Achieving margin negative resection-doing less is justified: oncological outcomes of wedge excision of liver in gallbladder cancer (GBC) surgery

Gallbladder cancer: Progress in the Indian subcontinent

Gallbladder cancer (GBC) is one of the commonest biliary malignancies seen in India, Argentina, and Japan. The disease has dismal outcome as it is detected quite late due to nonspecific symptoms and signs. Early detection is the only way to improve the outcome. There have been several advances in basic as well as clinical research in the hepatobiliary and pancreatic diseases in the West and other developed countries but not enough has been done in GBC. Therefore, it is important and the responsibility of the countries with high burden of GBC to find solutions to the many unanswered questions like etiopathogenesis, early diagnosis, treatment, and prognostication. As India being one of the largest hubs for GBC in the world, it is important to know how the country has progressed on GBC. In this review, we will discuss the outcome of the publications from India highlighting the work and the developments taken place in past several decades both in basic and clinical research.

Lessons learnt from 1300 consecutive gallbladder cancer surgeries: Evolving role of peri-operative chemotherapy in the treatment paradigm

BACKGROUND

Level I evidence for multi-modality management of gallbladder cancers (GBC) is evolving.

METHODS

Prospectively maintained operative GBC database of 1307 patients (year 2010-2019) was analysed to study the impact of peri-operative chemotherapy (PCT) on survival outcomes.

RESULTS

1040 patients had pathologically confirmed GBC. Stage distribution showed: Stage I(85,8.2%), II(247,23.8%), III(460,44.2%), IV(248, 23.8%). PCT was used as follows: in stage II, 164 patients received adjuvant chemotherapy(ACT); in stage III, ACT was given to 444 patients, either operated upfront(244 patients) or after neoadjuvant chemotherapy (NACT)(216 patients); in stage IV, 32 patients (11 received NACT) underwent radical surgery followed by ACT and 216 patients had inoperable disease (77 received NACT) upon exploration. With a median follow-up of 30 months, the 3-year OS for stage I, II and III was 94.1%, 82.6% and 48.2% respectively. Corresponding DFS was 93.8%, 67.3% and 38.3%. Upon reassessment for surgery after NACT (n = 332), patients who underwent radical surgery (n = 235) had superior OS (p = 0.000) and DFS (p = 0.000) in comparison to those who had inoperable disease (n = 97). Amongst stage III and IV patients with operable disease (n = 492), those who were operated upfront (n = 238) had equivalent survival as those operated after NACT (n = 254). This was also confirmed by a 1:1 propensity matched analysis (118 patients each), matching for T and N stage.

CONCLUSION

The role of peri-operative chemotherapy in management of GBC is evolving. While the role of NACT for locally advanced GBC is unsettled and merits testing prospectively, it helps in selection of patients with favourable disease biology for radical surgery.

Surgical and Oncological Outcomes of Wedge Resection Versus Segment 4b + 5 Resection for T2 and T3 Gallbladder Cancer: a Meta-Analysis

BACKGROUND

Liver resection is the standard operative procedure for patients with T2 and T3 gallbladder cancers (GBC). However, the optimal extent of hepatectomy remains unclear.

METHODS

We conducted a systematic literature search and meta-analysis to assess the safety and long-term outcomes of wedge resection (WR) vs. segment 4b + 5 resection (SR) in patients with T2 and T3 GBC. We reviewed surgical outcomes (i.e., postoperative complications and bile leak) and oncological outcomes (i.e., liver metastasis, disease-free survival (DFS), and overall survival (OS)).

RESULTS

The initial search yielded 1178 records. Seven studies reported assessments of the above-mentioned outcomes in 1795 patients. WR had significantly fewer postoperative complications than SR, with an odds ratio of 0.40 (95% confidence interval, 0.26 - 0.60; p < 0.001), although there were no significant differences in bile leak between WR and SR. There were no significant differences in oncological outcomes such as liver metastases, 5-year DFS, and OS.

CONCLUSIONS

For patients with both T2 and T3 GBC, WR was superior to SR in terms of surgical outcome and comparable to SR in terms of oncological outcomes. WR that achieves margin-negative resection may be a suitable procedure for patients with both T2 and T3 GBC.

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.

Comparative Study of Laparoscopic Versus Open Liver Resection in Gallbladder Cancer

Background: In recent decades, laparoscopic liver resection (LLR) has been gradually adopted at high-volume centers, particularly for hepatocellular carcinoma and liver metastasis. However, LLR in patients with gallbladder cancer (GBC) is a controversial issue, and there are few studies of LLR for GBC. Our aim was to compare the outcomes of patients who underwent laparoscopic or open liver resection for GBC. Materials and Methods: All patients admitted with stage II or III GBC requiring liver resection, together with cholecystectomy and lymphadenectomy, were analyzed retrospectively. Patients with thickness of the resected liver specimen >2 cm in pathology reports were included. Results: A total of 56 patients with stage II or III GBC were included in this study; 23 (41.1%) underwent laparoscopic surgery and 33 (58.9%) underwent open surgery. Propensity score matching was performed using a 1:1 matching scheme. After matching, 12 patients were included in each group. The preoperative characteristics of both groups were similar, as were the operative times (laparoscopic versus open group: 237.5 minutes versus 272.5 minutes, respectively; P = .319) and blood loss (300 mL versus 275 mL, respectively; P = .307). The laparoscopic group had a significantly shorter postoperative hospital stay than the open surgery group (4.5 days versus 8 days, respectively; P = .012). There were no major complications in either group. There was no difference between the groups in the number of lymph nodes harvested at surgery (P = .910). There were no differences between the two groups in disease-free (P = .503) or overall (P = .719) survival. Conclusion: LLR extended to GBC provides outcomes similar to those of open surgery. With increasing experience, LLR can be a viable alternative to open surgery for GBC.

Revision Surgery for Incidental Gallbladder Cancer-Challenging the Dogma: Ideal Timing and Real-World Applicability

BACKGROUND

There is a lack of consensus on the ideal time interval and therapeutic value of revision surgery in patients with incidental gallbladder cancer (iGBC) in the context of multimodality management.

PATIENTS AND METHODS

Retrospective analysis of an institutional database of patients with iGBC who underwent surgery from January 2010 to December 2019 was performed. Patients who underwent upfront surgery were divided into four time interval groups: A, B, C, and D (< 6 weeks, 6-10 weeks, 10-14 weeks, and > 14 weeks, respectively).

RESULTS

A cohort of 517 patients planned for revision surgery was analyzed. Overall, 382 (73.9%) patients underwent upfront surgery while 135 (26.1%) were given neoadjuvant treatment. With median follow-up of 18 months, 2-year overall survival (OS) was 66% and disease-free survival (DFS) was 52.6%, with inferior survival outcomes observed with advancing stage and presence of residual disease on final histopathology. Propensity score-matched analysis after matching for pT stage of cholecystectomy specimen suggested a survival benefit for patients operated between 10 and 14 weeks in terms of OS (p = 0.049) and DFS (p = 0.006). Patients with locally advanced iGBC at presentation had superior OS when operated after neoadjuvant therapy [3-year estimated OS of 59.9% vs 32.3%, respectively (p = 0.001)].

CONCLUSIONS

Revision surgery is at best the most accurate staging procedure guiding timely initiation of systemic therapy. Patients with iGBC operated between 10 and 14 weeks after initial cholecystectomy tend to have favorable survival outcomes, although this depends on final disease stage. Revision surgery should also be offered to all patients presenting at any later point of time, if deemed operable.