Laparoscopic radical cholecystectomy with lymph node dissection for gallbladder carcinoma

Role of Minimally Invasive Reoperation for Postoperatively Diagnosed T2 Gallbladder Cancer: Multicenter Retrospective Cohort Study

BACKGROUND

Although T2 gallbladder cancer (GBC) incidentally diagnosed after cholecystectomy requires additional resection, the surgical approaches are technically difficult due to inflammatory adhesion or fibrosis around the hepatoduodenal ligament and gallbladder bed. In this study, we sought to compare the surgical and oncologic outcomes of open and minimally invasive reoperation for postoperatively diagnosed T2 GBC.

STUDY DESIGN

Patients who underwent open (110) and laparoscopic (38) reoperation for T2 GBC between November 2004 and October 2022 at 5 tertiary referral centers were included in this multicenter retrospective cohort study. The short- and long-term outcomes were compared between the 2 groups.

RESULTS

There were no differences in clinicopathologic characteristics between the open and laparoscopic groups. Liver resection was more frequent in the open group (101 [91.8%] vs 21 [55.3%], p < 0.001). Compared with open operation, laparoscopic reoperation was associated with shorter postoperative hospital stay (9.0 [8.0 to 10.0] vs 6.0 [3.8 to 8.3] days, p < 0.001) and a lower postoperative complication rate (24 [21.8%] vs 1 [2.6%], p = 0.013). Among patients who underwent liver resection, the postoperative hospital stay was shorter in the laparoscopic group (9.0 [8.0 to 10.0] vs 6.0 [4.0 to 9.0] days, p = 0.004). The 5-year disease-free survival (66.7% vs 76.1%, p = 0.749) and overall survival (75.2% vs 73.7%, p = 0.789) rates were not significantly different between the 2 groups.

CONCLUSIONS

The results indicate that laparoscopic reoperation for postoperatively diagnosed T2 GBC has favorable postoperative outcomes and similar oncologic safety compared with open operation.

Short- and long-term outcomes of laparoscopic radical gallbladder resection for gallbladder carcinoma: A multi-institutional retrospective study in Japan

BACKGROUND/PURPOSE

Laparoscopic resection of gallbladder carcinomas remains controversial. This study aimed to evaluate the surgical and oncological outcomes of laparoscopic procedures for suspected gallbladder carcinoma (GBC).

METHODS

In this retrospective study, data regarding suspected GBC treated with laparoscopic radical cholecystectomy before 2020 in Japan, was included. Patient characteristics, surgical procedure details, surgical outcomes, and long-term outcomes were analyzed.

RESULTS

Data of 129 patients with suspected GBC who underwent laparoscopic radical cholecystectomy were retrospectively collected from 11 institutions in Japan. Among them, 82 patients with pathological GBC were included in the study. Laparoscopic gallbladder bed resection was performed in 114 patients and laparoscopic resection of segments IVb and V was performed in 15 patients. The median operation time was 269 min (range: 83-725 min), and the median intraoperative blood loss was 30 mL (range: 0-950 mL). The conversion and postoperative complication rates were 8% and 2%, respectively. During the follow-up period, the 5-year overall survival rate was 79% and the 5-year disease-free survival rate was 87%. Recurrence was detected in the liver, lymph nodes, and other local tissues.

CONCLUSION

Laparoscopic radical cholecystectomy is a treatment option with potential favorable outcomes in selected patients with suspected GBC.

Application of laparoscopic surgery in gallbladder carcinoma

Gallbladder carcinoma (GC) is a rare type of cancer of the digestive system, with an incidence that varies by region. Surgery plays a primary role in the comprehensive treatment of GC and is the only known cure. Compared with traditional open surgery, laparoscopic surgery has the advantages of convenient operation and magnified field of view. Laparoscopic surgery has been successful in many fields, including gastrointestinal medicine and gynecology. The gallbladder was one of the first organs to be treated by laparoscopic surgery, and laparoscopic cholecystectomy has become the gold standard surgical treatment for benign gallbladder diseases. However, the safety and feasibility of laparoscopic surgery for patients with GC remain controversial. Over the past several decades, research has focused on laparoscopic surgery for GC. The disadvantages of laparoscopic surgery include a high incidence of gallbladder perforation, possible port site metastasis, and potential tumor seeding. The advantages of laparoscopic surgery include less intraoperative blood loss, shorter postoperative hospital stay, and fewer complications. Nevertheless, studies have provided contrasting conclusions over time. In general, recent research has tended to support laparoscopic surgery. However, the application of laparoscopic surgery in GC is still in the exploratory stage. Here, we provide an overview of previous studies, with the aim of introducing the application of laparoscopy in GC.

Current status and progress in laparoscopic surgery for gallbladder carcinoma

Gallbladder carcinoma (GBC) is the most common biliary tract malignancy associated with a concealed onset, high invasiveness and poor prognosis. Radical surgery remains the only curative treatment for GBC, and the optimal extent of surgery depends on the tumor stage. Radical resection can be achieved by simple cholecystectomy for Tis and T1a GBC. However, whether simple cholecystectomy or extended cholecystectomy, including regional lymph node dissection and hepatectomy, is the standard surgical extent for T1b GBC remains controversial. Extended cholecystectomy should be performed for T2 and some T3 GBC without distant metastasis. Secondary radical surgery is essential for incidental gall-bladder cancer diagnosed after cholecystectomy. For locally advanced GBC, hepatopancreatoduodenectomy may achieve R0 resection and improve long-term survival outcomes, but the extremely high risk of the surgery limits its implementation. Laparoscopic surgery has been widely used in the treatment of gastrointestinal malignancies. GBC was once regarded as a contraindication of laparoscopic surgery. However, with improvements in surgical instruments and skills, studies have shown that laparoscopic surgery will not result in a poorer prognosis for selected patients with GBC compared with open surgery. Moreover, laparoscopic surgery is associated with enhanced recovery after surgery since it is minimally invasive.

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.

Laparoscopic versus open oncological extended re-resection for incidental gallbladder adenocarcinoma: we can do more than T1/2

BACKGROUND

The laparoscopic and open approaches have comparable safety and oncological efficacy to treat early (T1b or T2) stage incidental gallbladder cancer (IGBC). However, their effects on T3 stage or above tumors unclear.

METHODS

Data of IGBC patients who underwent radical re-resection were retrospectively analyzed. Demographic characteristics, surgical variables, and tumor characteristics were evaluated for association with survival.

RESULTS

We analyzed retrospectively 201 patients (72 men, 129 women; median age 63 years; range, 36-85 years). 84 underwent laparoscopic re-resection and 117 underwent open surgery. The 5-year OS post-resection was 74.7%, with a median survival of 74.52 months. The median OS (73.92 months vs. 77.04 months, P = 0.67), and disease-free survival (72.60 months vs. 71.09 months, P = 0.18) were comparable between the laparoscopic re-resection and open surgery groups. The survival of patients with T1/T2 (median: 85.50 months vs. 80.14 months; P = 0.67) and T3 (median: 68.56 months vs. 58.85 months; P = 0.36) disease were comparable between the open re-resection and laparoscopic re-resection groups even after PS matching. Open surgery group lost significantly more blood, while laparoscopic surgery took longer. The postsurgical stay in the laparoscopic re-resection group was significantly shorter. Combined extrahepatic bile duct resection, gallbladder perforation, pT, pStage, histological grade, microscopic liver invasion, status of the resected margin, and adjuvant therapy comprised significant independent prognostic indicators for IGBC.

