Skip to main content
  • Research article
  • Open access
  • Published:

Diagnosis of incidental gallbladder cancer after laparoscopic cholecystectomy: our experience

Abstract

Background

Gallbladder carcinoma is a rare high malignancy neoplasm. The incidence of intra or post-operative incidental gallbladder carcinoma diagnosis is estimated between 0,2 and 2,8%. Primary aim of our study is to evaluate incidental gallbladder carcinoma's incidence in our experience.

Methods

We retrospectively reviewed our Surgery Division's experience about the totality of laparoscopic cholecystectomies with post-operative histological evidence of incidental gallbladder cancer. We evaluated patients' characteristics, surgical related variables, histological response, surgivcal radicalization characteristics and surgical outcome.

Results

In the considered sample we observed 7 accidental gallbladder adenocarcinomas in post-operative histological examination. Pathological results were:1 pT1b N0 (G1), 2 pT2 N0 (G2), 2 pT2 N1 (G3b), 2 pT3 N1 (G3b) (Table 1). In 5 cases we performed neoplasm radicalization surgery with standard procedure revision. Two patients died before radicalization. Median global survival was 34 months.

Conclusion

With the increase of laparoscopic cholecystectomies both elective and urgent performed in our centre we observed also an increase of incidentally diagnosed gallbladder neoplasms. Early diagnosis, meticulous peri-operative study and accurate surgical strategy are essential factors to obtain good results in incidental gallbladder cancer.

Background

Gallbladder carcinoma is a rare, high malignancy neoplasm, with an incidence rate of 0,3-1,5%[1–3]. The incidence of intra or post-operative incidental gallbladder carcinoma diagnosis is estimated between 0,2 and 2,8%; in this group, 15-30% of patients prove to be asymptomatic at the time presentation, without clinical evidences, intra or pre-operative, of neoplasm [1–3]. Primary aim of our study is to evaluate incidental gallbladder carcinoma's incidence in our experience, and to correlate it with age variable; second end-point of the study is to consider the possible relation between laparoscopic cholecystectomy indication increase in our centre and neoplasm observation incidence.

Methods

Our work is a retrospective study conducted at University Section of General Surgery in "San Luigi Gonzaga" Hospital, Orbassano (Torino). We reviewed our Surgery Division's experience about the totality of laparoscopic cholecystectomies between November 2008 and November 2012. Afterwards we created a subgroup (N Group - Neoplasm Group), made of patients who received a post-operative histological diagnosis of gallbladder neoplasm. In this group we studied: demographic variables (age, gender, ethnic group), clinical variables (clinical presentation, symptoms), haematic values (WBC, CRP, bilirubin), pre-operative ecographic features (associated cholelythiasis, gallbladder adenomyomathosis, cholecystitis, evident hepatic lesions), intra-operative data (type of surgery, elective or urgent surgery, intra-operative complications), histology (stage, grade, resection margins), and surgical outcome (radicalization technique, result), adjuvant chemotherapy (Table 1) [3, 4, 10–14]. We excluded from the study all patients with pre-operative malignancy suspect.

Table 1 Data about demographic and operative characteristics

For stadiation we used the Sixth Edition of AJCC TNM Manual. All laparoscopic cholecystectomies were executed with standard 4 trocars thecnique, and Endo-Bag protected gallbladder extraction.

In the matter of surgical radicalization, we executed 4b-5 segmentectomies (we did not perform right hepatectomies) [6, 7]. We always performed hepatic peduncle lymphadenectomy: if peduncle's nodes resulted positive, we executed N1 lymphadenectomy with hepatic porta and over-duodenal nodes removal. If second station nodes were suspected, we executed additional lymphadenectomy.

Resection completeness was classified in: R0 without residuals on hepatic margins, R1 microscopically positive margin, R2 macroscopic residuals on hepatic margins.

