, of whom 19 survived for more than 5 years after resection. Univariate analysis revealed that both the location (P < 0.0001) and the number (P < 0.0001) of positive nodes were significant prognostic factors. Multivariate analysis revealed that the number of positive nodes was an independent prognostic factor (P < 0.001), whereas the location of positive nodes failed to remain as an independent variable. The cumulative 5-year survival rates were 81% for patients without regional nodal disease, 62% for patients with a single positive node, 43% for patients with 2-3 positive nodes, and 15% for patients with > or =4 positive nodes (P < 0.0001).

CONCLUSIONS

The number, not the location, of positive lymph nodes independently determines the prognosis after resection in gallbladder carcinoma. No nodal disease or a single positive node indicates a favorable outcome after resection, whereas radical lymph node dissection is effective for selected patients with multiple positive nodes, provided that an R0 resection is feasible.

Mode of hepatic spread from gallbladder carcinoma: an immunohistochemical analysis of 42 hepatectomized specimens

This study aimed to clarify the mode of hepatic spread from gallbladder carcinoma and to elucidate its prognostic value. A retrospective analysis was conducted of 42 consecutive patients who underwent resection for gallbladder carcinoma with hepatic involvement verified histologically. The mode of hepatic spread was classified into 3 patterns: direct invasion through the gallbladder bed, portal tract invasion, and hepatic metastatic nodules. Intrahepatic lymphatic invasion was declared when either single tumor cells or cell clusters were clearly visible within vessels that showed immunoreactivity to the D2-40 monoclonal antibody. Seven, 24, and 11 patients had direct invasion alone, portal tract invasion with (22 patients) or without (2 patients) direct invasion, and hepatic metastatic nodules, respectively. Of the 24 patients with portal tract invasion, 14 had intrahepatic lymphatic invasion, 8 had neither intrahepatic lymphatic nor venous invasion, and 2 had both intrahepatic lymphatic and venous invasion. To date, 4 patients with direct invasion alone and 4 patients with portal tract invasion survived more than 5 years after resection, whereas all the patients with hepatic metastatic nodules died within 11 months after resection, irrespective of the type of hepatectomy. The mode of hepatic spread (P<0.001) was a strong independent prognostic factor. Direct liver invasion and portal tract invasion, which features intrahepatic lymphatic invasion, are the main modes of hepatic spread from resectable gallbladder carcinoma. The mode of hepatic spread independently predicts long-term survival after resection for patients with gallbladder carcinoma. Hepatic metastatic nodules indicate a dismal outcome after resection.

Evolving treatment strategies for gallbladder cancer

Gallbladder cancer is an uncommon cancer that has traditionally been associated with a poor prognosis. In the era of laparoscopic cholecystectomy, incidental gallbladder cancer has dramatically increased and now constitutes the major way patients present with gallbladder cancer. While patients with incidental gallbladder cancer have a better survival than patients with nonincidental gallbladder cancer, incidental gallbladder cancer can be associated with a varied prognosis. Imaging with computed tomography (CT), magnetic resonance imaging (MRI), and [18]F-fluorodeoxyglucose (FDG) positron emission tomography (PET), as well as diagnostic laparoscopy, all have varying roles in the workup of patients with incidental gallbladder cancer. For patients with T1b, T2, and T3 incidental gallbladder cancer re-resection is generally recommended. At re-exploration, many patients with incidental gallbladder cancer will have residual disease. Definitive oncologic management requires re-resection of the liver, portal lymphadenectomy, and attention to the common bile duct. The extent of the hepatic resection should be dictated by the ability to achieve a microscopically negative (R0) margin. Routine resection of the common bile duct is unnecessary but should be undertaken in the setting of a positive cystic duct margin. If an incidental gallbladder cancer is discovered at the time of surgery, whether the surgeon should directly proceed with a more definitive oncologic operation should depend on the surgeon's skill-set and experience. Gallbladder cancer has a propensity to recur. Although data for adjuvant therapy following resection are limited, some data do suggest a survival benefit for adjuvant chemoradiation therapy. Management of patients with gallbladder cancer requires a multidisciplinary approach with input from a surgeon skilled in hepatobiliary surgery.