CONCLUSIONS

Laparoscopic and open surgery can achieve similar short and long-term outcomes for T3 IGBC; however, careful surgical manipulation is necessary to avoid secondary injuries.

Short- and long-term outcomes of laparoscopic vs open surgery for T2 gallbladder cancer: A systematic review and meta-analysis

BACKGROUND

With the development of laparoscopic techniques, gallbladder cancer (GBC) is no longer a contraindication to laparoscopic surgery (LS). Although LS is recommended for stage T1 GBC, the value of LS for stage T2 GBC is still controversial.

AIM

To evaluate the short- and long-term outcomes of LS in comparison to those of open surgery (OS) for stage T2 GBC.

METHODS

We searched the PubMed, Embase, Cochrane Library, Ovid, Google Scholar, and Web of Science databases for published studies comparing the efficacy of LS and OS in the treatment of stage T2 GBC, with a cutoff date of September 2022. The Stata 15 statistical software was used for analysis. Relative risk (RR) and weighted mean difference (WMD) were calculated to assess binary and continuous outcome indicators, respectively. Begg’s test and Egger’s test were used for detecting publication bias.

RESULTS

A total of five studies were included, with a total of 297 patients, 153 in the LS group and 144 in the OS group. Meta-analysis results showed that the LS group was better than the OS group in terms of operative time [WMD = -41.29, 95% confidence interval (CI): -75.66 to -6.92, P = 0.02], estimated blood loss (WMD = -261.96, 95%CI: -472.60 to -51.31, P = 0.01), and hospital stay (WMD = -5.67, 95%CI: -8.53 to -2.81, P = 0.0001), whereas there was no significant difference between the two groups in terms of blood transfusion (RR = 0.60, 95%CI: 0.31-1.15, P = 0.13), complications (RR = 0.72, 95%CI: 0.39-1.33, P = 0.29), number of lymph nodes retrieved (WMD = –1.71, 95%CI: -4.27 to -0.84, P = 0.19), recurrence (RR = 0.41, 95%CI: 0.06-2.84, P = 0.36), 3-year and 5-year overall survival (RR = 0.99, 95%CI: 0.82-1.18, P = 0.89 and RR = 1.02, 95%CI: 0.68-1.53, P = 0.92; respectively), and 3-year and 5-year disease-free survival (RR = 1.01, 95%CI: 0.84-1.21, P = 0.93 and RR = 1.15, 95%CI: 0.90-1.46, P = 0.26; respectively).

CONCLUSION

The long-term outcomes of LS for T2 GBC are similar to those of OS, but LS is superior to OS in terms of operative time, intraoperative bleeding, and postoperative hospital stay. Nevertheless, these findings should be validated via high-quality randomized controlled trials and longer follow-ups.

Laparoscopic segment 4b+5 liver resection for stage T3 gallbladder cancer

BACKGROUND

There is still controversy over whether to perform laparoscopic surgery for T3 stage gallbladder cancer. In addition, the necessity of segment 4b+5 liver resection for stage T3 gallbladder has not been reported. This article aims to explore the safety, effectiveness, and short-term prognosis of laparoscopic segment 4b+5 liver resection for T3 stage gallbladder cancer.

METHODS

This is a retrospective multicenter propensity score-matched study. Disease-free survival, perioperative complications, and intraoperative safety were analyzed to evaluate safety and effectiveness.

RESULTS

There was no significant difference in the incidence of intraoperative bleeding, number of lymph nodes obtained, postoperative complications, or disease-free survival (DFS) between the open group (OG) and laparoscopic group (LG) (P > 0.05). The DFS time of the S4b+5 resection group (S4b5) was longer than that of the wedge group (P = 0.016). Cox regression showed that positive margins (HR, 5.32; 95% CI 1.03-27.63; P = 0.047), lymph node metastasis (HR, 2.70; 95% CI 1.31-5.53; P = 0.007), and liver S4b+5 resection (HR, 0.30; 95% CI 0.14-0.66; P = 0.003) were independent risk factors for DFS. The operative time of indocyanine green (ICG) fluorescence-guided liver S4b5 segment resection was shorter than that of traditional laparoscopic S4b+5 resection guided by hepatic veins (P ≤ 0.001).

CONCLUSION

Laparoscopic liver S4b+5 resection for T3 stage gallbladder cancer is safe and feasible and can prolong DFS. ICG fluorescence-guided negative staining may reduce the difficulty of the operation.

EGFR-targeted fluorescent imaging using the da Vinci® Firefly™ camera for gallbladder cancer

Background

Fluorescent imaging may aid with the precise diagnosis and treatment of patients with gallbladder cancer. In this study, we sought to demonstrate whether the da Vinci® surgical system and Firefly™ camera could detect EGFR-targeted fluorescent images in orthotopic mouse models of gallbladder cancer.

Methods

An orthotopic mouse model of gallbladder cancer was created by injecting NOZ gallbladder cancer cells mixed with Matrigel into the gallbladder. In vivo imaging of subcutaneous and orthotopic gallbladder tumors was performed after the injection of DyLight 650- or 800-conjugated EGFR antibody.

Results

Western blotting, flow cytometry, and confocal microscopy showed the presence of EGFR in NOZ cells, but not in HEK293 cells. Subcutaneous NOZ cell tumors fluoresced after injection with fluorescent EGFR antibody, but subcutaneous HEK293 tumors did not. Fluorescent EGFR antibody made orthotopic NOZ tumors fluoresce, with an intensity stronger than that in the surrounding normal tissues. Histochemical examination confirmed the location of the tumors inside the gallbladder and adjacent liver parenchyma. Fluorescent signal was also detected in orthotopic gallbladder tumors with Firefly™ camera.

Conclusion

Our study showed that fluorescent EGFR antibodies and the Firefly camera in the da Vinci system can detect fluorescing gallbladder tumors, which demonstrates their potential use for molecular imaging-based prevision surgery in the near future.

Comparison of the Oncological Outcomes of Open versus Laparoscopic Surgery for T2 Gallbladder Cancer: A Propensity-Score-Matched Analysis

Although laparoscopic treatment for T1 gallbladder cancer (GBC) has been described previously, the differences in oncologic outcomes between laparoscopic and conventional open surgery for T2 GBC have not been investigated. We aimed to assess the role of laparoscopic surgery using retrospectively collected data for 81 patients with T2 GBC who underwent surgical resection between January 2010 and December 2017. Eligible patients were classified into “laparoscopic” and “open” groups. Propensity-score matching was performed in a 1:1 ratio. The effects of surgery type on surgical and oncological outcomes were investigated. After propensity-score matching, 19 patients were included in the open and laparoscopic surgery groups. The median follow-up durations were 70 and 26 months in the open and laparoscopic groups, respectively. The operative time (316.8 ± 80.3 vs. 218.9 ± 145.0 min, p = 0.016) and length of postoperative hospital stay (14.4 ± 6.0 vs. 8.4 ± 5.9 days, p = 0.004) were significantly shorter in the laparoscopic group. The three-year overall (86.3% vs. 88.9%, p = 0.660) and disease-free (76.4% vs. 60.2%, p = 0.448) survival rates were similar between the groups. Propensity-score matching showed that laparoscopic surgery for T2 GBC yielded similar long-term oncological outcomes and favorable short-term outcomes in comparison with open surgery. Laparoscopic treatment should be considered in patients with T2 GBC.

