Minimally Invasive Surgery for Gallbladder Cancer

Innovations in surgery for gallbladder cancer: A review of robotic surgery as a feasible and safe option

BACKGROUND

This study evaluates the efficacy and safety of robotic-assisted surgical techniques in the treatment of gallbladder cancer, comparing it with traditional open and laparoscopic methods.

METHODS

A systematic review of the literature searched for comparative analyses of patient outcomes following robotic, open, and laparoscopic surgeries, focusing on oncological results and perioperative benefits.

RESULTS

Five total studies published between 2019 and 2023 were identified. Findings indicate that robotic-assisted surgery for gallbladder cancer is as effective as traditional methods in terms of oncological outcomes, with potential advantages in precision and perioperative recovery.

CONCLUSIONS

Robotic surgery offers a viable and potentially advantageous alternative for gallbladder cancer treatment, warranting further research to confirm its benefits and establish comprehensive surgical guidelines.

Standardized lymph node dissection for gallbladder cancer under laparoscopy: en-bloc resection technique

PURPOSE

Positive lymph node (LN) is a key prognostic factor in radically resected gallbladder cancer (GBCA). However, only a few underwent an adequate lymphadenectomy, and the number and extent of lymph node dissection (LND) have not been standardized. This study aims to develop an en bloc and standardized surgical procedure of LND for GBCA under laparoscopy.

METHODS

Data of patients with GBCA underwent laparoscopic radical resection using a standardized and en bloc technique for LND were collected. Perioperative and long-term outcomes were retrospectively analyzed.

RESULTS

A total of 39 patients underwent laparoscopic radical resection using standardized and en bloc technique for LND except one case (open conversion rate: 2.6%). Patients with stage T1b had significantly lower LNs involved rate than patients with stage T3 (P = 0.04), whereas median LN count in stage T1b was significantly higher than that in stage T2 (P = 0.04), which was significantly higher than that in stage T3 (P = 0.02). Lymphadenectomy with ≥ 6 LNs accounted for 87.5% in stage T1b, up to 93.3% in T2 and 81.3% in T3, respectively. All the patients in stage T1b were alive without recurrence at this writing. The 2-year recurrence-free survival rate was 80% for T2 and 25% for T3, and the 3-year overall survival rate was 73.3% for T2 and 37.5% for T3.

CONCLUSION

The standardized and en bloc LND permits complete and radical removal of lymph stations for patients with GBCA. This technique is safe and feasible with low complication rates and good prognosis. Further studies are required to explore its value and long-term outcomes compared to conventional approaches.

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.

Heterogeneity of management practices surrounding operable gallbladder cancer - results of the OMEGA-S international HPB surgical survey

BACKGROUND

Gallbladder cancer (GBC) is an aggressive, uncommon malignancy, with variation in operative approaches adopted across centres and few large-scale studies to guide practice. We aimed to identify the extent of heterogeneity in GBC internationally to better inform the need for future multicentre studies.

METHODS

A 34-question online survey was disseminated to members of the European-African Hepatopancreatobiliary Association (EAHPBA), American Hepatopancreatobiliary Association (AHPBA) and Asia-Pacific Hepatopancreatobiliary Association (A-PHPBA) regarding practices around diagnostic workup, operative approach, utilization of neoadjuvant and adjuvant therapies and surveillance strategies.

RESULTS

Two hundred and three surgeons responded from 51 countries. High liver resection volume units (>50 resections/year) organised HPB multidisciplinary team discussion of GBCs more commonly than those with low volumes (p < 0.0001). Management practices exhibited areas of heterogeneity, particularly around operative extent. Contrary to consensus guidelines, anatomical liver resections were favoured over non-anatomical resections for T3 tumours and above, lymphadenectomy extent was lower than recommended, and a minority of respondents still routinely excised the common bile duct or port sites.

CONCLUSION

Our findings suggest some similarities in the management of GBC internationally, but also specific areas of practice which differed from published guidelines. Transcontinental collaborative studies on GBC are necessary to establish evidence-based practice to minimise variation and optimise outcomes.