Results

We analyzed 508 consecutive laparoscopic cholecystectomies: 457 executed for cholelytiasis (150 urgencies), 51 patients for gallbladder adenomyomathosis (all elective).

We observed 7 accidental gallbladder adenocarcinomas in post-operative histological examination (N Group - Neoplasm).

4 patients out of 7 were females (Table 1), and the mean age of Group N was 67,8 years old (range 64-75). The totality of the sample resulted in Caucasic ethnic group.

Three cholecystectomies were performed in emergency (2 for acute lythiasic cholecystitis with US evidence, and 1 for alythiasic cholecistitis in adenomyomathosis) and the other 4 in elective regime (1 for adenomyomathosis, 3 for cholelytiasis) (Table 1). Patients who underwent urgent surgery presented acute inflammatory haematic setting (Table 1). Hepato-biliary settings at admittance were normal in all patients. Intra-operative gallbladder wall morphology appeared normal in all cases. Cholecistectomies were all carried out by laparoscopy without laparotomic conversions. Gallbladder was always extracted with protections, and we didn't observe cutaneous trocar-site metastases.

Pathological results were:1 pT1b N0 (G1), 2 pT2 N0 (G2), 2 pT2 N1 (G3b), 2 pT3 N1 (G3b) (Table 1). In 5 cases we performed neoplasm radicalization surgery with standard procedure revision: hepatic 4b-5 segmentectomy, hepatic peduncle lymphadenectomy and trocar-site excisions. We didn't perform radicalization right hepatectomies. We executed a N1 lymphadenectomy, and the second station resulted intra-operatively negative. Two patients died before radicalization (both patients with pT3N1 histological finding). We didn't observe any intra-operative biliary ducts invasion, and we didn't perform any biliary resection.

Pathological results on hepatic margin were: 3 R0 and 2 R1 (these two both on pT2N1 histological result and both patients died in 1 month). 4 patients underwent adjuvant chemotherapy (Table 1).

Median global survival was 34 months; 3 patients are still alive and, at now, disease free.

Discussion

In literature gallbladder cancer incidence is 0,3-1,5%; it also seems to be an increase over last years. In our study incidental gallbladder adenocarcinoma's rate resulted 1,38%. Some authors affirm that major risk factors for the disease are: female gender, obesity, age over 60 years old, and cholelythisasis [3, 4, 10–14]. According to literature, incidence resulted higher in female gender (4/7 patients), in patients with a long story of cholelythiasis (5/7), and the whole sample resulted aged over 60 (7/7). Symptoms are aspecific and the most important prognostic factor is pathological stage; also our patients resulted asymptomatic for the questioned disease [3, 4, 10–14].

Literature reported median survival rate varies between 8,1 and 68 months (range 3-100 months); in our study median survival was 34 months (range 2-63 months).

Surgical resection with curative intent in post laparoscopic cholecystectomy gallbladder carcinoma is: for stage T1a surgery is not proved to be necessary but watchful follow-up only seems to be required, for stage T1b the correct approach is still debated and some authors define as sufficient hepatic gallbladder bed resection with hepatic peduncle lymphadenectomy, for stage T2-3-4 surgical approach with hepatic S4b-5 radicalization (or more extended, "a la dèmande") is recommended, with hepatic peduncle lymphadenectomy associated to trocar-site excisions [4, 5, 8, 11, 12].

Some authors from Sloan-Kattering Institute, basing on their experience and cases, drew up a flow-chart for a correct re-evaluation method in incidentally diagnosed gallbladder cancer, suggesting always to perform an explorative laparoscopy at the beginning of radicalization surgery (that must be carried out by open technique), to exclude peritoneal carcinosis; in this way there is the possibility to better identify patients eligible for laparotomic radicalization [8].