Oncologic and Long-Term Outcomes of Laparoscopic and Open Extended Cholecystectomy for Gallbladder Cancer

Laparoscopic surgery has been traditionally contraindicated for gallbladder cancer, but there have been few reports demonstrating the oncologic outcomes of this treatment. This study aimed to compare the technical feasibility and the long-term outcomes after laparoscopic versus open extended cholecystectomy for gallbladder cancer. Between January 2011 and December 2018, 44 patients with gallbladder cancer who underwent extended cholecystectomy were included in this study, with 20 patients in the laparoscopic group and 24 patients in the open group. Perioperative outcomes, overall survival (OS), and recurrence-free survival (RFS) were retrospectively analyzed. There were no significant differences (p > 0.05) between the two groups in terms of perioperative outcomes, including blood loss, postoperative complications, R0 resection, and the number of lymph nodes retrieved. Patients in the laparoscopic group showed similar OS compared to the open group (5 year tumor-specific OS rate: 84.7% vs. 62.5%; p = 0.125). On subgroup analysis of patients with stage T2 and N0 disease, the laparoscopic group showed better OS (T2: 90.9% vs. 75.0%, p = 0.256; N0: 100.0% vs. 76.5%, p = 0.028). There was no difference in terms of RFS (3 year RFS: 74.4% vs. 64%; p = 0.571) and locoregional recurrence (10.0% vs. 16.9%, p = 0.895) between the two groups. There was no port-site recurrence in the laparoscopic group. This study suggests that laparoscopic extended cholecystectomy might be not inferior to open surgery in terms of oncologic safety or early and long-term outcomes in patients with early gallbladder cancer.

Treatment of Resectable Gallbladder Cancer

Gallbladder cancer (GBC) is the most common biliary tract cancer worldwide and its incidence has significant geographic variation. A unique combination of predisposing factors includes genetic predisposition, geographic distribution, female gender, chronic inflammation, and congenital developmental abnormalities. Today, incidental GBC is the most common presentation of resectable gallbladder cancer, and surgery (minimally invasive or open) remains the only curative treatment available. Encouragingly, there is an important emerging role for systemic treatment for patients who have R1 resection or present with stage III-IV. In this article, we describe the pathogenesis, surgical and systemic treatment, and prognosis.

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.

Comparison of Outcomes After Primary Laparoscopic Versus Open Approach for T1b/T2 Gallbladder Cancer

Objectives

The primary laparoscopic approach (PLA) for T1b/T2 gallbladder cancer (GBC) remains contradicted. We aimed to compare the perioperative and long-term outcomes after PLA versus open approach (OA) for T1b/T2 GBC.

Methods

Patients with resected T1b/T2 GBC were selected from our hospital between January 2011 and August 2018. Overall survival (OS), disease-free survival (DFS), and several secondary outcomes were used to evaluate safety and effectiveness. Subgroup analyses were performed to identify significant risk factors for OS/DFS in GBC patients undergoing PLA/OA.

Results

A total of 114 patients who underwent OA (n = 61) or PLA (n = 53) were included in the study. The percent of PLA cases was increased over time from 40.0% in 2011 to 70.0% in 2018 (p < 0.05). There was no significant difference in OS [hazard ratio (HR), 1.572; 95% confidence interval (CI), 0.866–2.855; p = 0.13] and DFS (HR, 1.225; 95% CI, 0.677–2.218; p = 0.49). No significance was found for intraoperative drainage placement (p = 0.253), intraoperative blood loss (p = 0.497), operation time (p = 0.105), postoperative hospitalization (p = 0.797), positive LNs (p = 0.494), total harvested LNs (p = 0.067), and recurrence rates (P = 0.334). Subgroup analyses demonstrated no significance of conversion rates after PLA (all p > 0.05). Patients undergoing PLA with good/poor OS would have similar recurrence rates (p = 0.402). Positive LNs (p = 0.032) and tumor differentiation (p = 0.048) were identified as risk factors for OS after PLA, while positive LNs (p = 0.005) was identified for OS after OA. Moreover, age (p = 0.013), gallbladder stone (p = 0.008), tumor size (p = 0.028), and positive LNs (p = 0.044) were potential risk factors for DFS after OA.

Conclusions

PLA for T1b/T2 GBC was comparable to OA in terms of perioperative and long-term outcomes. Less positive LNs and well-differentiated tumors were independent predictors for better OS after PLA, and less positive LNs were also identified for better OS after OA. Additionally, younger age, without gallbladder stone, smaller tumor size, and less positive LNs were potential risk factors for better DFS after OA.

Clinical Outcomes Between a Minimally Invasive and Open Extended Cholecystectomy for T2 Gallbladder Cancer: A Propensity Score Matching Analysis

Background: Although a minimally invasive extended cholecystectomy (MIEC) for T2 gallbladder cancer (T2 GBC) has been performed in many experienced centers, no oncologic comparison with open extended cholecystectomy (OEC) has yet been reported. Methods: T2 GBC patients who underwent MIEC (n = 60) or OEC (n = 135) were enrolled. We used propensity score matching (PSM) using pre- and intraoperative variables. Short- and long-term outcomes were then compared before and after PSM. Results: Before PSM, OEC patients more frequently showed completion of surgery after a simple cholecystectomy (standardized mean difference [SMD] = -0.551), and lymph node enlargement on preoperative computed tomography (SMD = -0.471). PSM was used to select 56 patients from each of the 2 patient groups. MIEC patients showed comparable complication rate (7.1% versus 12.5%, P = .365) and shorter hospital stay (5.7 days versus 9.8 days, P < .001). The median follow-up period was 26.2 months, and 5-year overall survival (OS) rate (96.8% versus 91.1%, P = .464) and 5-year recurrence free survival (RFS) (54.7% versus 44.4%, P = .580) outcomes were still comparable between MIEC and OEC groups. Conclusion: MIEC have advantages such as early recovery and comparable short-term outcomes compared with OEC. MIEC showed comparable OS and RFS outcomes compared with OEC. MIEC is a safe option without oncological compromise for T2 GBC.

Adverse Outcomes After Bile Spillage in Incidental Gallbladder Cancers: A Population-based Study

OBJECTIVE

To determine the effect of bile spillage during cholecystectomy on oncological outcomes in incidental gallbladder cancers.

BACKGROUND

Gallbladder cancer (GBC) is rare, but lethal. Achieving complete resection offers the best chance of survival. About 30% of GBCs are discovered incidentally after cholecystectomy for benign pathology. There is an anecdotal association between peritoneal dissemination and bile spillage during the index cholecystectomy. However, no population-based studies are available that measure the consequences of bile spillage on patient outcomes.

METHODS

We conducted a retrospective cohort comparison of patients with incidental GBC. All cholecystectomies and cases of GBC in Alberta, Canada, from 2001 to 2015, were identified. GBCs discovered incidentally were included. Operative events leading to bile spillage were reviewed. Patient outcomes were compared between cases of bile spillage versus no contamination.

