Intraoperative Suspicion of Gallbladder Carcinoma in Laparoscopic Surgery: What to Do?

Abstract

The frequency of gallbladder cancer in Europe is less than 1% of all gallstone operations. With the introduction of laparoscopic surgery and the higher acceptance of this technique, patients with gallstones have gallbladder removal much earlier in their gallstone history. So the percentage of gallbladder carcinomas will decrease in the future. We report on our surgical procedures in patients with suspicious gallbladders having laparoscopic gallbladder removal, and how to proceed after the diagnosis of gallbladder carcinoma. From June 1990 to December 2001, we have performed 7,130 cholecystectomies in a single department. 47 of these patients (0.66%) were identified as having carcinoma. There were 40 females and 7 males, with a mean age of 70.6 years. In 17 cases (36%) there was a preoperative suspicion of malignancy. Most commonly, in 30 cases (64%), malignancy was suspected intraoperatively or diagnosed postoperatively after pathological examination of the resected gallbladder. We recommend removal with a bag for all gallbladders with a suspected wall or scleroatrophic calcified gallbladder area. In stage Tis or T1 laparoscopy + cholecystectomy is sufficient. For T2 and T3 we perform reoperation with liver bed resection and lymphadenectomy.

Unsuspected gallbladder cancer diagnosed during or after laparoscopic cholecystectomy

“…F, female; GBP, gallbladder polyp (polypoid lesion); GS, gallstone; Hx, resection of the gallbladder bed with lymph node dissection following LC; LC, laparoscopic cholecystectomy; M, male; pap, papillary adenocarcinoma; pN0, no regional lymph node metastasis; pN2, metastases in peripancreatic (head only), periduodenal, periportal, coeliac and/or superior mesenteric lymph nodes; pNx, regional lymph nodes cannot be assessed; por, poorly differentiated adenocarcinoma; pT2, the tumor invades perimuscular connective tissue without extension beyond the serosa or into the liver; pT3, the tumor perforates the serosa or directly invades one adjacent organ (or both); well, well-differentiated adenocarcinoma. and for patients undergoing LC, unsuspected GBC has been detected in 0.2-2.9% of patients [2][3][4][5]8,18,19]. Among patients presenting with polypoid lesions of the gallbladder, the incidence of cancer is reported to range from 4 to 18% [20][21][22].…”

Surgical outcomes of laparoscopic cholecystectomy in scleroatrophic gallbladders

“…It is well known that preoperative diagnosis of gallbladder carcinoma is difficult. Kraas et al (30) reported that gallbladder malignancy is most commonly suspected intraoperatively or diagnosed postoperatively after pathological examination of the resected gallbladder. Ultrasonography is usually unsuccessful in the early detection of gallbladder cancer, especially if inflammation is present (31,32).…”

Early Gallbladder Cancer: Clinical, Morphological, Therapeutic and Evolutionary Aspects

“…It is well known that in the almost cases, the surgeon can perfectly suspect this cancer after opening the gallbladder. It is macroscopically apparent on the mucosa of the gallbladder in almost cases [2,3,6,7,11,12]. In our series, it was the case (macroscopically visible) in 29 cases (87.8%) after the opening of the gallbladder by the surgeon.…”

“…The prognosis of this form of gallbladder cancer is excellent with a cholecystectomy [2,11,14,16,18] and radical cholecystectomy. The 5 year survival fluctuates between 70% and 100% [2,7,8,11,14,[16][17][18][19][20][21]26]. In our experience, we encountered one death (radical cholecystectomy) not related to the surgery (myocardial infarction).…”

“…Currently, it can be recognized in 2 situations:  On preoperative course with ultrasonography [3][4][5].  On the histological examination after cholecystectomy for biliary lithiasis [5][6][7][8]. For a clinician to make a diagnosis before a surgical step, he needs an expert radiologist who should be vigilant during ultrasound examination.…”