Laparoscopic cholecystectomy and unsuspected gallbladder cancer.

Gallbladder cancer is a relatively uncommon malignancy. Its presentation is similar to that of gallstone disease and sometimes with non-specific symptoms. Laparoscopic cholecystectomy has become the method of choice for removing the gallbladder in most benign conditions. Occasionally, unsuspected gallbladder carcinoma is encountered in association with laparoscopic cholecystectomy. Overall gallbladder cancers have a poor prognosis, despite surgery or adjuvant therapies. However, in selected cases, a favourable outcome can be expected and the less favourable predicted outcome can be improved. Management of patients with gallbladder cancer in different situations is discussed: gallbladder cancer noted post-operatively on final pathology, gallbladder cancer noted after removal of the gallbladder and opening of the specimen at the time of surgery, difficulty encountered at the time of dissection and resultant suspicion of gallbladder cancer, and diagnosis of extensive disease at initial placement of the laparoscope. Copyright Harcourt Publishers Limited.     

A reappraisal of primary gallbladder carcinoma

A 10-year experience with 14 patients with primary carcinoma of the gallbladder encountered in a typical community hospital has been reviewed. Abdominal discomfort in its many manifestations occurred in all patients, with chronic pain of long duration frequently being noted. Six patients were jaundiced. Twelve had documented cholelithiasis. Histologic examination revealed adenocarcinoma in all instances. One patient is alive and well at 3 years; survival of the remaining patients was from 9 days to 25 months. Primary carcinoma of the gallbladder occurs in more than 1% of surgically removed gallbladders. The disease is largely one of elderly persons with chronic calculous cholecystitis. Not only will it be seen with increasing frequency as life expectancy increases, but also it is preventable. Improvement in treatment can thus be initiated by prophylactic removal of diseased gallbladders in otherwise healthy persons. Malignancy may be obscured in those patients presenting with acute cholecystitis eluding surgeon and pathologist alike. These cases, as well as all early malignancies, are diagnosed only by careful histologic examination. Therefore, all gallbladders should be opened and examined by the surgeon in the operating room. Suspicious areas should be evaluated histologically by frozen section so that extension of the operation to include removal of adjacent hepatic parenchyma and performance of an extensive regional lymphadenectomy can be undertaken if cancer is found. By routinely considering every older patient who comes to cholecystectomy as suspect of harboring gallbladder cancer, survival may well be improved.     

Management of cancer gallbladder found as a surprise on a resected gallbladder specimen

Carcinoma gallbladder is associated with an overall 5-year survival rate reported less than 5% due to late diagnosis. Advent of ultrasound scanning may help in detecting gallbladder polyps and an early gallbladder cancer. Excellent 5-year survival (up to 100%) has been reported for Stage Ia disease and the survival has significantly improved for Stage Ib, II, and III if appropriate re-operation is carried out soon after the incidental detection of gallbladder cancer. Laparoscopic cholecystectomy (LC) is contraindicated in the presence of gallbladder cancer. It is recommended to excise all laparoscopic port sites, at the time of re-operation. Re-operation for Stage II gallbladder cancer is associated with a 90-100% 3-year survival rate. Patients with Stage III and IV tumors also benefit from an extended cholecystectomy. Patients with bulky primary tumors without lymph node metastases (T4N0) seem to have a better prognosis than those with distant lymph node metastases, and should be treated aggressively. It is advantageous to perform the appropriate extent of surgery for gallbladder cancer at the initial operation. Heightened awareness of the presence of cancer and the knowledge of appropriate management are important. For patients whose cancer is an incidental finding on pathologic review, re-resection is indicated for all disease except Stage Ia. Radiotherapy and chemotherapy have not been found effective as an adjuvant or palliative therapy in gallbladder cancer.     

