Surgical treatment of incidental gallbladder cancer discovered during or following laparoscopic cholecystectomy. World J Surg. 2015;39:746-752. [PMID: 25403888 DOI: 10.1007/s00268-014-2864-9]

Laparoscopic Conversion to Open Cholecystectomy: Is Incidental Gallbladder Cancer Any Different?

BACKGROUND

A majority of gallbladder cancers present incidentally. Operative risk factors and outcomes for laparoscopic converted to open cholecystectomy in incidental gallbladder cancer are not well characterized.

METHODS

Patients with incidental gallbladder cancer and acute cholecystitis undergoing laparoscopic cholecystectomy and conversion to open cholecystectomy in the National Surgical Quality Improvement Program (NSQIP) database of the American College of Surgeons (ACS) from 2010-2019 were reviewed. The primary endpoint was risk factors for conversion to open cholecystectomy in incidental gallbladder cancer. Chi-squared test or Fisher's exact test was used for categorical variables. Continuous variables were compared using the Mann-Whitney U test.

RESULTS

A total of 5,789 patients undergoing laparoscopic cholecystectomy were identified, of which, 50 (0.9%) had incidental gallbladder cancer. For incidental gallbladder cancer patients, there were no differences in preoperative profile and risk factors between laparoscopic and converted to open cholecystectomy groups. Incidental carcinoma patients undergoing conversion to open cholecystectomy had lower preoperative sodium levels than the laparoscopic cholecystectomy group (P=0.007). Hospital length of stay (days) was longer for those with a conversion to open cholecystectomy for incidental carcinoma compared to non-conversion, 14 (10.8, 18.8) vs 2 (0.3, 5) (P=0.004). The patients converted to open cholecystectomy also had higher rates of postoperative sepsis (50% vs 0%, P<0.001) and reoperation than the laparoscopic cohort (50% vs 2.2%, P<0.001). Readmission and mortality rates, among other complications, were not significantly different between both surgical approaches in incidental gallbladder cancer patients.

CONCLUSIONS

 Patients with conversion to open cholecystectomy had worse outcomes including longer hospital stays and higher rates of sepsis and reoperation. It remains difficult to predict which incidental gallbladder patients will require a conversion to open surgery. Further study examining whether more complicated recovery results in worse oncologic outcomes is warranted.

Biliary tract cancers: French national clinical practice guidelines for diagnosis, treatments and follow-up (TNCD, SNFGE, FFCD, UNICANCER, GERCOR, SFCD, SFED, AFEF, SFRO, SFP, SFR, ACABi, ACHBPT)

INTRODUCTION

This document is a summary of the French intergroup guidelines of the management of biliary tract cancers (BTC) (intrahepatic, perihilar and distal cholangiocarcinomas, and gallbladder carcinomas) published in September 2023, available on the website of the French Society of Gastroenterology (SNFGE) (www.tncd.org).

METHODS

This collaborative work was conducted under the auspices of French medical and surgical societies involved in the management of BTC. Recommendations were graded in three categories (A, B and C) according to the level of scientific evidence until August 2023.

RESULTS

BTC diagnosis and staging is mainly based on enhanced computed tomography, magnetic resonance imaging and (endoscopic) ultrasound-guided biopsy. Treatment strategy depends on BTC subtype and disease stage. Surgery followed by adjuvant capecitabine is recommended for localised disease. No neoadjuvant treatment is validated to date. Cisplatin-gemcitabine chemotherapy combined to the anti-PD-L1 inhibitor durvalumab is the first-line standard of care for advanced disease. Early systematic tumour molecular profiling is recommended to screen for actionable alterations (IDH1 mutations, FGFR2 rearrangements, HER2 amplification, BRAFV600E mutation, MSI/dMMR status, etc.) and guide subsequent lines of treatment. In the absence of actionable alterations, FOLFOX chemotherapy is the only second-line standard-of-care. No third-line chemotherapy standard is validated to date.

CONCLUSION

These guidelines are intended to provide a personalised therapeutic strategy for daily clinical practice. Each individual BTC case should be discussed by a multidisciplinary team.

Decoding the Conundrum: Navigating Intra-operatively Encountered Suspicious Gallbladder Wall Thickening with Laparoscopic Transhepatic Needle Decompression and Beyond Cystic Plate Cholecystectomy

BACKGROUND

Suspicious gallbladder wall thickening encountered during laparoscopic cholecystectomy poses challenges in its management. This study aims to address this problem by proposing a technique that involves laparoscopic transhepatic needle decompression and modified cystic plate cholecystectomy.

METHODS

In this report, we describe the case of a 36-year-old female with symptomatic gallstone disease and ultrasound findings of a well-distended gallbladder with a uniform wall thickness. Diagnostic laparoscopy revealed a distended, tense gallbladder with suspicious areas of thickness. Transhepatic aspiration was performed for gallbladder decompression, followed by modified cystic plate cholecystectomy with preservation of the thin rim of liver tissue over the cystic plate. The gallbladder was removed in a specimen bag, and final histopathology showed a hyalinized gallbladder wall with calcification and pyloric gland metaplasia, with liver tissue adhered to the gallbladder wall (Video).

RESULTS

The proposed technique aimed to minimize the risk of bile spillage and violation of oncological planes while maintaining surgical integrity. It offers a middle path between standard and extended cholecystectomy, reducing the chance of over- or under-treatment. This approach ensures patient safety, minimizes the need for conversion to open surgery, and preserves the tumour-tissue interface.

CONCLUSION

Intraoperatively encountered suspicious gallbladder wall thickening can be effectively managed with laparoscopic transhepatic needle decompression and modified cystic plate cholecystectomy.

Risk stratification of gallbladder masses by machine learning-based ultrasound radiomics models: a prospective and multi-institutional study

OBJECTIVE

This study aimed to evaluate the diagnostic performance of machine learning (ML)-based ultrasound (US) radiomics models for risk stratification of gallbladder (GB) masses.

METHODS

We prospectively examined 640 pathologically confirmed GB masses obtained from 640 patients between August 2019 and October 2022 at four institutions. Radiomics features were extracted from grayscale US images and germane features were selected. Subsequently, 11 ML algorithms were separately used with the selected features to construct optimum US radiomics models for risk stratification of the GB masses. Furthermore, we compared the diagnostic performance of these models with the conventional US and contrast-enhanced US (CEUS) models.

RESULTS

The optimal XGBoost-based US radiomics model for discriminating neoplastic from non-neoplastic GB lesions showed higher diagnostic performance in terms of areas under the curves (AUCs) than the conventional US model (0.822-0.853 vs. 0.642-0.706, p < 0.05) and potentially decreased unnecessary cholecystectomy rate in a speculative comparison with performing cholecystectomy for lesions sized over 10 mm (2.7-13.8% vs. 53.6-64.9%, p < 0.05) in the validation and test sets. The AUCs of the XGBoost-based US radiomics model for discriminating carcinomas from benign GB lesions were higher than the conventional US model (0.904-0.979 vs. 0.706-0.766, p < 0.05). The XGBoost-US radiomics model performed better than the CEUS model in discriminating GB carcinomas (AUC: 0.995 vs. 0.902, p = 0.011).