Hepatic resection in 485 R0 pT2 and pT3 cases of advanced carcinoma of the gallbladder: results of a Japanese Society of Biliary Surgery survey--a multicenter study

PURPOSE

We conducted this study to evaluate the optimal hepatic resection for pT2 and pT3 advanced carcinoma of the gallbladder without invasion of the hepatoduodenal ligament.

METHODS

We conducted a questionnaire survey regarding 4,243 cases of carcinoma of the gallbladder treated during the recent 10-year period at 112 institutions belonging to the Japanese Society of Biliary Surgery. The questionnaires included questions on preoperative-diagnosis, complications, treatment, and surgical treatment, procedures of resection, surgical result, path histological findings, mode, and site of recurrence, additional post-operative treatment. They included 293 pT2 and 192 pT3 R0 cases, which were negative for hepatoduodenal ligament invasion, and the cumulative survival rates and sites of postoperative recurrence in the form of liver metastasis, were retrospectively analyzed in these 485 cases.

RESULT

There were no significant differences in survival rate or recurrence rates in the form of liver metastasis between the groups that underwent resection of the gallbladder bed, the group that underwent segmentectomy 4a+5, and the group that underwent hepatectomy in patients with of both pT2 or pT3 gallbladder cancers. Our results also did not show that liver metastasis to segment 4a5 alone was particularly common.

CONCLUSION

For gallbladder cancer, neither with hepatoduodenal ligament invasion nor hepatic invasion, resection of the gallbladder bed is more preferable for surgical hepatic procedure. For gallbladder cancer that invades any hepatic sites, a hepatic surgical procedure that could eliminate surgical margins would be desirable.

Combined major hepatectomy and pancreaticoduodenectomy for locally advanced biliary carcinoma: long-term results

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--a comprehensive review

AIM

Gallbladder cancer is the fifth most common cancer involving the gastrointestinal tract, but it is the most common malignant tumour of the biliary tract worldwide. The percentage of patients diagnosed to have gallbladder cancer after simple cholecystectomy for presumed gallbladder stone disease is 0.5-1.5%. This tumour is traditionally regarded as a highly lethal disease with an overall 5-year survival of less than 5%. The marked improvement in the outcome of patients with gallbladder cancer in the last decade is because of the aggressive radical surgical approach that has been adopted, and improvements in surgical techniques and peri-operative care. This article aims to review the current approach to the management of gallbladder cancer.

METHODS

A Medline, PubMed database search was performed to identify articles published from 1990 to 2007 using the keywords 'carcinoma of gallbladder', 'gallbladder cancer', 'gallbladder neoplasm' and 'cholecystectomy'.

RESULTS AND CONCLUSIONS

The overall 5-year survival for patients with gallbladder cancer who underwent Ro curative resection was reported to range from 21% to 69%. Laparoscopic cholecystectomy is absolutely contraindicated when gallbladder cancer is known or suspected pre-operatively. Patients with a pre-operative suspicion of gallbladder cancer should undergo open exploration and cholecystectomy after proper pre-operative assessment. For patients whose cancer is an incidental finding on pathological review, a second radical resection is indicated except for Tis and T1a disease. There is still controversy for the optimal management of T1b disease. Although the role of surgery for advanced disease remains controversial, patients with advanced gallbladder cancer can benefit from radical resection, provided a potentially curative Ro resection is possible. There is still no effective adjuvant therapy for gallbladder cancer.

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.

Management of carcinoma of the gallbladder: a single-institution experience in 16 years

BACKGROUND

Radical surgery is the only curative treatment for carcinoma of gallbladder. This study aimed to evaluate the outcome of patients with carcinoma of gallbladder managed in a single institution over 16 years.

METHODS

From April 1988 to November 2003, 86 patients (29 males, 57 females) were diagnosed to have carcinoma of gallbladder. Tumor staging, treatment modalities and clinical outcome of these patients were evaluated. Thirty-two patients (37%) had early stage (TNM stage I or II) disease whereas 54 patients (63%) had advanced stage (TNM stage III or IV) disease. Curative treatment by surgical resection was performed in 23 patients (27%).