19例原发性胆囊癌疗效分析

目的:探讨浸润肌层的胆囊癌是否是局部疾病,行单纯胆囊切除术后是否要行二次根治手术治疗方法:回顾分析了19例浸润肌层的原发性胆囊癌患者,8例行单纯胆囊切除术,11例行根治性淋巴结清扫术68个区域淋巴结被检查平均随访时间97个月结果:组织学检查均未发现血管浸润,1例有淋巴管浸润淋巴结均未见转移10年生存率为89%,单纯胆囊切除术与根治术结果相比,差别无统计学意义.2例行根治术的患者死于肿瘤复发结论:多数浸润肌层的早期原发性胆囊癌仅是局部扩散,行单纯胆囊切除术后不需再行根治术。     

Surgical strategies in patients with gallbladder cancer: nihilism to optimism

INTRODUCTION: Gallbladder cancer is an aggressive disease with dismal results of surgical treatment and a poor prognosis. However, over the last few decades selected groups have reported improved results with aggressive surgery for gallbladder cancer. METHODS: Review of recent world literature was done to provide an update on the current concepts of surgical treatment of this disease. RESULTS: Long-term survival is possible in early stage gallbladder carcinoma. Tis and T1a gallbladder carcinoma can be treated with simple cholecystectomy only. However, in T1b and beyond cancers, aggressive surgery (extended cholecystectomy) is important in improving the long-term prognosis. Laparoscopic cholecystectomy should not be performed where there is a high index of suspicion of malignancy due to the frequent association with factors (such as gallbladder perforation and bile spill) which may lead to implantation of cancer cells and dissemination. Surgical resection for advanced carcinoma gallbladder is recommended only if a potentially curative R0 resection is possible. Aggressive surgery with vascular and multivisceral resection has been shown to be feasible albeit with an increase in mortality and morbidity. However, the true benefit of these radical resections is yet to be realized, as the actual number of long-term survivors of advanced gallbladder carcinoma is few. CONCLUSIONS: Surgery for gallbladder carcinoma, like other malignancies, has the potential to be curative only in local or regional disease. Pattern of loco-regional spread of disease dictates the surgical procedure. Radical surgery improves survival in early gallbladder carcinoma. The long-term benefit of aggressive surgery for advanced disease is unclear and may be offset by the high mortality and morbidity.     

Staging,Treatment, and Future Approaches of Gallbladder Carcinoma

Background

Gallbladder cancer is the most common malignant cancer of the bile ducts and third most common gastrointestinal malignant in the world for public health. Its relatively low incidence and confused symptoms result in advanced disease at the time of presentation, contributing to poor prognosis and reduced survival associated with this disease. The main function of the gallbladder is to store excreted bile acids from the liver in preparation for a meal. Its main risk factor is prolonged exposure to biliary calculations, although bacterial infections and other inflammatory conditions are associated. Chronic inflammatory bowel conditions are associated with gallbladder cancer. T stage translates to identifying residual disease at reoperation for incidental gallbladder cancer and residual disease negatively affects survival.

Conclusion

It is the most common cancer of gallbladder, gallbladder cancer remains a rare disease. Gallbladder cancer is a rare disease that can be accidentally diagnosed after cholecystectomy or accidentally, often with more advanced disease. The prognosis is generally extremely poor and improvements in surgical resection of this approach have to be re-evaluated, while the role of chemotherapy and radiotherapy remains controversial.

     

Gallbladder cancer

Gallbladder cancer has a reputation for being aggressive and incurable. Single institution series, however, have defined successful management strategies in which the extent of resection is based on the stage of the tumor at presentation. Careful ultrasound screening for abnormalities in the gallbladder wall, and CA19-9 serum determination prior to routine cholecystectomy may heighten awareness for cancer in this population. For tumors confined to the muscular layer of the gallbladder a simple cholecystectomy is associated with an almost 100% cure rate. Tumors invading through the muscle wall (Stage II) should be managed with extended cholecystectomy, including resection of hepatic segments IVb and V, and an extensive lymph node dissection of the porta hepatis, posterior pancreaticoduodenal, and interaortocaval lymph nodes. This operation for Stage II gallbladder cancer is associated with a 90% to 100% 3-year survival rate. Simple cholecystectomy fails in the majority of Stage II patients. Patients with Stage III and IV tumors may also benefit from an extended cholecystectomy. Patients with bulky primary tumors without lymph node metastases (T4N0) seem to have a better prognosis than those with distant lymph node metastases, and should be treated aggressively when possible. It is advantageous to perform the appropriate extent of surgery for gallbladder cancer at the initial operation. Heightened awareness of the presence of cancer and the knowledge of appropriate management are important. For patients whose cancer is an incidental finding on pathologic review, re-resection is indicated for all disease except Stage I. This review will discuss the epidemiology, pathology, and staging of gallbladder cancer and describe the appropriate surgical management based on the stage of the cancer.     