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.

Cáncer de vesícula biliar, una visión actual

Introducción. El diagnóstico de cáncer de vesícula biliar se realiza generalmente de forma incidental durante el estudio de las piezas quirúrgicas o cuando la enfermedad está avanzada y se expresa por su diseminación. Muy pocas veces se diagnostica de forma preoperatoria. Corresponde a la neoplasia más común de las vías biliares y su incidencia varía de acuerdo a la región geográfica. La región andina en Latinoamérica presenta una de las mayores incidencias a nivel mundial. Métodos. Se realizó una revisión narrativa de la literatura, para presentar una información actualizada en lo referente a los factores de riesgo (incluyendo las alteraciones genéticas y moleculares), al diagnóstico y al tratamiento de esta patología. Basados en los datos actuales, presentamos algunas recomendaciones dirigidas al diagnóstico temprano, que permita un manejo más adecuado de nuestros pacientes. Resultados. Se han implicado nuevos factores de riesgo relacionados con la etiología del cáncer de vesícula biliar, como la obesidad, factores genéticos y moleculares. A pesar de la disponibilidad de los métodos diagnósticos imagenológicos, no ha ocurrido una importante variación porcentual en cuanto al estadio al momento del diagnóstico. Conclusiones. El manejo quirúrgico del cáncer de vesícula biliar está indicado en los estadios más tempranos de la enfermedad y es importante evaluar las opciones terapéuticas en pacientes con enfermedad avanzada. Se considera de suma importancia el estudio anatomopatológico de la pieza quirúrgica y la revisión del informe por parte del cirujano

Long non-coding RNA TMPO-AS1 promotes cell proliferation, migration, invasion and epithelial-to-mesenchymal transition in gallbladder carcinoma by regulating the microRNA-1179/E2F2 axis

Gallbladder carcinoma (GBC), which is a common tumor of the biliary system, poses a serious threat to human life and health. The present study aimed to investigate the molecular mechanism of the long non-coding (lnc)RNA thymopoietin antisense transcript 1 (TMPO-AS1)/microRNA (miRNA/miR)-1179/E2F transcription factor 2 (E2F2) axis in GBC. The viability, proliferation, migration, invasion and epithelial-to-mesenchymal transition (EMT) of GBC cell lines were assessed via the Cell Counting Kit-8, colony formation, Transwell migration and invasion, immunofluorescence and western blot assays. In the present study, lncRNA TMPO-AS1 was significantly upregulated in clinical GBC tissues and cell lines, and was highly expressed in stage III+IV patients with GBC compared with stage I+II patients with GBC. In addition, the overall survival rate of patients with low TMPO-AS1 expression levels was higher than those with high TMPO-AS1 expression levels. Furthermore, TMPO-AS1 knockdown inhibited the viability, proliferation, migration, invasion and EMT of GBC cell lines. In addition, miR-1179 expression was downregulated in clinical GBC tissues and cell lines, and negatively correlated with TMPO-AS1 expression. The results revealed that miR-1179 is a target of TMPO-AS1, which was confirmed via the dual-luciferase reporter assay and RNA pull-down analysis. Overexpression of miR-1179 inhibited the viability, proliferation, migration, invasion and EMT of GBC cell lines. Furthermore, E2F2 was verified as a direct target of miR-1179 by binding to its 3'-untranslated region. E2F2 expression was significantly upregulated in clinical GBC tissues and cell lines, and negatively correlated with miR-1179 expression. Notably, E2F2 knockdown partially hindered the effects of TMPO-AS1/miR-1179 on the proliferation and metastasis of GBC cell lines. Taken together, the results of the present study suggest that TMPO-AS1 potentially plays a tumor-promoting role in the occurrence and development of GBC, which may be achieved by regulating the miR-1179/E2F2 axis.

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.