CONCLUSIONS

The proposed ML-based US radiomics models possess the potential capacity for risk stratification of GB masses and may reduce the unnecessary cholecystectomy rate and use of CEUS.

CLINICAL RELEVANCE STATEMENT

The machine learning-based ultrasound radiomics models have potential for risk stratification of gallbladder masses and may potentially reduce unnecessary cholecystectomies.

KEY POINTS

• The XGBoost-based US radiomics models are useful for the risk stratification of GB masses. • The XGBoost-based US radiomics model is superior to the conventional US model for discriminating neoplastic from non-neoplastic GB lesions and may potentially decrease unnecessary cholecystectomy rate for lesions sized over 10 mm in comparison with the current consensus guideline. • The XGBoost-based US radiomics model could overmatch CEUS model in discriminating GB carcinomas from benign GB lesions.

Laparoscopic vs open radical resection in management of gallbladder carcinoma: A systematic review and meta-analysis

BACKGROUND

Radical resection offers the only hope for the long-term survival of patients with gallbladder carcinoma (GBC) above the T1b stage. However, whether it should be performed under laparoscopy for GBC is still controversial.

AIM

To compare laparoscopic radical resection (LRR) with traditional open radical resection (ORR) in managing GBC.

METHODS

A comprehensive search of online databases, including Medline (PubMed), Cochrane Library, and Web of Science, was conducted to identify comparative studies involving LRR and ORR in GBCs till March 2023. A meta-analysis was subsequently performed.

RESULTS

A total of 18 retrospective studies were identified. In the long-term prognosis, the LRR group was comparable with the ORR group in terms of overall survival and tumor-free survival (TFS). LRR showed superiority in terms of TFS in the T2/tumor-node-metastasis (TNM) Ⅱ stage subgroup vs the ORR group (P = 0.04). In the short-term prognosis, the LRR group had superiority over the ORR group in the postoperative length of stay (POLS) (P < 0.001). The sensitivity analysis showed that all pooled results were robust.

CONCLUSION

The meta-analysis results show that LRR is not inferior to ORR in all measured outcomes and is even superior in the TFS of patients with stage T2/TNM Ⅱ disease and POLS. Surgeons with sufficient laparoscopic experience can perform LRR as an alternative surgical strategy to ORR.

Reappraisal of T1b gallbladder cancer (GBC): clinicopathologic analysis of 473 in situ and invasive GBCs and critical review of the literature highlights its rarity, and that it has a very good prognosis

There are highly conflicting data on relative frequency (2-32%), prognosis, and management of pT1b-gallbladder carcinoma (GBC), with 5-year survival ranging from > 90% in East/Chile where cholecystectomy is regarded as curative, versus < 50% in the West, with radical operations post-cholecystectomy being recommended by guidelines. A total of 473 in situ and invasive extensively sampled GBCs from the USA (n = 225) and Chile (n = 248) were re-evaluated histopathologically per Western invasiveness criteria. 349 had invasive carcinoma, and only 24 were pT1. Seven cases previously staged as pT1b were re-classified as pT2. There were 19 cases (5% of all invasive GBCs) qualified as pT1b and most pT1b carcinomas were minute (< 1mm). One patient with extensive pTis at margins (but pT1b focus away from the margins) died of GBC at 27 months, two died of other causes, and the remainder were alive without disease (median follow-up 69.9 months; 5-year disease-specific survival, 92%). In conclusion, careful pathologic analysis of well-sampled cases reveals that only 5% of invasive GBCs are pT1b, with a 5-year disease-specific survival of > 90%, similar to findings in the East. This supports the inclusion of pT1b in the "early GBC" category, as is typically done in high-incidence regions. Pathologic mis-staging of pT2 as pT1 is not uncommon. Cases should not be classified as pT1b unless extensive, preferably total, sampling of the gallbladder to rule out a subtle pT2 is performed. Critical appraisal of the literature reveals that the Western guidelines are based on either SEER or mis-interpretation of stage IB cases as "pT1b." Although the prognosis of pT1b-GBC is very good, additional surgery (radical cholecystectomy) may be indicated, and long-term surveillance of the biliary tract is warranted.

Robotic Hepatic Bisegmentectomy (s4b + s5) and Hilar Lymphadenectomy for Incidental Gallbladder Cancer Using Glissonian Approach

BACKGROUND

Gallbladder carcinoma is a rare cancer with a poor prognosis and the most common biliary tract malignancy. This video shows robotic treatment of a patient with incidental gallbladder cancer diagnosed after laparoscopic cholecystectomy. The operation consisted of a robotic bisegmentectomy (liver segments 4b and 5) using a Glissonian approach and a hilar lymphadenectomy.

METHODS

A 73-year-old woman with no relevant history underwent a laparoscopic cholecystectomy at another hospital facility. The pathology revealed a gallbladder carcinoma. The patient was then referred for further treatment. Pathologic revision confirmed T2a carcinoma and staging was negative for distant metastases. The multidisciplinary team decided on a radical resection that will consist of a hilar lymphadenectomy and a frozen section of the cystic stump along the resection of segments 4b and 5. A robotic approach was proposed, and consent was obtained.

RESULTS

The operation time was 300 min and was performed 21 days after the cholecystectomy. Estimated blood loss was 120 mL with no transfusions required during or after the procedure. The postoperative recovery was uneventful, and the patient was discharged on the fourth postoperative day. The final pathology showed no residual disease in the liver specimen and no metastases among 16 removed lymph nodes.

CONCLUSIONS

The robotic approach is safe and feasible for radical treatment after incidentally discovered gallbladder cancer. The Glissonian approach is useful for anatomic resection of liver segments 4b and 5. This video can help oncologic surgeons to perform this challenging procedure.

Incidental gallbladder cancer: what is the prevalence and how do we perform cholecystectomy for presumably benign biliary disease?

OBJECTIVE

to determine the prevalence of incidental gallbladder cancer (IGBC) in cholecystectomies performed in a tertiary public hospital and to describe technical and epidemiological aspects of performing cholecystectomies for presumably benign disease.

METHOD

descriptive, retrospective observational study, based on analysis of medical records of patients undergoing cholecystectomy with preoperative hypothesis of benign disease between January 2018 and January 2022.

RESULTS

prevalence of gallbladder adenocarcinoma in our sample was 0.16%, similar to data in the literature. Technical aspects during cholecystectomy were also described with a frequency similar to that found in the literature.

CONCLUSION

despite a rare disease, IGBC is relevant in the routine of the General Surgeon. Its diagnosis, staging and treatment directly affect the prognosis. Technical aspects during cholecystectomy are not always remembered by surgeons and can interfere with the prognosis and subsequent treatment of the patient.

Current management of incidental gallbladder cancer: A review

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

Câncer incidental de vesícula biliar: qual a prevalência e como operamos a colecistectomia por doença presumidamente benigna?