Gallbladder cancer: a global perspective

Gallbladder cancer, the commonest malignancy of the biliary tract worldwide, is common in northern India. It can be clinically obvious, an unexpected finding at laparotomy, detected incidentally on histological examination or may be missed only to present with recurrence during follow up. US, CECT, uppeer gastro-intestinal endoscopy, and laparoscopy are useful for diagnosis and staging. We have adopted a 'middle path'--between pessimistic nihilism of the West and aggressive radicalism of Japan--of management, i.e., extended cholecystectomy for early disease confined to the gallbladder and hepato-dudodenal ligament, and non-surgical palliation for advanced disease. The aetiological role of gallstones in the causation of gallbladder cancer needs to be investigated to decide the place of prophylactic cholecystectomy, if any.     

Epidemiology of gallbladder cancer and trends in cholecystectomy rates in Scotland, 1968-1998

The aim of this study was to describe the epidemiology of gallbladder cancer in Scotland during the last 30 years. A secondary aim was to describe trends in cholecystectomy rates because it has been suggested that changing rates of cholecystectomy for benign gallbladder disease may be influencing the epidemiology of gallbladder cancer. A retrospective analysis of cancer registration and mortality (gallbladder cancer) and hospital discharge (cholecystectomy) data from Scotland in 1968-1998 was carried out. In Scotland the incidence of, and mortality from, gallbladder cancer have been falling in women since at least 1968, and in men since the late 1980s. Whilst overall survival remains poor, survival in older patients may have improved recently, and survival is better in patients from affluent areas. Cholecystectomy rates increased until 1977 then fell until the introduction of laparoscopic surgery caused them to return to the rates previously observed. The current declining incidence of gallbladder cancer in Scotland is probably, in part, related to the increasing cholecystectomy rates seen prior to 1977. Further studies addressing changes in stage at diagnosis and treatment provided are required to investigate the recent apparent improvement in survival of elderly gallbladder cancer patients.     

Polyps of the gallbladder

One of the unusual problems associated with gallbladder disease is a polyp discovered by either ultrasonography or by oral cholecystogram. We report a recent experience of two cases of polyps of the gallbladder removed by cholecystectomy. The incidence of gallbladder polyps of any type is quite varied in the medical literature. Eighty percent of polyps occur in females, and these occur after the third decade of life. The polyps can either be cholesterol or inflammatory polyps that are not really benign tumors but just reactions of the gallbladder wall. The true mucosal benign lesions are either adenomyomas or papillomas. The adenomyomas and papillomas have malignant potential. There are case reports of carcinoma in situ and cancer arising from these lesions. The treatment for a gallbladder polyp is a cholecystectomy.     

Incidental finding of gallbladder carcinoma detected during or after laparoscopic cholecystectomy.

AIM: Carcinoma of the gallbladder is a rare neoplasm with a dismal prognosis. With the increase of cholecystectomies due to the wide acceptance of laparoscopic cholecystectomy, the incidental diagnosis of gallbladder carcinoma is more frequent. We report our experience with gallbladder cancer diagnosed during or after the performance of laparoscopic cholecystectomy. METHODS: We evaluated 11 patients with gallbladder cancer out of 5539 patients who underwent laparoscopic cholecystectomy. Patient clinical and demographic characteristics were reviewed. RESULTS: Intraoperatively in 297 patients there was the suspicion of adenocarcinoma and frozen sections were performed. In four of them the diagnosis of adenocarcinoma was confirmed. In two of them the procedure was converted to open with gallbladder liver bed resection and regional lymph node dissection while the other two were considered inoperable. Of the remaining 5242 patients, seven were diagnosed postoperatively at the pathologic examination. Of these, five patients refused to undergo a repeat operation. We did not observe port site metastasis in any of our patients. Survival was low and ranged from 3-14 months. CONCLUSION: Gallbladder cancer runs a short course, with a poor prognosis. The use of a meticulous laparoscopic technique seems to be important for the diagnosis and the avoidance of early complications of the disease.     