RESULTS

In all, 115,484 cholecystectomies were performed, and a detailed analysis was possible in 82 incidental GBC cases. In 55 cases (67%), there was bile spillage during the index cholecystectomy. Peritoneal carcinomatosis occurred more frequently in those with bile spillage (24% vs 4%; P = 0.0287). Patients with bile spillage were less likely to undergo a radical re-resection (25% vs 56%; P = 0.0131) and were less likely to achieve an R0 resection margin [odds ratio 0.19, 95% confidence interval (CI) 0.06-0.55]. On Cox regression modeling, bile spillage was an independent predictor of shorter disease-free survival (hazard ratio 1.99, 95% CI 1.07-3.67).

CONCLUSION

For incidentally discovered GBC, bile spillage at the time of index cholecystectomy has measureable adverse consequences on patient outcomes. Early involvement of a hepatobiliary specialist is recommended where concerning features for GBC exist.

Hepatectomy strategy for T2 gallbladder cancer between segment IVb and V resection and wedge resection: A propensity score-matched study

BACKGROUND

Liver resection is recommended for T2 gallbladder cancer, but the optimal hepatectomy strategy remains controversial. We aimed to assess the safety and effectiveness of segment IVb and V resection versus wedge resection in patients with T2 gallbladder cancer.

METHODS

This is a retrospective multicenter propensity score-matched study in China. Overall survival, disease-free survival, perioperative complications, and hospital length of stay were used to evaluate safety and effectiveness.

RESULTS

There are a total of 512 patients. 112 of 117 patients undergoing segment IVb and V resection were matched to 112 patients undergoing wedge resection. After matching, segment IVb and V resection demonstrated no statistical difference in overall survival (hazard ratio, 0.970 [0.639-1.474]; P = .886), but significance in disease-free survival (hazard ratio, 0.708 [0.506-0.991]; P = .040). Patients with incidental gallbladder cancer (hazard ratio, 0.390 [0.180-0.846]; P = .019), stage T2b (hazard ratio, 0.515 [0.302-0.878]; P = .016), and negative lymph nodes status (hazard ratio, 0.627 [0.406-0.991]; P = .043) were associated with improved disease-free survival after segment IVb and V resection, but not in wedge resection. However, perioperative complications occurred more frequently after segment IVb and V resection (28.5% vs 9.1%, P < .001) along with the longer hospital length of stay (17.3 vs 10.2 days, P < .001). Notably, patients with jaundice (odds ratio, 4.053 [1.361-12.23]; P = .013), undergoing laparoscopic resection (odds ratio, 2.387 [1.059-4.484]; P = .028) or surgeon performing per the first 10 segment IVb and V resections (odds ratio, 2.697 [1.035-6.998]; P = .041), were the independent risk factors for perioperative complications in the segment IVb and V resection group.

CONCLUSION

T2 gallbladder cancer patients undergoing segment IVb and V resection rather than wedge resection have an improved disease-free survival, especially for incidental gallbladder cancer or hepatic-sided (T2b) gallbladder cancer. However, high rates of perioperative complications and longer hospital length of stay after segment IVb and V resection indicated that surgeons must rely on their own surgical skills and the patient profile to decide the optimal hepatectomy strategy.

Safety and feasibility of pure laparoscopic extended cholecystectomy: comparison with the open technique in a propensity analysis at a single center

BACKGROUND

The aim of this study was to validate the safety and feasibility of pure laparoscopic extended cholecystectomy (LEC) by comparing the outcome with that of open extended cholecystectomy (OEC). Moreover, on the basis of our experience, we also aimed to investigate the learning curve of pure LEC.

METHODS

This single-center study enrolled patients who were diagnosed primary gallbladder cancer with pathologically confirmed and underwent R0 resection with curative intent between January 2016 and December 2019. A total of 31 patients who underwent OEC and 17 patients who underwent LEC were selected. Propensity score matching analysis was performed in a 1:1 ratio using the nearest-neighbor matching method, and clinical information was retrospectively collected from medical records and analyzed.

RESULTS

The postoperative hospital stay was statistically shorter in the LEC group (7 days) than in the OEC group (12 days). The overall surgical complication rate did not differ between the two groups. The 1- and 3-year disease-free survival rates were 82.4% and 82.4% in the OEC group and 94.2% and 71.5% in the LEC group, respectively (P = 0.94). Considering the correlation between the number of cumulative cases and the operation time and between the number of cumulative cases and the number of retrieved lymph nodes in the LEC group, as the cases were accumulated, both the operation time and the number of retrieved lymph nodes had a statistically significant correlation with the number of cases.

CONCLUSIONS

LEC showed a significant advantage in terms of achieving shorter postoperative hospital stay and similar results to OEC with respect to overall complications and pathological outcomes. The present results confirm that laparoscopy can be considered a safe treatment for primary gallbladder cancer in selected patients.

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.

Laparoscopic surgery for oncologic extended resection of T1b and T2 incidental gallbladder carcinoma at a high-volume center: a single-center experience in China

BACKGROUND

Surgical treatment is still the most effective treatment for gallbladder cancer. For the patients with stage T1b and above, the current guidelines recommend the extended radical operation, and oncologic extended resection can benefit the survival of the patients. The laparoscopic approach is still in the early phase, and its safety and oncological outcomes are not well known.

OBJECTIVE

To evaluate the technical feasibility and oncological outcomes of laparoscopic surgery for oncologic extended resection of early-stage incidental gallbladder carcinoma.

RESULTS

This study included 18 male and 32 female patients. Twenty patients underwent laparoscopic oncologic extended resection and 30 patients underwent open oncologic extended resection. All of the patients had R0 resection. A laparoscopic approach was associated with less intraoperative blood loss (242 ± 108.5 vs 401 ± 130.3; p < 0.01) and shorter duration of postoperative hospital stay (6.2 ± 2.4 vs 8.6 ± 2.3; p < 0.01). There was no statistically significant difference between two groups for lymph nodes yield (5.4 ± 3.5 vs 5.8 ± 2.1; p > 0.05), incidence of lymphatic metastasis (15% vs 16.67%; p > 0.05), residual disease (20% vs 23.3%; p > 0.05), and postoperative morbidity (15% vs 20%; p > 0.05). During follow-up time of median 20.95 (12-29.5) months, no significant difference was found between the two groups for early tumor recurrence (10% vs 13.33%; p > 0.05) and disease-free survival (p > 0.05).

CONCLUSION

Laparoscopic surgery may offer similar intraoperative, perioperative, and short-term oncological outcomes as an open oncologic extended resection for incidental gallbladder carcinoma.

Long-term survival following minimally invasive extended cholecystectomy for gallbladder cancer: A 7-year experience from the National Cancer Database

BACKGROUND

Open extended cholecystectomy (O-EC) has long been the recommended treatment for resectable gallbladder cancer (GBC), while the minimally-invasive approach for EC (MIS-EC) remains controversial. Our aim was to analyze overall survival of GBC patients treated with MIS-EC vs O-EC at the national level.

METHODS

A retrospective review of the National Cancer Database of patients with resectable GBC (2010-2016) and treated with either MIS-EC or O-EC was performed. Overall survival (OS) was compared by the surgical approach.