RESUMO Objetivos: determinar a prevalência de câncer incidental de vesícula biliar (CIVB) em colecistectomias realizadas em um hospital público terciário e descrever aspectos técnicos e epidemiológicos na realização de colecistectomias por doença presumidamente benigna. Método: estudo observacional descritivo, retrospectivo, a partir da análise de prontuários de pacientes submetidos à colecistectomia com hipótese pré-operatória de doença benigna entre janeiro de 2018 e janeiro de 2022. Resultados: a prevalência de adenocarcinoma de vesícula biliar na amostra avaliada foi de 0,16%, semelhante aos dados da literatura mundial. Os aspectos técnicos durante a realização da colecistectomia também foram descritos com frequência semelhante ao encontrado na literatura. Conclusão: o CIVB é uma doença rara mas de importância relevante na rotina do Cirurgião Geral. Seu diagnóstico, estadiamento e tratamento implicam diretamente no prognóstico. Aspectos técnicos durante a realização da colecistectomia nem sempre são lembrados pelos cirurgiões e podem interferir no prognóstico e tratamento subsequente do paciente.

Radical Resection Versus Simple Cholecystectomy for Gallbladder Carcinoma: A Systematic Review and Meta-analysis

PURPOSE

The goal of this study was to review relevant randomized controlled trials or case-control studies to determine radical resection compared with simple cholecystectomy for gallbladder carcinoma.

METHODS

Using appropriate keywords, we identified relevant studies using PubMed, the Cochrane Library, and Embase. Key pertinent sources in the literature were also reviewed, and all articles published through September 2019 were considered for inclusion. For each study, we assessed odds ratios, mean difference, and 95% confidence interval (CI) to assess and synthesize outcomes.

RESULTS

We included 19 studies with a total of 1791 patients in the radical resection group and 3014 in the simple cholecystectomy group. Compared with simple cholecystectomy, radical resection significantly improved the 5-year disease-free survival rate [relative risk (RR): 1.36, 95% CI: 1.02-1.81], the 1-year overall survival (OS) rate (RR: 1.27, 95% CI: 1.04-1.54), and the 3-year OS rate (RR: 1.71, 95% CI: 1.02-2.85). However, there was no significant difference in the recurrence rate (RR: 1.04, 95% CI: 0.87-1.23), and in the 5-year OS rate (RR: 1.05, 95% CI: 0.92-1.19) between the 2 groups.

CONCLUSION

Compared with simple cholecystectomy, radical resection has advantages in improving the 5-year disease-free survival rate, and the 1- and 3-year OS rate of gallbladder carcinoma patients.

Unusual Case of Gallbladder Adenocarcinoma Metastasis to the Abdominal Wall 11 Years Later: Synchronous Presentation with Two Malignant Colon Tumors, Coincidence or Not?

Introduction

Abdominal wall masses are a common finding in clinical practice. A high percentage of these masses are malignant. We present the case of a patient operated for a gallbladder adenocarcinoma, who consulted eleven years later for a malignant mass of the abdominal wall in synchrony with two adenocarcinomas of the left colon and sigmoid. Case Report. A 75-year-old male underwent a laparoscopic cholecystectomy with an incidental diagnosis of adenocarcinoma in situ (TisN0M0 according to AJCC 8th edition). The operative report mentioned that the removal of the gallbladder was difficult due to the inflammatory process, and the gallbladder was accidentally opened during the operation. It was not clear from the operative report whether an extraction bag was utilized to remove the specimen, but the histopathological study confirmed an open gallbladder. He presented 11 years later with an asymptomatic heterogeneous complex cystic mass involving the anterior rectus abdominis muscle. Colonoscopy showed synchronous tumors in the descending and sigmoid colon with pathology confirming adenocarcinoma. The patient underwent an elective laparotomy with resection of the anterior abdominal wall mass, left hemicolectomy, and sigmoidectomy. The histopathological results of the abdominal mass (CK7, CK20, EMA, CEA positive) were described as metastasis of adenocarcinoma of biliary origin. Discussion. Port site recurrences are rare complications following laparoscopic surgery when malignancy is unsuspected. Possible factors related to local implantation include direct seeding of spilled bile or tumor cells into the wound or shedding of tumor cells due to pneumoperitoneum-induced loss of the peritoneal barrier at the trocar site. In the absence of distant metastasis, treatment should include wide port site excision with malignancy-free surgical margins.

Conclusion

Abdominal wall metastasis from gallbladder carcinoma is rare, and its synchronous presentation with a malignant neoplasm of the colon is exceptional. This is the first report of a patient with abdominal wall metastasis from a gallbladder adenocarcinoma operated eleven years ago that debuted synchronously with two adenocarcinomas of the left colon and sigma.

Clinical practice guidelines for the management of biliary tract cancers 2019: The 3rd English edition

BACKGROUND

The Japanese Society of Hepato-Biliary-Pancreatic Surgery launched the clinical practice guidelines for the management of biliary tract cancers (cholangiocarcinoma, gallbladder cancer, and ampullary cancer) in 2007, then published the 2nd version in 2014.

METHODS

In this 3rd version, clinical questions (CQs) were proposed on six topics. The recommendation, grade for recommendation, and statement for each CQ were discussed and finalized by an evidence-based approach. Recommendations were graded as Grade 1 (strong) or Grade 2 (weak) according to the concepts of the Grading of Recommendations Assessment, Development, and Evaluation (GRADE) system.

RESULTS

The 31 CQs covered the six topics: (a) prophylactic treatment, (b) diagnosis, (c) biliary drainage, (d) surgical treatment, (e) chemotherapy, and (f) radiation therapy. In the 31 CQs, 14 recommendations were rated strong and 14 recommendations weak. The remaining three CQs had no recommendation. Each CQ includes a statement of how the recommendations were graded.

CONCLUSIONS

This latest guideline provides recommendations for important clinical aspects based on evidence. Future collaboration with the cancer registry will be key for assessing the guidelines and establishing new evidence.

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.

Long-term outcomes of incidental gallbladder carcinoma without additional resection: A single institution experiment

Incidental gallbladder carcinoma (IGC), defined as unexpected malignancy identified in the surgical gallbladder specimen of a cholecystectomy performed for a benign diagnosis, can be difficult to suspect preoperatively. Furthermore, there are valid clinical reasons to defer reoperation for additional resection, particularly in elderly patients. The present study aimed to determine the long-term outcomes and prognostic factors associated with recurrence in patients with IGC. The medical records of 678 patients who underwent cholecystectomy at Toyooka Hospital between September 2011 and November 2017 were reviewed. The cases identified to be IGC were retrospectively analyzed to determine patient and histopathological characteristics, surgical details, long-term outcomes and factors associated with cancer recurrence. A total of 22 patients were diagnosed with gallbladder carcinoma following cholecystectomy by histopathological examination, and 12 of these were identified to be IGC. The median age was 80 years (range 70-89 years). Although 6 of the 12 patients with IGC had stage pT2 or pT3 tumors, only 1 patient underwent additional resection. Recurrence occurred in 3 of the 8 patients who did not undergo additional resection and were available for long-term follow-up. Recurrence was not associated with the extent of tumor invasion but may be associated with other histopathological findings, preoperative treatment history and risk factors for recurrence. Furthermore, long-term survival was observed in patients with pT2 and pT3 tumors who did not undergo additional resection. Recurrence was not associated with the extent of tumor invasion but may be associated with other histopathological findings, preoperative treatment history, and risk factors for recurrence. Furthermore, long-term survival was observed in patients with pT2 and pT3 tumors who did not undergo additional resection. Even if it is a progressive IGC case, appropriate preoperative treatment or cholecystectomy without persistence of the carcinoma cell, based on a preoperative image evaluation and a postoperative histopathological examination, may greatly influence the long-term prognosis of IGC.