Cholecystectomy and the incidence of breast cancer: a cohort study.

A cohort comprising 11678 women who had undergone cholecystectomy in the period 1964 through 1967 for a benign gallbladder disease was investigated. They represented almost a total ascertainment from a defined geographic area. Follow-up during 11-14 completed years of observation revealed a total of 202 breast cancer cases after the cholecystectomy. This number was close to the expected incidence of 199.1 (relative risk 1.0). Further analysis of the risk in relation to duration of observation and age at operation did not reveal any trend or subgroup with a significantly increased or decreased risk. It was concluded that despite the many epidemiologic observations indicating that in Western Countries dietary habits are particularly important determinants of the high incidence of both gallstone disease and breast cancer, our results contradict the idea that the diseases share common aetiologic factors.     

胆囊癌与胆囊结石关系的临床分析

目的　探讨胆囊癌与胆囊结石的关系。方法　对所收集的胆囊癌病人 47例 ,胆囊结石病人 2 86 3例进行了分析。结果　 47例胆囊癌病人均伴有胆囊结石 ,全部经手术治疗。其生存率 :1年为 46例 ( 97.87% ) ,2年 32例 ( 6 8.0 8% ) ,3年 2 8例 ( 5 9.5 7% ) ,4年 12例 ( 2 5 .5 3% ) ,年 2例 ( 4 .2 5 % )。胆囊结石病人 2 86 3例 ,经手术治疗 10 6 9例。结论　胆囊癌与胆囊结石的关系极为密切 ,胆囊结石是诱发胆囊癌的重要因素之一。对胆囊结石的病人行胆囊切除是预防胆囊癌发生的较为有效的方法之一。     

Carcinoma of the gallbladder

Carcinoma of the gallbladder is the most common malignant tumour of the biliary tract and a particularly high incidence is observed in Chile, Japan, and northern India. The aetiology of this tumour is complex, but there is a strong association with gallstones. Owing to its non-specific symptoms, gallbladder carcinoma is generally diagnosed late in the disease course, but if a patient with gallstones experiences a sudden change of symptoms, then a cancer diagnosis should be considered. Treatment with radical or extended cholecystectomy is potentially curative, although these procedures are only possible in 10-30% of patients. There is no role for cytoreductive surgery in this disease. If a gallbladder carcinoma is discovered via pathological examination of tissue samples, then the patient should be examined further and should have radical surgery if the tumour is found to be T1b or beyond. Additional port-site excision is necessary if the patient has already had their gallbladder removed during laparoscopy; however, patients with an intact gallbladder who are suspected to have gallbladder carcinoma should not undergo laparoscopic cholecystectomy. Patients with advanced inoperable disease should receive palliative treatment; however, the role of chemotherapy and radiation in these patients needs further evaluation.     

Gallbladder carcinoma incidentally encountered during laparoscopic cholecystectomy: how to deal with it

Gallbladder cancer (GBC), characterised by rapid progression and a poor prognosis with a high mortality rate, is a complex disease to treat. Incidental gallbladder carcinoma (IGBC) is defined as carcinoma of the gallbladder suspected for the first time during cholecystectomy or accidentally found on histological examination of the gallbladder. With the increasingly widespread acceptance of laparoscopic cholecystectomy (LC) and difficulties in diagnosing GBC preoperatively, the number of cases of IGBC during and after LC has increased. However, management of IGBC is a difficult issue in the absence of established guidelines. Problems associated with IGBC related to LC are the decisions of whether, when and how to perform additional surgery. Controversy remains regarding the effectiveness of additional resection in different stages of GBC. This review gives an overview of IGBC related to LC, and further discusses the preoperative, intraoperative and postoperative diagnosis and management of IGBC during LC.     