RESULTS

Overall survival was significantly better in patients with curative treatment (1-year: 85%; 2-year: 63%; 3-year: 55%) than those with palliative treatment (1-year: 11%; 2-year: 3%; 3-year: 0%; P < 0.01). Using Cox regression model, curative treatment was the only independent prognostic factor affecting overall survival of patients with carcinoma of gallbladder. A significantly better survival was associated with curative treatment compared with palliative treatment in patients with incidental gallbladder cancer. The median survival was 33.9 months for the curative treatment group versus 3 months for the palliative treatment group (P = 0.0001).

CONCLUSION

Favorable survival outcome can be achieved in patients with carcinoma of gallbladder after curative resection.

Guidelines for the management of biliary tract and ampullary carcinomas: surgical treatment

The only curative treatment in biliary tract cancer is surgical treatment. Therefore, the suitability of curative resection should be investigated in the first place. In the presence of metastasis to the liver, lung, peritoneum, or distant lymph nodes, curative resection is not suitable. No definite consensus has been reached on local extension factors and curability. Measures of hepatic functional reserve in the jaundiced liver include future liver remnant volume and the indocyanine green (ICG) clearance test. Preoperative portal vein embolization may be considered in patients in whom right hepatectomy or more, or hepatectomy with a resection rate exceeding 50%–60% is planned. Postoperative complications and surgery-related mortality may be reduced with the use of portal vein embolization. Although hepatectomy and/or pancreaticoduodenectomy are preferable for the curative resection of bile duct cancer, extrahepatic bile duct resection alone is also considered in patients for whom it is judged that curative resection would be achieved after a strict diagnosis of its local extension. Also, combined caudate lobe resection is recommended for hilar cholangiocarcinoma. Because the prognosis of patients treated with combined portal vein resection is significantly better than that of unresected patients, combined portal vein resection may be carried out. Prognostic factors after resection for bile duct cancer include positive surgical margins, especially in the ductal stump; lymph node metastasis; perineural invasion; and combined vascular resection due to portal vein and/or hepatic artery invasion. For patients with suspected gallbladder cancer, laparoscopic cholecystectomy is not recommended, and open cholecystectomy should be performed as a rule. When gallbladder cancer invading the subserosal layer or deeper has been detected after simple cholecystectomy, additional resection should be considered. Prognostic factors after resection for gallbladder cancer include the depth of mural invasion; lymph node metastasis; extramural extension, especially into the hepatoduodenal ligament; perineural invasion; and the degree of curability. Pancreaticoduodenectomy is indicated for ampullary carcinoma, and limited operation is also indicated for carcinoma in adenoma. The prognostic factors after resection for ampullary carcinoma include lymph node metastasis, pancreatic invasion, and perineural invasion.

Simultaneous gallbladder and bile duct cancers: revisiting the pathological possibilities

The pathogenesis of gallbladder cancer presenting synchronously with malignancy of the bile duct has not been clearly understood. The possible causes for the simultaneous presence of these tumors could be due to local spread, metastases, de novo multifocal origin, or as part of a field change in the extrahepatic biliary apparatus. In this article, we discuss the cases of four patients with simultaneous gallbladder and bile duct malignancies and analyze their individual pathologies to provide an explanation into the mechanisms that may play a role in such conditions.

Biliary obstruction in gall bladder cancer is not sine qua non of inoperability

BACKGROUND

The presence of biliary obstruction in patients with gallbladder cancer (GBC) is generally viewed as an indicator of advanced disease, inoperability and poor prognosis.

METHODS

Data was collected from patients with GBC with obstructive jaundice who underwent resection during the period January 2001 to October 2003. Systematic analysis of prospective data was undertaken; patients were analyzed for resectability, post-operative morbidity, mortality and disease-free survival.

RESULTS

During this period 14 patients with GBC with biliary obstruction underwent resection with curative intent. In these jaundiced patients, the resectability rate was 27.45% (14 of 51). In the jaundiced group the mortality was 7.14% the morbidity rate 50%, the mean disease free survival was 23.46 months (median 26 months and range of 2 to 62 months). Seven patients (50%) survived more than two years.

