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Five cases of gallbladder adenocarcinoma treated at Surgical Department 2, Maciel Hospital, Montevideo, Uruguay, in a period ranging from 1985 to 1989 and follow-up to date are reported.All cases were first diagnosed by microscopic examination of the gallbladder, which had been removed for presumed benign disease; there were no intramucosal carcinomas, and 60% of the cases were classified as Nevin's stage I1 (submucosal and muscularis).Based on the pattern of spread (mainly direct hepatic infiltration, as well as venous and lymphatic involvement), our radical surgical treatment of gallbladder carcinoma includes cholecystectomy , extended lymphatic clearance (along the porta hepatis or R , , pre-and retroduodenopancreatic and hepatic artery R,, and celiac axis R3), and medial hepatectomy (segments, IV, V, and VIII according to Couinaud).Simple cholecystectomy is the treatment of choice in mucosal (Tl) neoplasms; otherwise, histologically diagnosed gallbladder carcinoma following cholecystectomy for presumed benign disease calls for reoperation to achieve lymph node dissection and hepatic resection.Overall 2-and 3-year survival was 100% and 80%; mean survival was SO months. Medial hepatectomy was selected according to gallbladder carcinoma patterns of spread and failures, and entails resection of the parenchyma most frequently involved without compromising liver function, in a quick and safe surgical procedure. o 1993 WiIey-Liss, Inc.-

The impact of our evolving health care system on a commonly performed surgical procedure, cholecystectomy, was assessed in a county-subsidized and private university hospital setting. Although condition on admission, use of resources, and outcome were unchanged in the private setting between 1980 and 1988, significant differences were noted among the largely uninsured patients at the county facility during this same time interval. There was a significant increase in the acuity of illness among patients undergoing cholecystectomy at the county hospital in 1988 as compared with 1980. These data suggest that alterations in reimbursement strategies and allocation of resources are significantly impacting on patient care, particularly in nonprivate health care facilities.