Cholelithiasis in gallbladder cancer: Coincidence,cofactor, or cause!

Background

While gallstones are associated with cancers of the gallbladder, the actual nature of their relationship needs to be clarified. This would aid the recommendations on the need for prophylactic cholecystectomy.

Methods

A systematic search of the scientific literature was carried out using the Medline, the Embase, and the Cochrane Central Register of Controlled Trials for the years 1891–2009 to obtain access to all publications involving gallstones in gallbladder cancer.

Results

While some epidemiological evidence supports a causal relationship for gallstones in gallbladder cancer, other studies have demonstrated a relatively low incidence of gallbladder cancer in countries reporting a high incidence of gallstones as a whole. In those studies where gallstones appear to have a causative role for cancer, the risk increases with increasing size, volume and weight, and number of the stones. The impact of duration of the stone or its composition is not clear. Experimental evidence from studies examining the impact of artificially introducing gallstones in the gallbladder has failed to lead to carcinogenesis.

Conclusions

The evidence at the current time indicates that gallstones are a cofactor in the causation of gallbladder cancer. Absolute proof of their role as a cause for gallbladder cancer is lacking. The recommendation for prophylactic cholecystectomy in countries reporting a high incidence of gallbladder cancer and associated gallstones needs to be tailored to the epidemiological profile of the place.     

A genetic model for gallbladder carcinogenesis and its dissemination

Gallbladder cancer, although regarded as the most common malignancy of the biliary tract, continues to be associated with a dismal overall survival even in the present day. While complete surgical removal of the tumour offers a good chance of cure, only a fraction of the patients are amenable to curative surgery owing to their delayed presentation. Moreover, the current contribution of adjuvant therapies towards prolonging survival is marginal, at best. Thus, understanding the biology of the disease will not only enable a better appreciation of the pathways of progression but also facilitate the development of an accurate genetic model for gallbladder carcinogenesis and dissemination. This review provides an updated, evidence-based model of the pathways of carcinogenesis in gallbladder cancer and its dissemination. The model proposed could serve as the scaffolding for elucidation of the molecular mechanisms involved in gallbladder carcinogenesis. A better understanding of the pathways involved in gallbladder tumorigenesis will serve to identify patients at risk for the cancer (and who thus could be offered prophylactic cholecystectomy) as well as aid oncologists in planning the most suitable treatment for a particular patient, thereby setting us on the vanguard of transforming the current treatment paradigm for gallbladder cancer.     

Laparoscopic bile duct resection with lymph node dissection for gallbladder cancer diagnosed after laparoscopic cholecystectomy

IntroductionLaparoscopic reoperation of postoperatively diagnosed gallbladder cancer is a technically challenging procedure due to inflammatory adhesion or fibrosis around the hepatoduodenal ligament and gallbladder bed [1,2]. Here we describe a technique for laparoscopic bile duct resection with lymph node dissection in a patient with cystic duct cancer diagnosed after laparoscopic cholecystectomy.VideoA 73-year-old woman presented with postoperatively diagnosed gallbladder cancer. She underwent laparoscopic cholecystectomy to treat symptomatic gallbladder stones at another hospital, 2 months earlier. Postoperative pathology revealed a 0.9 × 0.7 cm, T2 lesion of adenosquamous carcinoma located at the cystic duct. The cystic duct margin showed high-grade dysplasia. We planned to perform laparoscopic bile duct resection with lymph node dissection. After adhesiolysis to expose the hepatoduodenal ligament, the lymph nodes were dissected around the retropancreatic area, hepatoduodenal ligament, and common hepatic artery in an en bloc fashion. Combined segmental resection of the bile duct, including the fibrotic scar around the cystic duct stump, was completed with negative resection margins. Retrocolic choledochojejunostomy and side-to-side jejunojejunostomy were then performed intracorporeally.ResultsThe operation time was 195 minutes and the estimated intraoperative blood loss was minimal. The postoperative pathologic report revealed no residual tumor tissue and negative resection margins. Lymph node metastasis was found in one of eight retrieved lymph nodes. The patient was discharged on postoperative day 4 with no postoperative complications.Conclusion.Laparoscopic radical surgery involving bile duct resection and lymph node dissection can be safely performed in patients with postoperatively diagnosed gallbladder cancer.     