RESULTS

A total of 680 patients were identified, of whom 235 (34.6%) underwent MIS-EC. There were no differences in the rates of positive margins between MIS-EC and O-EC (14% vs 19%, respectively; P = .278), and in the mean lymph node yield (6.54 vs 6.66, respectively; P = .914). The median survival following MIS-EC was significantly higher than that of O-EC (39 vs 26 months; P = .048). After stratification by pathological stage and after adjustment, there was no significant difference in OS between the groups (HR = 0.9, 95% CI, 0.6-1.5).

CONCLUSION

In this large national cohort, MIS-EC oncologic outcomes were noninferior to the O-EC. Proficiency with MIS techniques, proper patient selection, and referral to specialized centers may allow a greater benefit from this treatment modality.

Current status and future perspectives of minimally invasive surgery in gallbladder carcinoma

BACKGROUND

Gallbladder carcinoma (GBC) is the most common biliary tract malignancy, which is characterized by easy local invasion, lymph nodes metastasis, local vascular invasion. Hence, minimally invasive surgery (MIS) can be performed in a limited number of patients. In our study, we reviewed the current studies on laparoscopic surgery (LS) and robotic surgery (RS) for GBC and analysed the limitations and difficulties of MIS for GBC.

METHODS

Multiple electronic databases were used for a systematic literature retrieval. All studies involving MIS of GBC were included (up to August 2019).

RESULTS

A total of 24 studies were included, of which 18 studies involved LS for GBC and six studies concerned RS of GBC. For LS, 16 studies contained relevant information of T stage, and 323 patients (98.8%) had T3 or lower stage; the average rate of R0 resection, conversion, postoperative complications and mortality was 95.3% (range 80.5-100%), 1.9% (range 0-16.7%), 13.4% (range 0-33.3%) and 1.0% (range 0-10%), respectively. For RS, four studies contained relevant information of T stage, and all patients were T3 or lower stage; the average rate of R0 resection, conversion and postoperative complications was 96.8% (range 81.8-100%), 5.5% (range 0-14.8%) and11.9% (range 0-36.4%), respectively. In addition, no patient had perioperative mortality.

CONCLUSIONS

MIS for GBC is limited to highly selected patients and is considered to be technically feasible in experienced surgeons. However, improvements in technical and instrumental are needed to reduce the associated postoperative complications and implantation metastasis, and to promote MIS in the treatment of GBC.

Oncologic safety of laparoscopic radical cholecystectomy in pT2 gallbladder cancer: A propensity score matching analysis compared to open approach

The role of laparoscopic radical cholecystectomy (LRC) in the surgical management of T2 gallbladder carcinoma (GBC) is still controversial.The medical records of patients with T2 GBC treated with radical cholecystectomy were retrospectively reviewed. In this study, we compare the short- and long-term oncologic outcomes, using propensity score matching analysis, of patients with T2 GBC who underwent LRC and open radical cholecystectomy (ORC).Among 183 patients, 86 were selected by propensity score matching (LRC = 43 and ORC = 43). The ORC group underwent more extensive surgery (liver resections and extended lymph node dissections [ELND]) than the LRC group. The LRC group had less operative blood loss, shorter length of hospital stay, fewer complications, and had the earlier start of adjuvant chemotherapy. There was no significant difference between the laparoscopic and open surgery groups in terms of 5-year overall survival rate (64.6% vs 80.4%, P = .214) and disease-free survival rate (77.1% vs 82.2%, P = .641). A subgroup analyses showed that liver resection and ELND had no survival advantage compared to no liver resection and regional lymph node dissection, respectively.Our LRC approach is safe and effective, with long-term survival comparable to that of ORC.

Robotic extended cholecystectomy in gallbladder cancer

BACKGROUND

The application of minimally invasive surgery (MIS) in advanced gallbladder cancer (GBC) requiring extended cholecystectomy is challenging, in terms of achieving clinically safe and complete oncologic resection. Recently developed robotic systems, however, may provide advantages in overcoming difficulties faced by laparoscopic MIS. The purpose of this study is to investigate the feasibility and advantages of a robotic system to assist with extended cholecystectomy.

METHODS

Patients diagnosed with clinically suspected stage T2 or above, GBC (as determined by preoperative computed tomography or ultrasonography) underwent robotic extended cholecystectomy (REC) from February 2018 to January 2020. The attached video shows the detailed procedure in the following order: the positioning of the patient and the trocars, Kocher maneuver, lymph node dissection (#8, 9, 12, 13), skeletonization of hepatoduodenal ligament, ligation of the cystic duct and liver resection.

RESULTS

Of 16 patients who underwent REC, mean operation time was 198.3 min and the median estimated blood loss was 295 ml. 11 patients (68.8%) were pathologically diagnosed as stage T2 or above, and the metastatic lymph node was identified in 3 patients (18.8%). All cases had secured tumor-free resection margins, and 3 patients (18.8%) showed invasion to the hepatic parenchyma. The mean number of retrieved lymph nodes was 7.2. The median duration of hospital stay was 7 days. There were no mortality or recurrence within 90 days after the operation.

CONCLUSION

This study suggests that robotic systems can be safely utilized in advanced stage GBC, facilitating oncologically sufficient lymph node dissection and rapid recovery.

Laparoscopic surgery for early gallbladder carcinoma: A systematic review and meta-analysis

BACKGROUND

There is a controversy as to whether laparoscopic surgery leads to a poor prognosis compared to the open approach for early gallbladder carcinoma (GBC). We hypothesized that the laparoscopic approach is an alternative for early GBC.

AIM

To identify and evaluate the safety and feasibility of laparoscopic surgery in the treatment of early GBC.

METHODS

A comprehensive search of online databases, including MEDLINE (PubMed), Cochrane libraries, and Web of Science, was performed to identify non-comparative studies reporting the outcomes of laparoscopic surgery and comparative studies involving laparoscopic surgery and open surgery in early GBC from January 2009 to October 2019. A fixed-effects meta-analysis was performed for 1- and 5-year overall survival and postoperative complications, while 3-year overall survival, operation time, blood loss, the number of lymph node dissected, and postoperative hospital stay were analyzed by random-effects models.

RESULTS

The review identified 7 comparative studies and 8 non-comparative studies. 1068 patients (laparoscopic surgery: 613; open surgery: 455) were included in the meta-analysis of 1-, 3-, and 5-year overall survival with no significant differences observed [(HR = 0.54; 95%CI: 0.29-1.00; I² = 0.0%; P = 0.051), (HR = 0.75; 95%CI: 0.34-1.65; I² = 60.7%; P = 0.474), (HR = 0.71; 95%CI: 0.47-1.08; I² = 49.6%; P = 0.107), respectively]. There were no significant differences in operation time [weighted mean difference (WMD) = 18.69; 95%CI: −19.98-57.36; I² = 81.4%; P = 0.343], intraoperative blood loss (WMD = −169.14; 95%CI: −377.86-39.57; I² = 89.5%; P = 0.112), the number of lymph nodes resected (WMD = 0.12; 95%CI: −2.95-3.18; I² = 73.4%; P = 0.940), and the complication rate (OR = 0.69; 95%CI: 0.30-1.58; I² = 0.0%; P = 0.377 ) between the two groups, while patients who underwent laparoscopic surgery had a reduced length of hospital stay (WMD = −5.09; 95%CI: −8.74- −1.45; I² = 91.0%; P= 0.006).

CONCLUSION

This systematic review and meta-analysis confirms that laparoscopic surgery is a safe and feasible alternative to open surgery with comparable survival and operation-related outcomes for early GBC.