Incidental Carcinoma after Cholecystectomy for Benign Disease of the Gallbladder: A Meta-Analysis

This study aimed to determine the incidence and the prognosis of incidental carcinoma of the gallbladder (IGBC) after cholecystectomy through a meta-analysis. This meta-analysis included 51 studies and 436,636 patients with cholecystectomy. The incidence rate of IGBC after cholecystectomy was 0.6% (95% confidence interval (CI) 0.5%-0.8%). The incidence rate of recent studies was not significantly different from those of past studies. The mean age and female ratio of the IGBC subgroup were not significantly different from those of the overall patient group. The estimated rates of IGBC were 13.0%, 34.1%, 39.7%, 22.7%, and 12.5% in the pTis, pT1, pT2, pT3, and pT4 stages, respectively. Patients with IGBC had a favorable overall survival rate compared to patients with non-IGBC (hazard ratio (HR) 0.574, 95% CI 0.445-0.739). However, there was no significant difference of disease-free survival between the IGBC and non-IGBC subgroups (HR 0.931, 95% CI 0.618-1.402). IGBC was found in 0.6% of patients with cholecystectomy. The prognosis of patients with IGBC was favorable compared to those with non-IGBC. In the pathologic examination after cholecystectomy for benign diseases, a sufficient examination for histology should be guaranteed to detect IGBC.

Incidental gallbladder cancer after laparoscopic cholecystectomy: incidence, management, and prognosis

Aims

Although incidental gallbladder cancer (IGBC) diagnosed after laparoscopic cholecystectomy (LC) is not rare, its incidence, management, and prognosis are still unclear and controversial. The present study aimed to increase the understanding of IGBC after LC in the medical community.

Methods

Patients with IGBC treated at our institution between January 2001 and December 2018 were enrolled. Data collected included demographic characteristics, treatment pattern, pathological information, and prognoses. We compared the characteristics of patients with different prognoses and calculated the cumulative overall survival rate and mean survival period for IGBC.

Results

The cohort comprised 26 patients with a mean age of 66.4 ± 12.5 years. All patients were diagnosed with IGBC via postoperative pathology. Three patients underwent radical reoperation. As of June 2019, 26 patients were followed for a mean of 31.6 ± 29.6 months. Fourteen patients died during the follow‐up period, and 12 survived without recurrence. The mean survival duration was 50.5 months. The 1‐, 3‐, and 5‐year cumulative overall survival rates of the entire cohort were 79.8, 49.0, and 40.8%, respectively. IGBC patients with T1a stage had significantly longer survival than those with T1b or more advanced stages (96.1 vs 32.6 months, P = .006).

Conclusions

IGBC after LC is diagnosed in 0.2% of patients, accounting for 5.4% of all gallbladder cancer cases. IGBC patients with T1a stage had significantly longer survival than those with T1b or more advanced stages. Simple cholecystectomy is probably acceptable only in T1a lesions.

Comparative incidence of incidental gallbladder cancer in emergency cholecystectomies versus in elective cholecystectomies

OBJECTIVE

to comparatively analyse the incidence of incidental gallbladder cancer in emergency cholecystectomies versus in elective cholecystectomies performed in public hospitals in Teresina city, Piaui state (PI).

METHODS

descriptive, quantitative, observational, cross-sectional study, whose scenarios were two public hospitals in Teresina-PI. We analysed 6,329 medical records of patients undergoing cholecystectomy between January 2011 and December 2017. The collected data were divided into two groups and statistically compared using Z-test for difference between proportions.

RESULTS

incidental gallbladder cancer was detected in 6.53% of emergency cholecystectomies and in 0.38% of elective ones. Regarding gender, it was observed that in emergency surgeries 69% of patients were women and 31% men, while in elective procedures 78% were women and 22% men. Regarding age, most patients were over 60 years old, and, among these, 69.3% underwent emergency cholecystectomies and 82.6% underwent elective cholecystectomies. The histopathological type "adenocarcinoma" was found in 84.6% of patients who underwent emergency surgeries and in 100% of patients who underwent elective surgeries.

CONCLUSION

incidental gallbladder cancer was more frequent in urgent cholecystectomies compared to elective cholecystectomies. The profile of patients with this malignant disease in both types of procedure was female, older than 60 years, and with histopathological diagnosis of adenocarcinoma.

Analysis of Incidental Gallbladder Cancer in Cholecystectomies

OBJECTIVE

To study incidental gallbladder cancer (IGBC) incidence in patients who underwent cholecystectomy.

METHODS

The records of patients who underwent cholecystectomy between 2004-2019 were retrospectively reviewed. The demographic information, preoperative radiological findings of the patients diagnosed with gallbladder cancer (GBC), as a result of routine histopathological examination and operation records, were reviewed and findings were recorded. The preoperative radiological records of the patients with GBC and, if any, findings of GBC suspected during surgery were recorded.

RESULTS

Between 2004-2019, a total of 6314 patients underwent cholecystectomy. Of the patients, 5404 (85.59%) were female and 910 (14.41%) were male. The median age was 47 years (min:19, max:94) and the mean age was 47.28±14.60 years. Nine out of 6314 patients (0.14%) were diagnosed with GBC by postoperative histopathological examination. All patients with GBC were female and their mean age was 64.33±11.08 years. Two out of nine GBC cases were prediagnosed with GBC in preoperative radiological findings; the remaining seven (0.11%) had IGBC without any preoperative findings.

CONCLUSION

Asian populations are reported to have a higher incidence of GBC. Turkey is located in the transition zone between Asia and Europe. However, the GBC rates in our study remain far below the rates reported in Asian publications. We believe that our results may be affected by the predominantly Mediterranean-type diet and the relatively higher socioeconomic level of the region where we conducted our study. Consequently, we recommend routine histopathological examination after cholecystectomies in regions with a high incidence of GBC.

Prospective multi-center study of surgeon's assessment of the gallbladder compared to histopathological examination to detect incidental malignancy

PURPOSE

Routine histopathological examination after cholecystectomy for gallstones is performed despite the low rates of incidental findings of malignancy. The aim of this study was to assess predictive values of macroscopic examination of cholecystectomy specimens by surgeons in gallstone disease.