Recent trends of gallbladder cancer in Japan: an analysis of 4,770 patients

BACKGROUND: Gallbladder cancer is the most common cancer of the biliary tract and has a particularly high incidence in Chile, Japan, and northern India. Many Japanese surgeons have reported that aggressive surgery improves the outcome of patients with gallbladder cancer. Differences in survival rates between Japan and other countries have been noted. The objective of this study was to determine whether there were any changes over time in the incidence, therapeutic approach, stage at diagnosis, or prognosis of gallbladder cancer in an unselected, community-based series of patients in Japan. METHODS: In total, 4,774 patients with gallbladder cancer were analyzed between 1988 and 1997 based on data from the Biliary Tract Cancer Registration Committee of the Japanese Society of Biliary Surgery. RESULTS: Survival was related closely to surgical stage, with 5-year survival rates of 77% for patients with stage I disease, 60% for patients with stage II disease, 29% for patients with stage III disease, 12% for patients with stage IVA disease, and 3% for patients with stage IVB disease. Patient age also affected survival. The survival rate for patients aged <49 years was significantly better compared with the survival rate for patients in the other groups (P < .05). The 5-year survival rate for patients aged <49 years was 38%. The survival rate for patients aged >79 years was significantly worse compared with the survival rate for patients in the other 4 groups (P < .01). The 5-year survival rate for patients aged >79 years was 21%. Stratifying patients by stage according to the Japanese Society of Biliary Surgery classification showed that women maintained a survival advantage over men among patients with stage I and II disease. Adjuvant chemotherapy did not provide a survival benefit. There were no apparent changes in patient demographics between the period from 1988 to 1992 and the period from 1993 to 1997. CONCLUSIONS: For this study, the authors evaluated the gallbladder cancer trends in Japan. The Classification of Biliary Tract Carcinoma proposed by the Japanese Society of Biliary Surgery reflected the prognosis of patients with gallbladder cancer. Patient outcomes were affected by patient age and sex. No substantial differences in patient survival were apparent over the 10-year study period. The data did not support any advantage for aggressive surgical resection and adjuvant chemotherapy. Further analysis of operative procedures will be necessary to determine conclusively whether there is any survival advantage from aggressive surgery in patients with advanced gallbladder cancer.     

Comparing survival rate and appropriate surgery methods according to tumor location in T2 gallbladder cancer

BackgroundThe survival outcomes and optimal extent of surgery of T2 gallbladder cancers remain controversial. We aimed to investigate the difference in overall/disease-free survival rates and assess the prognosis of T2 gallbladder cancers.MethodsWe retrospectively reviewed electronic medical records of 147 patients who underwent surgical resection for pathologically confirmed T2 gallbladder cancer between January 2003 and December 2012. Patients were categorized into two groups according to the tumor location (T2a vs. T2b) and three groups according to surgery method (simple cholecystectomy, cholecystectomy with lymph node dissection, and extended cholecystectomy). We compared the overall and disease-free survival rates according to T2 subgroups and surgery methods. Cox proportional hazard analysis was performed to evaluate prognostic factors for the overall survival of T2 gallbladder cancer.ResultsOf all patients, 40 (27.2%) and 107 (72.8%) were diagnosed with T2a and T2b gallbladder cancers, respectively. The 5-year overall and disease-free survival rates were 75.0% vs. 73.8% (p = 0.653) and 72.5% vs. 70.1% (p = 0.479) in T2a and T2b gallbladder cancers, respectively.There was no difference in the survival rate among T2a gallbladder cancer according to the surgery method. However, in T2b gallbladder cancer, extended cholecystectomy showed a better overall survival than simple cholecystectomy and cholecystectomy with lymph node dissection groups (p = 0.043 and p = 0.003, respectively).ConclusionsThere is no difference in overall and disease-free survival rates according to the location of T2 gallbladder cancers. Extended cholecystectomy increases overall survival rate, especially in T2b gallbladder cancers.