Comparison of oncological outcomes after open and laparoscopic re-resection of incidental gallbladder cancer

BACKGROUND

The safety and oncological efficacy of laparoscopic re-resection of incidental gallbladder cancer have not been studied. This study aimed to compare laparoscopic with open re-resection of incidentally discovered gallbladder cancer while minimizing selection bias.

METHODS

This was a multicentre retrospective observational cohort study of patients with incidental gallbladder cancer who underwent re-resection with curative intent at four centres between 2000 and 2017. Overall survival (OS) and recurrence-free survival (RFS) were analysed by intention to treat. Inverse probability of surgery treatment weighting using propensity scoring was undertaken.

RESULTS

A total of 255 patients underwent re-resection (190 open, 65 laparoscopic). Nineteen laparoscopic procedures were converted to open operation. Surgery before 2011 was the only factor associated with conversion. Duration of hospital stay was shorter after laparoscopic re-resection (median 4 versus 6 days; P < 0·001). Three-year OS rates for laparoscopic and open re-resection were 87 and 62 per cent respectively (P = 0·502). Independent predictors of worse OS were residual cancer found at re-resection (hazard ratio (HR) 1·91, 95 per cent c.i. 1·17 to 3·11), blood loss of at least 500 ml (HR 1·83, 1·23 to 2·74) and at least four positive nodes (HR 3·11, 1·46 to 6·65). In competing-risks analysis, the RFS incidence was higher for laparoscopic re-resection (P = 0·038), but OS did not differ between groups. Independent predictors of worse RFS were one to three positive nodes (HR 2·16, 1·29 to 3·60), at least four positive nodes (HR 4·39, 1·96 to 9·82) and residual cancer (HR 2·42, 1·46 to 4·00).

CONCLUSION

Laparoscopic re-resection for selected patients with incidental gallbladder cancer is oncologically non-inferior to an open approach. Dissemination of advanced laparoscopic skills and timely referral of patients with incidental gallbladder cancer to specialized centres may allow more patients to benefit from this operation.

Simple Cholecystectomy Is Adequate for Patients With T1b Gallbladder Adenocarcinoma < 1 cm in Diameter

Purpose: Consensus-based clinical guidelines recommend that simple cholecystectomy (SC) is adequate for T1a gallbladder adenocarcinoma (GBA), but extended cholecystectomy (EC), SC plus lymphatic dissection, should be considered for T1b and more advanced GBA. Whether lymphatic dissection is necessary for the treatment of T1b GBA remains controversial. This study attempts to better define the current criteria for local treatment of T1b GBA, by examining the relationship between lymph node (LN) metastasis and tumor size in such patients.

Patients and methods: Clinical data from patients with T1b GBA receiving curative surgical treatment between 2004 and 2015 were collected from the Surveillance, Epidemiology, and End Results (SEER) database. Baseline characteristics for the entire cohort were described, and overall survival (OS) and cancer-specific survival (CSS) were analyzed with the Kaplan–Meier method.

Results: In total, 277 patients were enrolled for further analysis; 127 underwent lymphadenectomy. Among them, 23 patients had tumors <1 cm in diameter, none of which had LN metastasis; 104 patients had tumors ≥1 cm, 15 of which had positive LNs. In the group with tumor size <1 cm, there was no significant survival difference between treatment with SC or EC (P = 0.694). A clinical benefit was observed in T1b GBA patients with a tumor size ≥1 cm receiving EC vs. those receiving SC (P = 0.012).

Conclusion: SC was adequate for treatment of T1b GBA < 1 cm in diameter. This evidence may be included as part of current guidelines.

Totally Laparoscopic Radical Cholecystectomy for Gallbladder Cancer: A Single Center Experience

Background: Primary laparoscopic approach for the treatment of cancers of the biliary tract is not popular in the surgical community. The aim of this study is to report the short-term data of patients who underwent total laparoscopic radical cholecystectomy for gallbladder cancer (GBC) at a single center of specialized hepatobiliary surgery. Methods: From November 2016 to January 2019, we routinely performed a laparoscopic approach for two groups of patients: (1) patients with primary GBC (diagnosed preoperatively) and (2) patients with incidental GBC (IGBC) discovered after cholecystectomy. Results: Our retrospective study included 18 patients (7 primary GBCs, 11 IGBCs). Conversion rate from laparoscopy to laparotomy was 28.6% and 9.1%, respectively, for the two groups, but this difference was not statistically significant (P = .28). Only 3 patients had liver recurrence (27.3%) and 1 had liver invasion (14.3%). A more advanced T category and TNM stage were presented in the preoperative suspicion cases (T3-T4 18.2% versus 57.1%, P = .06, stage IVA-B 9.1% versus 71.4%, P = .017). Regional lymphadenectomy was performed in 15 patients, in 73.3% the total number of lymph nodes (total LNs) retrieved was more than 7 (7-12 LNs in 66.7% of patients and >12 LNs in 6.6% of patients). The mean postoperative long stay was 8 days excluding for cases who developed complication. Conclusions: Laparoscopy can be considered a safe treatment for IGBC or primary GBC. The T3 stage with only liver involvement was not a contraindication. The real reasons that lead to convert the laparoscopic procedure were due to oncological concerns, unrelated to the liver infiltration.

Totally Laparoscopic Radical Resection of Gallbladder Cancer: Technical Aspects and Long-Term Results

INTRODUCTION

Gallbladder cancer (GBC) is a rare tumor in developed countries. Chile has one of the highest incidences worldwide. For patients affected by resectable T1b or more advanced GBC, radical cholecystectomy (RC) is considered the standard therapy. Our aim is to describe the surgical technique and clinical-pathological results of patients undergoing totally laparoscopic radical resection of GBC.

METHODS

Patients undergo laparoscopic radical resection for primary and incidental GBC, between the years 2009 and 2016 in two centers from Chile. Patients in whom suspected bile duct invasion, frozen biopsy did not confirm cancer and para-aortic lymph node sampling was positive were excluded.

RESULTS

Eighteen patients were operated, 77.8% were female with median age of 60.5 year, and 16 patients had previous cholecystectomy with incidental cancer finding. The median operative time was 490 min (400-550). No conversion to open surgery occurred. All patients achieved a R0 resection. Postoperative complications occurred in 2 patients (11.1%), and there was not mortality. After a median follow-up of 59 months, the 5-year survival was 80.7%.

CONCLUSION

This study shows the technical feasibility of the totally laparoscopic approach for radical resection of GBC with the same principles of classical open surgery. It appears that long-term oncological findings would also be similar at least in less advanced lesions.

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.

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Gallbladder carcinoma can be diagnosed during or after cholecystectomy.

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

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The intraoperative diagnosis of GBC facilitates surgical resection of tumors.

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Surgical strategies incorporating intraoperative diagnosis should be developed.

Early recurrence after laparoscopic radical cholecystectomy in a patient with gallbladder cancer

Laparoscopic radical cholecystectomy for gallbladder cancer (GBC) has been performed at various oncology centres reporting its technical feasibility. Considering GBC an aggressive malignancy, laparoscopic radical cholecystectomy should be dealt with caution. We recently encountered a case of carcinoma gallbladder who underwent laparoscopic radical cholecystectomy elsewhere and presented with early recurrence. The patient's records were evaluated and he underwent re-resection. Hereby, we discuss the factors that could lead to early recurrence after laparoscopic radical cholecystectomy and measures that can be taken to prevent it.