METHODS

A prospective multi-center diagnostic study was carried out between December 2015 and March 2017 at four different centers. All patients undergoing cholecystectomy for gallstone disease were consecutively screened for eligibility. Patients whose ages are 18 to 80 years, and preoperative imaging findings without any pathology except cholelithiasis were included. The gallbladder was first evaluated macroscopically ex situ by two operating surgeons and rated as macroscopically benign (group S1), suspicious for a benign diagnosis (group S2), and suspicious for malignancy (group S3). Thereafter, a pathologist made a final histopathological examination whose results are grouped as chronic cholecystitis (group P1), benign or precancerous lesions in which only cholecystectomy is the adequate treatment modality (group P2), and carcinoma (group P3). Diagnostic accuracy of the surgeon's assessment to the histopathological examination was evaluated using sensitivity, specificity, positive and negative predictive values, and accuracy, and correlated by a kappa agreement coefficient.

RESULTS

A total of 1112 patients were included in this trial. The specificity rates were 96.5%, 100%, and 98.7% for group S1-group S2, group S1-group S3, and group S2-group S3, respectively. Accuracy rates to detect malignancy were 100% and 95. 2% for group S1 and group S2, respectively. Kappa coefficient values were 1.0 and 0.64 for group S1-group S3 and group S2-group S3, respectively (p < 0.001 for both).

CONCLUSION

Assessment of the gallbladder specimen and selective histopathological examination may be adequate after cholecystectomy for gallstone diseases. Such a procedure would have the potential to reduce costs and prevent unnecessary loss of labor productivity without affecting patients' safety. However, higher number of patients in more centers is needed to confirm this hypothesis.

Intraoperative bile spillage is associated with worse survival in gallbladder adenocarcinoma

BACKGROUND

Gallbladder adenocarcinoma is often incidentally identified following cholecystectomy. We hypothesized that intraoperative bile spillage would be a negative prognostic factor.

METHODS

A retrospective review of patients treated at a cancer center with histologically confirmed gallbladder adenocarcinoma, 2009-2017, was performed. Patient, disease, and treatment factors were analyzed in terms of progression-free survival (PFS) and overall survival (OS).

RESULTS

Sixty-six patients were identified. Tumor stage was T1 (n = 8, 12%), T2 (n = 23, 35%), T3 (n = 35, 53%). Node stage was N0 (n = 22, 33%), N1+ (n = 26, 39%), Nx (n = 18, 27%). Operations included cholecystectomy alone (n = 27, 36%), cholecystectomy and partial hepatectomy (n = 30, 45%), or hepaticojejunostomy (n = 9, 14%). Median PFS was 7 months (interquartile range [IQR], 2-19); median OS was 16 months (IQR, 10-31). Subset multivariate proportional hazards regression of 41 patients who underwent initial cholecystectomy showed decreased PFS was associated with intraoperative spillage (n = 12, 29%; hazard ratio [HR], 5.5; P = .0014); decreased OS was associated with drain placement (n = 21, 51%; HR, 8.1; P = .006).

CONCLUSIONS

Intraoperative bile spillage and surgical drain placement at initial cholecystectomy are negatively associated with PFS and OS in gallbladder adenocarcinoma. Explicit documentation of spillage and drain placement rationale is critical, possibly indicating locally advanced disease and prompting stronger consideration of systemic therapy before definitive resection.

Is combined extra-hepatic bile-duct resection justified for advanced gallbladder carcinoma?

Background

Whether the extra-hepatic bile duct (EHBD) should be routinely resected for gallbladder carcinoma (GBC) remains controversial. The current study aimed to determine the clinical impact of combined EHBD resection during curative surgery for advanced GBC.

Methods

In total, 213 patients who underwent curative surgery for T2, T3 or T4 GBC were enrolled. The clinicopathological features were compared between the patients treated with EHBD resection and those without EHBD resection. Meanwhile, univariable and multivariable Cox-proportional hazards regression models were used to identify risk factors for overall survival (OS).

Results

Among the 213 patients identified, 87 (40.8%) underwent combined EHBD resection. Compared with patients without EHBD resection, patients with EHBD resection suffered more post-operative complications (33.3% vs. 21.4%, P = 0.046). However, the median OS of the EHBD resection group was longer than that of the non-EHBD resection group (25 vs. 11 months, P = 0.008). Subgroup analyses were also performed according to tumor (T) category and lymph-node metastasis. The median OS was significantly longer in the EHBD resection group than in the non-EHBD resection group for patients with T3 lesion (15 vs. 7 months, P = 0.002), T4 lesion (11 vs. 6 months, P = 0.021) or lymph-node metastasis (12 vs. 7 months, P < 0.001). No survival benefit of EHBD resection was observed in GBC patients with T2 lesion or without lymph-node metastasis. T category, lymph-node metastasis, margin status, pre-operative CA19-9 level and EHBD resection were identified as independent prognostic factors for OS of patients with advanced GBC (all P values <0.05). Conclusions EHBD resection can independently affect the OS in advanced GBC. For GBC patients with T3 lesion, T4 lesion and lymph-node metastasis, combined EHBD resection is justified and may improve OS.

Systematic review of management of incidental gallbladder cancer after cholecystectomy

BACKGROUND

Gallbladder cancer is rare, but cancers detected incidentally after cholecystectomy are increasing. The aim of this study was to review the available data for current best practice for optimal management of incidental gallbladder cancer.

METHODS

A systematic PubMed search of the English literature to May 2018 was conducted.

RESULTS

The search identified 12 systematic reviews and meta-analyses, in addition to several consensus reports, multi-institutional series and national audits. Some 0·25-0·89 per cent of all cholecystectomy specimens had incidental gallbladder cancer on pathological examination. Most patients were staged with pT2 (about half) or pT1 (about one-third) cancers. Patients with cancers confined to the mucosa (T1a or less) had 5-year survival rates of up to 100 per cent after cholecystectomy alone. For cancers invading the muscle layer of the gallbladder wall (T1b or above), reresection is recommended. The type, extent and timing of reresection remain controversial. Observation time may be used for new cross-sectional imaging with CT and MRI. Perforation at initial surgery had a higher risk of disease dissemination. Gallbladder cancers are PET-avid, and PET may detect residual disease and thus prevent unnecessary surgery. Routine laparoscopic staging before reresection is not warranted for all stages. Risk of peritoneal carcinomatosis increases with each T category. The incidence of port-site metastases is about 10 per cent. Routine resection of port sites has no effect on survival. Adjuvant chemotherapy is poorly documented and probably underused.

CONCLUSION

Management of incidental gallbladder cancer continues to evolve, with more refined suggestions for subgroups at risk and a selective approach to reresection.