Role of tumour location and surgical extent on prognosis in T2 gallbladder cancer: an international multicentre study

BACKGROUND

In gallbladder cancer, stage T2 is subdivided by tumour location into lesions on the peritoneal side (T2a) or hepatic side (T2b). For tumours on the peritoneal side (T2a), it has been suggested that liver resection may be omitted without compromising the prognosis. However, data to validate this argument are lacking. This study aimed to investigate the prognostic value of tumour location in T2 gallbladder cancer, and to clarify the adequate extent of surgical resection.

METHODS

Clinical data from patients who underwent surgery for gallbladder cancer were collected from 14 hospitals in Korea, Japan, Chile and the USA. Survival and risk factor analyses were conducted.

RESULTS

Data from 937 patients were available for evaluation. The overall 5-year disease-free survival rate was 70·6 per cent, 74·5 per cent for those with T2a and 65·5 per cent among those with T2b tumours (P = 0·028). Regarding liver resection, extended cholecystectomy was associated with a better 5-year disease-free survival rate than simple cholecystectomy (73·0 versus 61·5 per cent; P = 0·012). The 5-year disease-free survival rate was marginally better for extended than simple cholecystectomy in both T2a (76·5 versus 66·1 per cent; P = 0·094) and T2b (68·2 versus 56·2 per cent; P = 0·084) disease. Five-year disease-free survival rates were similar for extended cholecystectomies including liver wedge resection versus segment IVb/V segmentectomy (74·1 versus 71·5 per cent; P = 0·720). In multivariable analysis, independent risk factors for recurrence were presence of symptoms (hazard ratio (HR) 1·52; P = 0·002), R1 resection (HR 1·96; P = 0·004) and N1/N2 status (N1: HR 3·40, P < 0·001; N2: HR 9·56, P < 0·001). Among recurrences, 70·8 per cent were metastatic.

CONCLUSION

Tumour location was not an independent prognostic factor in T2 gallbladder cancer. Extended cholecystectomy was marginally superior to simple cholecystectomy. A radical operation should include liver resection and adequate node dissection.

Comparison of lymph node evaluation and yield among patients undergoing open and minimally invasive surgery for gallbladder adenocarcinoma

INTRODUCTION

Assessment of regional lymph nodes (LN) is essential for determining prognosis among patients with gallbladder cancer (GBC). The impact of surgical technique on LN yield has not been well explored. We investigated the impact of minimally invasive surgery (MIS; robotic or laparoscopic) on the evaluation and retrieval of regional LN for patients with GBC.

METHODS

We queried the National Cancer Database (NCDB) to identify patients with GBC who underwent curative-intent surgery between 2010 and 2015. Patients with metastatic disease or those with missing data on surgical resection or LN evaluation were excluded.

RESULTS

We identified 2014 patients who underwent an open (n = 1141, 56.6%) or MIS approach (n = 873, 43.4%) for GBC and met the inclusion criteria. Patients who underwent MIS were older (open: 68 years, IQR: 60, 75 vs. MIS: 70 years, IQR (61, 77); P = 0.02), and were more commonly treated at a comprehensive community cancer program (P < 0.001). Approximately 3 out of 4 patients (n = 1468, 72.9%) underwent an evaluation of regional LN, with nearly half of these patients (n = 607, 41.7%) having LN metastasis. Among patients who underwent a regional lymphadenectomy, average lymph node yield was 3 (IQR: 1, 6) and was similar between the two groups (P = 0.04). After controlling for all factors, operative approach was not associated with likelihood of receiving a lymphadenectomy during curative-intent resection (OR 0.81, 95% CI 0.63-1.04; P = 0.11).

CONCLUSION

In conclusion, patients undergoing curative-intent resection for GBC had similar rates of lymph node evaluation and yield regardless of operative approach. Over one-quarter of patients did not undergo a lymphadenectomy at the time of surgery. Further studies are needed to identify barriers to lymph node evaluation and yield among patients undergoing surgery for gallbladder cancer. Presented at the 2019 2nd World Congress of the International Laparoscopic Liver Society, Tokyo, Japan.

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.