Short-term outcomes of minimally invasive surgery for patients presenting with suspected gallbladder cancer: Report of 8 cases

Introduction:

Minimally invasive surgery (MIS) for gallbladder cancer (GBCa) has traditionally been discouraged, with limited studies reporting on its outcomes. The aim of this study was to evaluate the short-term outcomes of MIS for patients with GBCa or suspected GBCa.

Methods:

A retrospective study of 8 consecutive patients who underwent MIS for GBCa by a single surgeon over a 22-month period between 2015 and 2017.

Results:

Three patients underwent robotic surgery, while five underwent conventional laparoscopic surgery. Four patients presented with histologically proven GbCa detected incidentally after cholecystectomy. All 4 patients underwent resection of Segment 4b/5. Of these, 3 underwent hilar lymphadenectomy and 1 underwent hilar lymph node sampling. Four patients presenting with suspected GBCa underwent upfront extended cholecystectomy. Two patients who had malignancy on frozen section underwent hilar lymphadenectomy. The median operation time was 242.5 (range, 165–530) min, and the median blood loss was 175 (range, 50–700) ml. The median post-operative hospital stay was 3.5 (range, 2–8) days. There were no open conversion, post-operative morbidities and mortalities. Six had histologically proven GBCa. Five were T3 and one had T2 cancers.

Conclusions:

The results of the present study confirm the short-term safety and feasibility of MIS for patients with GBCa, as all eight patients underwent successful MIS with no major morbidity or mortality. Further studies with larger patient cohorts with long-term follow-up are needed to determine the oncologic outcomes and the definitive role of MIS in treating GBCa.

Laparoscopic Surgery for Gallbladder Cancer: An Expert Consensus Statement

BACKGROUND

Despite the increasing number of reports on the favorable outcomes of laparoscopic surgery for gallbladder cancer (GBC), there is no consensus regarding this surgical procedure.

OBJECTIVE

The study aimed to develop a consensus statement on the application of laparoscopic surgery for GBC based on expert opinions.

METHODS

A consensus meeting among experts was held on September 10, 2016, in Seoul, Korea.

RESULTS

Early concerns regarding port site/peritoneal metastasis after laparoscopic surgery have been abated by improved preoperative recognition of GBC and careful manipulation to avoid bile spillage. There is no evidence that laparoscopic surgery is associated with decreased survival compared with open surgery in patients with early-stage GBC if definitive resection during/after laparoscopic cholecystectomy is performed. Although experience with laparoscopic extended cholecystectomy for GBC has been limited to a few experts, the postoperative and survival outcomes were similar between laparoscopic and open surgeries. Laparoscopic reoperation for postoperatively diagnosed GBC is technically challenging, but its feasibility has been demonstrated by a few experts.

CONCLUSIONS

Laparoscopic surgery for GBC is still in the early phase of the adoption curve, and more evidence is required to assess this procedure.

Survey Results of the Expert Meeting on Laparoscopic Surgery for Gallbladder Cancer and a Review of Relevant Literature

BACKGROUND

Favorable outcomes of laparoscopic surgery for gallbladder cancer (GBC) have been reported; yet consensus on the indications and surgical techniques for laparoscopic surgery for GBC is lacking.

OBJECTIVE

To evaluate the current status of laparoscopic surgery for GBC by analyzing the results of a survey of experts and by reviewing the relevant published literature.

METHODS

Before an expert meeting was held on September 10, 2016 in Seoul, Korea, an international survey was undertaken of expert surgeons in the field of GBC surgery.

RESULTS

The majority of surgeons who responded agreed that laparoscopic surgery has an acceptable role for suspicious or early GBC, and that laparoscopic extended cholecystectomy has a value comparable to that of open surgery in selected patients with GBC. However, the selection criteria for laparoscopic surgery for overt GBC and the details of the surgical techniques varied among surgeons.

CONCLUSIONS

This survey and literature review revealed that laparoscopic surgery for GBC is performed in highly selected cases. However, the favorable outcomes in the published reports and the positive view of experienced surgeons for this operative procedure suggest a high likelihood that laparoscopic surgery will be more frequently performed for GBC in the future.

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.

Laparoscopic treatment for suspected gallbladder cancer confined to the wall: a 10-year study from a single institution

Objective

Although laparoscopic treatment of gallbladder cancer (GBC) has been explored in the last decade, long-term results are still rare. This study evaluates long-term results of intended laparoscopic treatment for suspected GBC confined to the gallbladder wall, based on our experience over 10 years.

Methods

Between August 2006 and December 2015, 164 patients with suspected GBC confined to the wall were enrolled in the protocol for laparoscopic surgery. The process for GBC treatment was analyzed to evaluate the feasibility of computed tomography (CT) and/or magnetic resonance imaging (MRI) combined with frozen-section examination in identifying GBC confined to the wall. Of 159 patients who underwent the intended laparoscopic radical treatment, 47 with pathologically proven GBC were investigated to determine the safety and oncologic outcomes of a laparoscopic approach to GBC.

Results

Among the 164 patients, 5 patients avoided further radical surgery because of unresectable disease and 12 were converted to open surgery; in the remaining 147 patients, totally laparoscopic treatment was successfully accomplished. Extended cholecystectomy was performed in 37 patients and simple cholecystectomy in 10. The T stages based on final pathology were Tis (n=6), T1a (n=2), T1b (n=9), T2 (n=26), and T3 (n=4). Recurrence was detected in 11 patients over a median follow-up of 51 months. The disease-specific 5-year survival rate of these 47 patients was 68.8%, and rose to 85% for patients with a normal cancer antigen 19-9 (CA19-9) level.

Conclusions

The favorable long-term outcomes demonstrate the feasibility of combined CT/MRI and frozen-section examination in the selection of patients with GBC confined to the gallbladder wall, confirm the oncologic safety of laparoscopic treatment in selected GBC patients, and favor measurement of preoperative CA19-9 in the selection of GBCs suitable for laparoscopic treatment.

Minimally invasive and open gallbladder cancer resections: 30- vs 90-day mortality

BACKGROUND

Minimally invasive surgery is increasingly used for gallbladder cancer resection. Postoperative mortality at 30 days is low, but 90-day mortality is underreported.

METHODS

Using National Cancer Database (1998-2012), all resection patients were included. Thirty- and 90-day mortality rates were compared.

RESULTS

A total of 36 067 patients were identified, 19 139 (53%) of whom underwent resection. Median age was 71 years and 70.7% were female. Ninety-day mortality following surgical resection was 2.3-fold higher than 30-mortality (17.1% vs 7.4%). There was a statistically significant increase in 30- and 90-day mortality with poorly differentiated tumors, presence of lymphovascular invasion, tumor stage, incomplete surgical resection and low-volume centers (P<0.001 for all). Even for the 1885 patients who underwent minimally invasive resection between 2010 and 2012, the 90-day mortality was 2.8-fold higher than the 30-day mortality (12.0% vs 4.3%).

CONCLUSIONS

Ninety-day mortality following gallbladder cancer resection is significantly higher than 30-day mortality. Postoperative mortality is associated with tumor grade, lymphovascular invasion, tumor stage, type and completeness of surgical resection as well as type and volume of facility.