Laparoscopic Excisional Cholecystectomy with Full-Thickness Frozen Biopsy in Suspected Gallbladder Carcinoma

Owing to the advantages of a laparoscopic approach, laparoscopic cholecystectomy (LC) is thought to be the treatment of choice in gallbladder disease, even in cases of suspected malignancy. However, it is difficult to differentiate between cholecystitis and gallbladder carcinoma (GBC). We performed radical hepatectomy in patients with pT2 GBC diagnosed by full-thickness frozen biopsy. A 75-year-old Japanese man presented to our hospital with discomfort in the right upper quadrant of the abdomen. This patient was diagnosed with suspected GBC and was scheduled to undergo LC and intraoperative histological examination. Following the procedure, we made a diagnosis of GBC with negative invasion of the cystic duct stump. We converted the laparoscopic procedure to an open surgery involving wedge liver resection with lymphadenectomy. The patient was discharged from our hospital in remission 14 days following the radical hepatectomy. Histological examination showed that the GBC had invaded the liver (T3a), but there was no lymph node metastasis (N0): stage IIIA. Between April 2009 and September 2018, 580 patients underwent cholecystectomy for gallbladder disease at our hospital. Among these, 8 (1.4%) were suspected to have GBC preoperatively and underwent laparoscopic excisional cholecystectomy. We performed elective surgery in the early stage in two patients and second-look surgery in two patients recently. We were able to perform what we termed a laparoscopic excisional cholecystectomy, involving LC with a full-thickness frozen biopsy, even in situations where intraoperative histological examination was not available. Altogether, laparoscopic excisional cholecystectomy is an effective surgical treatment for suspected early GBC.

Gallbladder cancer in Eastern Province of Saudi Arabia: A retrospective cohort study

BACKGROUND

There is paucity in the literature regarding gallbladder cancer in Saudi Arabia, possibly because it is not among the top 10 cancers diagnosed nationwide according to the Saudi Cancer Registry. Moreover, national or regional data on gallbladder cancer in Saudi Arabia have not been analyzed. The purpose of this study was to describe the presentation, disease stage, histology, and survival rates for gallbladder cancer in Saudi patients at a single institution between January 1, 2010 and December 31, 2017.

MATERIALS AND METHODS

This was a retrospective study of 76 patients who presented to our hospital between January 1, 2010 and December 31, 2017, with established diagnosis of gallbladder carcinoma. The diagnosis was made either histopathologically following simple laparoscopic cholecystectomy or biopsy from metastatic liver lesion in patients with gallbladder mass, or the high suspicion of gallbladder carcinoma based on incidental radiological findings. Presentation, disease stage, histology, and treatment modalities were analyzed using descriptive statistics and frequency distributions. Survival rates were analyzed and presented using Kaplan-Meier curves.

RESULTS

Based on initial analyses the disease was more frequent among women (62.0%) than men (39.0%). Surgical resection was attempted in 40.8% patients. The average age at presentation and diagnosis of gallbladder carcinoma was 62.4 years. The disease had two peaks, one at 51.0 years and the other between 66.0 and 70.0 years. The median survival time for the overall at-risk patients was only 1.0 year, while for stage IVB patients was 7.2 months. Adenocarcinoma not otherwise specified (NOS) was the most common histopathology type (75.0%), with most patients presenting with stage IVB disease (75.0%). Gallbladder carcinoma was incidentally detected in 42.1%, including three cases (3.9%) diagnosed at our hospital.

CONCLUSIONS

Gallbladder cancer is a rare type of cancer in Saudi Arabia, and most patients are treated surgically, despite being mostly diagnosed at the advanced stage of the disease.

Surgical strategy for suspected early gallbladder carcinoma including incidental gallbladder carcinoma diagnosed during or after cholecystectomy

Purpose

This paper presents an overview of the surgical strategy for patients with suspected gallbladder carcinoma (GBC), including incidental GBC cases, preoperatively or intraoperatively, as well as their outcomes.

Methods

Between April 2009 and December 2017, 529 patients underwent cholecystectomy for gallbladder disease at our hospital. Both intraoperative and postoperative histological examinations of the excised gallbladder facilitated the diagnosis of GBC. Surgery-related variables and surgical approaches were evaluated according to the extent of tumor invasion.

Results

Of 529 patients, eight were diagnosed with GBC during/after cholecystectomy, including four women and four men. Mean age was 75.4 (range, 59–89) years. Five patients had gallbladder stones and three had cholecystitis. Three patients with stages T1b and T2 underwent additional liver bed wedge resections with or without prophylactic common bile duct excision. Five of the eight patients are still alive and two of the remaining three died from other diseases; one patient with pT3 died of recurrent GBC (peritonitis carcinomatosa).

Conclusion

Because of the ability to obtain full-thickness frozen biopsies during laparoscopic cholecystectomy, we could diagnose GBC intraoperatively, allowing for rapid diagnosis and tumor resection. We recommend developing a surgical treatment strategy for suspected early GBC in advance of cholecystectomy.

•

Gallbladder carcinoma can be diagnosed during or after cholecystectomy.

•

Frozen biopsies from cholecystectomy allow for the intraoperative diagnosis of GBC.

•

The intraoperative diagnosis of GBC facilitates surgical resection of tumors.

•

Surgical strategies incorporating intraoperative diagnosis should be developed.

Laparoscopic versus open treatment of gallbladder cancer: A systematic review and meta-analysis

Background:

The aim of this review was to evaluate the effect of laparoscopic surgery on the treatment of patients with gallbladder cancer (GBC).

Methods:

A comprehensive search of Medline and Cochrane Library was conducted to identify relevant articles. A meta-analysis was subsequently performed.

Results:

A total of 20 studies including 1217 patients met the inclusion criteria. The meta-analysis showed that the 5-year survival rate was significant higher in laparoscopic group than open group (48.4% vs. 38.5%; odds ratio [OR], 1.63; 95% confidence interval [CI], 1.22–2.19; P = 0.001). Although the scar recurrence rate was significant higher in laparoscopic group than open group (7.1% vs. 4.0%; OR, 2.10; 95% CI, 1.11–3.96; P = 0.02), the overall recurrence rates between two groups were not significant different (44.8% vs. 42.2%; OR, 0.86; 95% CI, 0.64–1.14; P = 0.29). In addition, compared with open extended cholecystectomy (EC), laparoscopic EC (LEC) was associated with less intraoperative blood loss, shorter post-operative hospital stays and insignificant less complication rate (10.0% vs. 18.3%; OR, 0.51; 95% CI, 0.15–1.73; P = 0.28).

Conclusion:

Laparoscopic simple cholecystectomy does not lead to a worse prognosis when applied on patients with GBC. LEC can be performed in specialised expert centres on elective patients.

Minimally invasive surgical approach for radicalization of incidental post-cholecystectomy gallbladder carcinoma: safety, feasibility and outcomes

BACKGROUND AND AIMS

Gallbladder carcinoma is a rare but aggressive malignant neoplasm. The incidence of intra- or post-operative incidental gallbladder carcinoma diagnosis following laparoscopic cholecystectomy is estimated to be 1-2%. Aggressive re-resection is warranted as the majority of patients have residual disease either in the liver or the lymph nodes. However the use of a minimally invasive surgical approach (MISA) to perform a radicalization in these patients has not been investigated yet. We retrospectively analyzed surgical and oncologic outcome of a small selected cohort of patients with incidental gallbladder carcinoma whom underwent redo radicalization surgery by MISA.

MATERIAL AND METHODS

From April 2012 to June 2014 at our department six patients (three females and three males) with incidental findings of gallbladder carcinoma pT1b (stage I) following laparoscopic cholecystectomy, and referred to our center from other secondary-level referral hospitals, underwent a redo surgery for radicalization by means of laparoscopic (n. 3) or robotic approach (n. 3). A retrospective analysis of prospective collected data was performed.