CONCLUSION

Biliary obstruction in gall bladder cancer is not sine qua non of inoperability and resection results in meaningful prolongation of survival.

The standardized surgical approach improves outcome of gallbladder cancer

Background

The objective of this study was to examine the extent of surgical procedures, pathological findings, complications and outcome of patients treated in the last 12 years for gallbladder cancer.

Methods

The impact of a standardized more aggressive approach compared with historical controls of our center with an individual approach was examined. Of 53 patients, 21 underwent resection for cure and 32 for palliation.

Results

Overall hospital mortality was 9% and procedure related mortality was 4%. The standardized approach in UICC stage IIa, IIb and III led to a significantly improved outcome compared to patients with an individual approach (Median survival: 14 vs. 7 months, mean+/-SEM: 26+/-7 vs. 17+/-5 months, p = 0.014). The main differences between the standardized and the individual approach were anatomical vs. atypical liver resection, performance of systematic lymph dissection of the hepaticoduodenal ligament and the resection of the common bile duct.

Conclusion

Anatomical liver resection, proof for bile duct infiltration and, in case of tumor invasion, radical resection and lymph dissection of the hepaticoduodenal ligament are essential to improve outcome of locally advanced gallbladder cancer.

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.

Diagnosis and surgical management of gallbladder cancer: a review

Gallbladder cancer is one of the most lethal carcinomas and continues to pose many challenges for surgeons. Identifiable risk factors for carcinoma of the gallbladder include cholelithiasis, an anomalous pancreaticobiliary junction, and focal mucosal microcalcifications. Adenocarcinoma is the primary histologic type in most patients and the tumor is frequently associated with Kras and p53 mutations. Radiologic and endoscopic advances in endoscopic ultrasonography and magnetic resonance cholangiopancreatogram, plus helical computed tomography, have enhanced preoperative staging. Surgical options include cholecystectomy for disease limited to the mucosa (Tis/T1) or a radical cholecystectomy (subsegmental resection of segments IVB and V plus a hepatoduodenal ligament lymphadenectomy) for advanced disease without signs of distant metastasis (T2-4/N0-N2). Some surgeons have advocated more radical hepatic resection including extended right hepatectomy or central bisegmentectomy plus caudate lobectomy. Japanese surgeons have reported studies that included patients having a pancreaticoduodenectomy to improve distal ductal margins and lymphadenectomy for T3 and T4 cancers. These patients have a lower rate of local recurrence but no survival advantage. Options for adjuvant therapy remain limited. Radiation therapy with fluorouracil radiosensitization is the most commonly used postoperative treatments. Current trials are investigating the role of capecitabine, oxaliplatin, and bevacizumab in the management of gallbladder carcinoma.

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.

Is major hepatectomy with pancreatoduodenectomy justified for advanced biliary malignancy?

BACKGROUND/PURPOSE

Major hepatectomy with concomitant pancreatoduodenectomy (M-HPD) is usually indicated for the resection of diffuse bile duct cancer or advanced gallbladder cancer. This is the only procedure that can potentially cure such advanced cancers, so both a low mortality rate and long-term survival could potentially justify performing this procedure.

METHODS

Between 1990 and 2005, the morbidity, mortality, and long-term survival of 26 patients with advanced biliary tract carcinoma 14 with diffuse bile duct cancer, 9 with advanced gallbladder cancer, and 3 with hilar bile duct cancer, who underwent hepatopancreatoduodectomy (HPD) were reviewed and analyzed.

RESULTS

The overall morbidity and mortality rates were 30.8% and 0%, respectively. Postoperative infectious complications occurred in 6 patients (23.0%). The 5-year survival rate of the 14 patients with diffuse bile duct cancer who underwent HPD was 51.9%, while the 5-year survival rate in the 12 of these patients who underwent M-HPD was 61.4%. Patients with diffuse bile duct cancer without residual tumor and those without lymph node metastasis had 5-year survival rates of 68.6% and 80%, respectively. Thirty-three percent (2 of 6) of the patients who underwent M-HPD for advanced gallbladder cancer survived for more than 5 years.