Laparoscopic radical cholecystectomy for carcinoma gallbladder: A case series

Introduction: Nowadays laparoscopic surgery is a very common form of treatment strategy for digestive diseases and these ‘keyhole’ surgeries provide many benefits to the patients. However, controversy exists when the laparoscopic surgery is done for early gallbladder cancer. The aim of our study was to report two such cases to see feasibility and safety of laparoscopic radical cholecystectomy with lymph node dissection. Case Series: Two patients underwent laparoscopic radical cholecystectomy with lymph node dissection for gallbladder carcinoma. Both patients were preoperatively diagnosed. Mean operative time was 172 minutes, and average estimated blood loss was 225 ml. There was no intraoperative complication. The liver dissection was done by Harmonic in one case and by Waterjet in the other case. Average hospital stay after surgery was four days. Postoperative morbidity included minimal bile leak in one patient only and no bile leak in patient operated with Waterjet system. Postoperative histopathology revealed adenocarcinoma of gallbladder with no lymph node invasion T2N0M0 (Stage II) in both patients. The mean lymph node retrieval was 5.5. Both patients received adjuvant chemotherapy with gemcitabine and carboplatin. Conclusion: We conclude that laparoscopic radical cholecystectomy with lymph node dissection is safe and beneficial for the patients with T1b/T2 gallbladder carcinoma and is useful in selected patients with a preoperative suspicion of early-stage gallbladder cancer by sparing them the necessity of a second-stage open procedure.

Laparoscopic Radical Cholecystectomy for Primary or Incidental Early Gallbladder Cancer: The New Rules Governing the Treatment of Gallbladder Cancer

AIM

To evaluate the technical feasibility and oncologic safety of laparoscopic radical cholecystectomy (LRC) for primary or incidental early gallbladder cancer (GBC) treatment.

METHODS

Articles reporting LRC for GBC were reviewed from the first case reported in 2010 to 2015 (129 patients). 116 patients had a preoperative diagnosis of gallbladder cancer (primary GBC). 13 patients were incidental cases (IGBC) discovered during or after a laparoscopic cholecystectomy.

RESULTS

The majority of patients who underwent LRC were pT2 (62.7% GBC and 63.6% IGBC). Parenchyma-sparing operation with wedge resection of the gallbladder bed or resection of segments IVb-V were performed principally. Laparoscopic lymphadenectomy was carried out according to the reported depth of neoplasm invasion. Lymph node retrieved ranged from 3 to 21. Some authors performed routine sampling biopsy of the inter-aorto-caval lymph nodes (16b1 station) before the radical treatment. No postoperative mortality was documented. Discharge mean day was POD 5th. 16 patients had post operative morbidities. Bile leakage was the most frequent post-operative complication. 5 y-survival rate ranged from 68.75 to 90.7 months.

CONCLUSION

Laparoscopy can not be considered as a dogmatic contraindication to GBC but a primary approach for early case (pT1b and pT2) treatment.

Laparoscopic approach to suspected T1 and T2 gallbladder carcinoma

AIM

To evaluate a laparoscopic approach to gallbladder lesions including polyps, wall-thickening lesions, and suspected T1 and T2 gallbladder cancer (GBC).

METHODS

We performed 50 cases of laparoscopic whole-layer cholecystectomy (LCWL) and 13 cases of laparoscopic gallbladder bed resection (LCGB) for those gallbladder lesions from April 2010 to November 2016. We analyzed the short-term and long-term results of our laparoscopic approach.

RESULTS

The median operation time was 108 min for LCWL and 211 min for LCGB. The median blood loss was minimal for LCWL and 28 ml for LCGB. No severe morbidity occurred in either procedure. Nine patients who underwent LCWL and 7 who underwent LCGB were postoperatively diagnosed with GBC. One of these patients had undergone LCGB for pathologically diagnosed T2 GBC after LCWL. All of the final surgical margins were negative. Three of these 15 patients underwent additional open surgery. The mean follow-up period was 26 mo, and only one patient developed recurrence.

CONCLUSION

LCWL and LCGB are safe and useful procedures that allow complete resection of highly suspected or early-stage cancer and achieve good short-term and long-term results.

Current Role of Minimally Invasive Radical Cholecystectomy for Gallbladder Cancer

Background. For Tis and T1a gallbladder cancer (GbC), laparoscopic cholecystectomy can provide similar survival outcomes compared to open cholecystectomy. However, for patients affected by resectable T1b or more advanced GbC, open approach radical cholecystectomy (RC), consisting in gallbladder liver bed resection or segment 4b-5 bisegmentectomy, with locoregional lymphadenectomy, is considered the gold standard while minimally invasive RC (MiRC) is skeptically considered. Aim. To analyze current literature on perioperative and oncologic outcomes of MiRC for patients affected by GbC. Methods. A Medline review of published articles until June 2016 concerning MiRC for GbC was performed. Results. Data relevant for this review were presented in 13 articles, including 152 patients undergoing an attempt of MiRC for GbC. No randomized clinical trial was found. The approach was laparoscopic in 147 patients and robotic in five. Conversion was required in 15 (10%) patients. Postoperative complications rate was 10% with no mortality. Long-term survival outcomes were reported by 11 studies, two of them showing similar oncologic results when comparing MiRC with matched open RC. Conclusions. Although randomized clinical trials are still lacking and only descriptive studies reporting on limited number of patients are available, current literature seems suggesting that when performed at highly specialized centers, MiRC for GbC is safe and feasible and has oncologic outcomes comparable to open RC.

Laparoscopic radical cholecystectomy for suspected early gall bladder carcinoma: thinking beyond convention

BACKGROUND

Gall bladder cancer (GBC) is the most common and aggressive malignancy of the biliary tract with extremely poor prognosis. Radical resection remains the only potential curative treatment for operable lesions. Although laparoscopic approach is now considered as standard of care for many gastrointestinal malignancies, surgical community is still reluctant to use this approach for GBC probably because of fear of tumor dissemination, inadequate lymphadenectomy and overall nihilistic approach. Aim of this study was to share our initial experience of laparoscopic radical cholecystectomy (LRC) for suspected early GBC.

METHODS

From 2008 to 2013, 91 patients were evaluated for suspected GBC, of which, 14 patients had early disease and underwent LRC.

RESULTS

Mean age of the cohort was 61.14 ± 4.20 years with male/female ratio of 1:1.33. Mean operating time was 212.9 ± 26.73 min with mean blood loss of 196.4 ± 63.44 ml. Mean hospital stay was 5.14 ± 0.86 days without any 30-day mortality. Bile leak occurred in two patients. Out of 14 patients, 12 had adenocarcinoma, one had xanthogranulomatous cholecystitis and another had adenomyomatosis of gall bladder as final pathology. Resected margins were free in all (>1 cm). Median number of lymph nodes resected was 8 (4-14). Pathological stage of disease was pT2N0 in eight, pT2N1 in three and pT3N0 in one patient. Median follow-up was 51 (14-70) months with 5-year survival 68.75 %.

CONCLUSIONS

Laparoscopic radical cholecystectomy with lymphadenectomy can be a viable alternative for management of early GBC in terms of technical feasibility and oncological clearance along with offering the conventional advantages of minimal access approach.