RESULTS

The redo procedure consisted of a liver resection (segments IVb + V) and lymph nodes clearance of hepatoduodenal hilum and common hepatic artery. Conversion rate was zero. Median operative time was 290 (250-310) min. Estimate blood loss was 175 (100-350) ml. Total hospital stay was 6 (5-10) days. All liver resections were performed without inflow vascular clamping. One patient was re-operated for hemoperitoneum while peri-operative mortality was zero. Oncologically, an R0 resection was always achieved with a mean number of lymph nodes retrieved of 17,5 (14-22). The stage of the neoplasm was confirmed in all cases but one, who was found to have a pN1 status (stage IIIb). At 21 (6-32) months follow-up all patients are alive and no recurrence has been observed.

CONCLUSIONS

Our data suggest that radicalization of patients with stage I incidental postoperative gallbladder carcinoma can be done by a MISA without compromising the oncologic outcome. Larger studies are needed to validate these results.

Threonine and tyrosine kinase may serve as a prognostic biomarker for gallbladder cancer

AIM

To detect the expression of threonine and tyrosine kinase (TTK) in gallbladder cancer (GBC) specimens and analyze the associations between TTK expression and clinicopathological parameters and clinical prognosis.

METHODS

A total of 68 patients with GBC who underwent surgical resection were enrolled in this study. The expression of TTK in GBC tissues was detected by immunohistochemistry. The assessment of TTK expression was conducted using the H-scoring system. H-score was calculated by the multiplication of the overall staining intensity with the percentage of positive cells. The expression of TTK in the cytoplasm and nucleus was scored separately to achieve respective H-score values. The correlations between TTK expression and clinicopathological parameters and clinical prognosis were analyzed using Chi-square test, Kaplan-Meier method and Cox regression.

RESULTS

In both the nucleus and cytoplasm, the expression of TTK in tumor tissues was significantly lower than that in normal tissues (P < 0.001 and P = 0.026, respectively). Using the median H-score as the cutoff value, it was discovered that, GBC patients with higher levels of TTK expression in the nucleus, but not the cytoplasm, had favorable overall survival (P < 0.001), and it was still statistically meaningful in Cox regression analysis. Further investigation indicated that there were close negative correlations between TTK expression and tumor differentiation (P = 0.041), CA 19-9 levels (P = 0.016), T stage (P < 0.001), nodal involvement (P < 0.001), distant metastasis (P = 0.024) and TNM stage (P < 0.001).

CONCLUSION

The expression of TTK in GBC is lower than that in normal tissues. Higher levels of TTK expression in GBC are concomitant with longer overall survival. TTK is a favorable prognostic biomarker for patients with GBC.

Long-term survival after multidisciplinary therapy for residual gallbladder cancer with peritoneal dissemination: a case report

Background

Although surgical resection is the only curative treatment for gallbladder cancer (GBC), concomitant peritoneal dissemination is considered far beyond the scope of resection. We report a long-term survivor with a residual GBC with multiple peritoneal disseminations who underwent an extended resection after effective chemotherapy.

Case presentation

A 59-year-old male underwent an open cholecystectomy for Mirizzi syndrome at a local hospital. Because of severe inflammation, the gallbladder was perforated during surgery, ending in a piecemeal resection. A pathological examination revealed GBC with positive margins, and the patient was referred to our hospital 1 month after surgery for further treatment. A multidetector-row computed tomography (MDCT) showed three hypoattenuated tumours: a tumour (3.9 cm) at the left medial segment corresponding to the gallbladder bed, a tumour (1.8 cm) around the hepatic flexure of the transverse colon, and a tumour (1.0 cm) at the stump of the cystic duct. Percutaneous needle biopsy was performed, which provided histologic evidence of adenocarcinoma. Thus, the patient had a rapidly progressive local relapse with limited peritoneal dissemination, labelled ycT3N0M1, stage IVB disease according to the UICC system. After the administration of 3 cycles of gemcitabine plus cisplatin combination chemotherapy, the size of all tumours and the CA19-9 level decreased significantly. Since the patient’s general condition and liver function reserve were satisfactory, we decided the initial unresectable scenario to perform surgical therapy. After portal vein embolization, right hepatectomy, resection of the extrahepatic bile duct, partial duodenectomy, and partial colectomy were performed. Operative time was 555 min, and intraoperative blood loss was 1654 mL. Pathologic diagnosis of residual gallbladder carcinoma with peritoneal dissemination was confirmed, and the surgical margins were tumour-free. The patient was discharged on postoperative day 29, with a Clavien-Dindo IIIa complication (abdominal wall abscess). Postoperative adjuvant chemotherapy with tegafur/gimeracil/oteracil was administered during 1 year after surgery. The patient is doing well 6 years after the second surgery without evidence of disease.

Conclusions

Although specific clinical factors were associated with a favourable outcome in this patient, the present report suggests that multidisciplinary therapy may be a promising option in selected patients with distant metastatic GBC.

Evaluation of surgical treatment for incidental gallbladder carcinoma diagnosed during or after laparoscopic cholecystectomy: single center results

BACKGROUND

Laparoscopic cholecystectomy (LC) is the accepted standard management for benign gallbladder disease. LC rarely results in a diagnosis of incidental gallbladder carcinoma (IGBC). The aim of our study was to report our experience with IGBC diagnosed during or following LC.

METHODS

Between January 2008 and January 2015, 352 patients underwent LC at Iwakuni Clinical Center. Among these patients, 8 (2.3%) were diagnosed with IGBC. We evaluated their characteristics, surgical related variables, histopathological findings and surgical outcomes.

RESULTS

Patient median age was 71 (range 49-88) years, and 3 out of 8 were female. All patients with IGBC were Japanese. The grade of cancer was as follows: pT1a (3 cases), pT2 (4 cases) and pT3 (1 case). Two patients with pT2 disease underwent radical surgery. The median follow-up time of these patients was 24 (range 11-80) months. All patients are still alive and two of three patients who refused radical surgery have developed recurrence (liver metastases and recurrence in the peritoneum).

CONCLUSIONS

Although the number of cases was small, the results of this study further support the suggestion that gallbladder carcinoma may be curable if diagnosed as IGBC at an early stage. If the cancer has reached an advanced stage, radical surgery should be performed.

Incidental gallbladder cancer after cholecystectomy: 1990 to 2014

INTRODUCTION

Cancer of the gallbladder is a serious diagnostic and therapeutic problem. According to the literature, 30% of cases are not confirmed before surgery. Other cases are detected incidentally by histopathology. Clinical trials and meta-analyses show that incidental gallbladder cancer (iGBC) occurs in 0.19%-2.8% of patients after cholecystectomy. The aim of this study was to analyze the incidence and severity of iGBC in cholecystectomy procedures performed in the surgical department at the 4th Military Teaching Hospital in Wroclaw during the years 1990-2014.