CONCLUSIONS

Preoperative biliary drainage, portal embolization, complete external drainage of pancreatic juice, reduction of intraoperative bleeding, and prevention of bacterial colonization of bile may enable the incidence of mortality and hepatic failure to approach zero in patients who undergo HPD. Surgeons should strive for complete clearance of the tumor with a negative surgical margin to achieve long-term survival when performing M-HPD.

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.

Hepatopancreatoduodenectomy: its suitability for bile duct cancer versus gallbladder cancer

BACKGROUND/PURPOSE

We aimed to determine whether bile duct cancer (BDC) or gallbladder cancer (GBC) was a better candidate for hepatopancreatoduodenectomy (HPD).

METHODS

Ten patients with BDC and ten with GBC were treated by HPD with major hepatectomy between 1994 and 2004 and compared, in terms of surgical outcome and survival.

RESULTS

In the BDC patients, the International Union Against Cancer (UICC) stage was I in three patients; II in four; III in one; and IV in two; of the GBC patients, one was stage II; four were stage III; and five were stage IV. The reasons for choosing HPD for BDC were: superficial spreading, in three patients; intramural wide invasion, in five; and hepatoduodenal ligament (HDL) invasion, in two; and for GBC, extrahepatic bile duct invasion, in seven; and HDL invasion, in three. The morbidity and mortality rates for BDC and GBC were 40% and 60%, and 0% and 30%, respectively. All three of the GBC patients who died in hospital had undergone a right trisectionectomy with caudate lobectomy. The cumulative 5-year survival rate of the BDC patients was 64%; the 1-year survival rate for the GBC patients was only 20%, and none survived for over 2 years (P < 0.001). Of the patterns of BDC cancer invasion, the superficial-spreading type appeared to have a better prognosis than the others, but the difference was not statistically significant.

CONCLUSIONS

HPD is indicated for any type of BDC, but HPD did not show any survival benefits in treating patients with GBC with obstructive jaundice.

Operative approach to gallbladder cancer

In most Western countries gallbladder cancer is a rare tumor with a poor prognosis. The majority of patients present with advanced-stage tumors (stage IV) that are not amenable to surgical resection. At the other end of the spectrum a small percentage of patients present with stage I disease that may be cured by cholecystectomy. The role for surgery in patients with stage II and III disease remains controversial, but most hepatobiliary surgeons believe that an aggressive surgical approach improves survival for these patients. However, the extent of hepatic and lymph node resection, the need for resection of the extrahepatic ducts in nonjaundiced patients, the role of vascular resection, and the advisability of hepatopancreatoduodenectomy remain a matter of debate. Although no data from prospective, randomized studies are available, resection of the gallbladder and adjacent liver with or without the extrahepatic bile ducts and with a regional lymph node dissection is the operative approach recommended for selected patients with gallbladder cancer.

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.

Primary undifferentiated spindle-cell carcinoma of the gallbladder presenting as a liver tumor

Undifferentiated spindle-cell carcinoma (SpCC) of the gallbladder is extremely rare. There is very little information available regarding the characteristics and treatment of this disease. We herein report the unique case of a 76-year-old female patient with a primary SpCC of the gallbladder that presented as a liver tumor. Preoperative radiologic examinations showed a 5-cm liver tumor around the gallbladder bed, and irregular thickening of the gallbladder wall. The patient underwent en-bloc resection of the gallbladder and segments 4b and 5 of the liver (including the liver tumor). Microscopic findings revealed that both lesions consisted mainly of a sarcomatous spindle-shaped component. Small foci of well-differentiated adenocarcinoma cells were identified in the gallbladder mucosa. There was a gradual transition between the two different components, thereby implying that these two cell types had a common origin. Immunohistochemical studies showed that the spindle-shaped cells were epithelial in nature. The patient's postoperative course was uneventful. However, she died of recurrent liver disease 6 months after the surgery. In conclusion, we surmised that the sarcomatous spindle cells originated from a carcinomatous component in the gallbladder mucosa through dedifferentiation. Further studies are needed to better understand the characteristics of this deadly tumor, and to establish an effective therapy for it.