PATIENTS AND METHODS

In the years 1990-2014, a total of 7,314 cholecystectomies were performed in the surgical department because of cholecystolithiasis: 6,145 were performed using the laparoscopic approach (84.02%), 867 were performed as open surgery (11.8%), and 302 cases required conversion (5.1%). In this group, 5,214 of the patients were females (71.3%) and 2,100 were males (28.7%), with an average age of 54.7 years.

RESULTS

We found 64 iGBC cases which were confirmed by histopathology. This represented 0.87% of all cases. In this group, 50 patients were females (78.1%) and 14 were males (21.8%), with an average age of 67.1 years. Of this group, 40 patients underwent a classic cholecystectomy, while 24 underwent laparoscopic procedures, out of which 13 cases ultimately required traditional surgery. The histopathology showed 15 carcinomas that were classified as G1 (23.4%), 28 were G2 (43.75%), and 21 were G3 (32.8%).

CONCLUSION

iGBC detected after a cholecystectomy due to cholecystolithiasis is a rare disease. We found iGBC in 0.87% of cases, which is on a comparable scale to the world literature. In the case of cancer, we frequently found it necessary to convert to an open surgical procedure. This cancer is more common in females and in people over 60 years of age.

Risk factors for conversion to conventional laparoscopic cholecystectomy in single incision laparoscopic cholecystectomy

Purpose

The aim of this study was to investigate the risk factors for conversion to conventional laparoscopic cholecystectomy (CLC) in single incision laparoscopic cholecystectomy (SILC) along with the proposal for procedure selection guidelines in treating patients with benign gallbladder (GB) diseases.

Methods

SILC was performed in 697 cases between April 2010 and July 2014. Seventeen cases (2.4%) underwent conversion to conventional LC. We compared these 2 groups and analyzed the risk factors for conversion to CLC.

Results

In univariate analysis, American Society of Anesthesiologist score > 3, preoperative percutaneous transhepatic GB drainage status and pathology (acute cholecystitis or GB empyema) were significant risk factors for conversion (P = 0.010, P = 0.019 and P < 0.001). In multivariate analysis, pathology (acute cholecystitis or GB empyema) was significant risk factors for conversion to CLC in SILC (P < 0.001).

Conclusion

Although SILC is a feasible method for most patients with benign GB disease, CLC has to be considered in patients with acute cholecystitis or GB empyema because it is likely to result in inadequate visualization of the Calot's triangle and greater bleeding risk.

Impact of Type of Surgery on Survival Outcome in Patients With Early Gallbladder Cancer in the Era of Minimally Invasive Surgery: Oncologic Safety of Laparoscopic Surgery

Laparoscopic surgery has been widely accepted as a feasible and safe treatment modality in many cancers of the gastrointestinal tract. However, most guidelines on gallbladder cancer (GBC) regard laparoscopic surgery as a contraindication, even for early GBC. This study aims to evaluate and compare recent surgical outcomes of laparoscopic and open surgery for T1(a,b) GBC and to determine the optimal surgical strategy for T1 GBC.The study enrolled 197 patients with histopathologically proven T1 GBC and no history of other cancers who underwent surgery from 2000 to 2014 at 3 major tertiary referral hospitals with specialized biliary-pancreas pathologists and optimal pathologic handling protocols. Median follow-up was 56 months. The effects of depth of invasion and type of surgery on disease-specific survival and recurrence patterns were investigated.Of the 197 patients, 116 (58.9%) underwent simple cholecystectomy, including 31 (15.7%) who underwent open cholecystectomy and 85 (43.1%) laparoscopic cholecystectomy. The remaining 81 (41.1%) patients underwent extended cholecystectomy. Five-year disease-specific survival rates were similar in patients who underwent simple and extended cholecystectomy (96.7% vs 100%, P = 0.483), as well as being similar in patients in the simple cholecystectomy group who underwent open and laparoscopic cholecystectomy (100% vs 97.6%, P = 0.543). Type of surgery had no effect on recurrence patterns.Laparoscopic cholecystectomy for T1 gallbladder cancer can provide similar survival outcomes compared to open surgery. Considering less blood loss and shorter hospital stay with better cosmetic outcome, laparoscopic cholecystectomy can be justified as a standard treatment for T1b as well as T1a gallbladder cancer when done by well-experienced surgeons based on exact pathologic diagnosis.

Totally Laparoscopic Hepatic Bisegmentectomy (s4b+s5) and Hilar Lymphadenectomy for Incidental Gallbladder Cancer

BACKGROUND

Gallbladder cancer is suspected preoperatively in only 30 % of all patients, while the remaining 70 % of cases are discovered incidentally by the pathologist. The increasing rate of cholecystectomies via laparoscopy has led to the detection of more gallbladder cancers in an early stage, and extended resection with regional lymph node dissection has been suggested. We present a video of a totally laparoscopic liver resection (segments 5 and 4b) with regional lymphadenectomy in a patient with an incidental gallbladder cancer.

METHODS

A 50-year-old woman underwent laparoscopic cholecystectomy, and pathology revealed a T1b gallbladder carcinoma. The patient was referred for further treatment. Contact with the primary surgeon revealed that no intraoperative cholangiogram was performed, and the gallbladder was removed intact, with no perforation, and inside a plastic retrieval bag. Pathology revision confirmed T1b, and positron emission tomography/computed tomography was negative. The multidisciplinary tumor board recommended radical re-resection, and a decision was made to perform a laparoscopic extended hilar lymphadenectomy, along the resection of segments 5 and 4b.

RESULTS

Operative time was 5 h, with an estimated blood loss of 240 mL. Recovery was uneventful and the patient was discharged on the fourth postoperative day. Final pathology showed no residual disease and no lymph node metastasis.

CONCLUSIONS

Laparoscopic resection of liver segments 5 and 4b combined with a locoregional lymphadenectomy of the hepatoduodenal ligament is an oncologically appropriate technique, provided it is performed in a specialized center with experience in hepatobiliary surgery and advanced laparoscopic surgery. This video may help oncological surgeons to perform this complex procedure.

Loss of angiotensin-converting enzyme 2 promotes growth of gallbladder cancer

The aim of this study is to investigate the role of angiotensin-converting enzyme 2 (ACE2) in gallbladder cancer (GBC) and the therapeutic potential of angiotensin receptor blocker in GBC. Human gallbladder epithelial cells (HGBEC) together with GBC cells and tissue samples were used. In vitro studies were carried out to investigate the role of ACE2 in GBC cells. ACE2 levels were studied in in vivo GBC mouse models subject to ARB treatment. ACE2 level was decreased in GBC cells compared with that in normal gallbladder cells. Replenishment of angiotensin II (A2) promoted tumour cell growth, which could be mitigated by ACE2 supplement. ARB blocked A2-induced GBC cell growth and activated ERK. Activity of mTOR was not altered with different ACE2 status. ARB inhibited tumour growth in xenograft mouse models. In vivo study also showed that decreased expression of ACE2 was associated with enlarged tumour size. By genetic replenishment of ACE2 and pharmaceutical use of ARB, restored ACE2 level mitigated GBC growth. Our results supported the rationale for the use of ARB in GBC patients for potential therapeutic benefit.