Conclusion

Incidental gallbladder cancer incidence in literature is reported with the higher value of 2,85% (biblio); in our experience this rate resulted to be 1,38%. Despite retrospective study limits and the small N Group sample, with the increase of both elective and urgent laparoscopic cholecystectomies perfored in our section we observed also an increase of incidentally diagnosed gallbladder neoplasms (Table 2) [15, 16]. Surgery is more difficult in elderly patinents [17] but we consider laparoscopy as feasible and secure technique also in the elderly [18]. According to literature, also in our experience incidental gallbladder cancer resulted more frequent in over 60 years old patients and in female subjects. We consider being fundamental the extemporaneous histological test during cholecystectomy in case of intra-operative disease nature doubt. Gallbladder cancer mortality remains high for its biological aggressiveness [9–11]; surgical treatment is still the only radical treatment possibility. Also in our experience early diagnosis, meticulous peri-operative study and accurate surgical strategy are essential factors to obtain good results in incidental gallbladder cancer.

Table 2 Data about years stratification.

References

  1. Clemente G, Nuzzo G, De Rose AM, Giovannini I, La Torre G, Ardito F, Giuliante F: Unexpected gallbladder cancer after laparoscopic cholecystectomy for acute cholecystitis: a worrisome picture. J Gastrointest Surg. 2012, 1462-8. 16

  2. Benoist S, Panis Y, Fagniez PL: Long-term Results of the curative Resection for carcinoma of the Gallbladder. The Am J Surg. 1998, 175: 118-22. 10.1016/S0002-9610(97)00269-9.

    Article  CAS  PubMed  Google Scholar 

  3. Bertran E, Heise K, Andia ME, Ferreccio C: Gallbalder cancer: Incidence and survival in a high-risk area of Chile. Int J Cancer. 2010, 127: 2446-54. 10.1002/ijc.25421.

    Article  CAS  PubMed  Google Scholar 

  4. Chan SY, Poon RTP, Lo CM, Ng KK, Fan ST: Management of Carcinoma of Gallbladder: A Single-Institution Experience in 16 years. J Surg Oncol. 2008, 97: 156-64. 10.1002/jso.20885.

    Article  PubMed  Google Scholar 

  5. Chijiiwa K, Noshiro H, Nakano K, Okido M, Sugitani A, Yamaguchi K, et al: Role of surgery for gallbladder carcinoma with special reference to lymph node metastasis and stage using western and Japanese classification systems. World J Surg. 2000, 24: 1271-6. 10.1007/s002680010253.

    Article  CAS  PubMed  Google Scholar 

  6. Choi SB, Han JH, Kim CY, Kim WB, Song TJ, Suh SO, et al: Surgical Outcomes and Prognostic Factors for T2 Gallbladder Cancer Following Surgical Resection. J Gastrointestinal Surg. 2010, 14: 668-78. 10.1007/s11605-009-1132-z.

    Article  Google Scholar 

  7. Donohue JH, Stewart AK, Menck HR: The National Cancer Data Base report on carcinoma of the gallbladder, 1989-1995. Cancer. 1998, 83: 2618-28. 10.1002/(SICI)1097-0142(19981215)83:12<2618::AID-CNCR29>3.0.CO;2-H.

    Article  CAS  PubMed  Google Scholar 

  8. Duffy A, Capanu M, Abou-Alfa GK, Huitzil D, Jarnargin W, Fong Y et al: Gallbladder Cancer (GBC): 10-year Experience at Memorial Sloan-Kettering Cancer Centre (MSKCC). J Surg Oncol. 2008, 98: 485-6. 10.1002/jso.21141.

    Article  CAS  PubMed  Google Scholar 

  9. Hatzaras I, Schimidt C, Muscarella P, Melvin WS, Elisson EC, Bloomston M: Elevated CA 19.9 portends poor prognosis in patients undergoing resection of biliary malignancies. HPB. 2010, 12: 134-8. 10.1111/j.1477-2574.2009.00149.x.

    Article  PubMed Central  PubMed  Google Scholar 

  10. Rispoli C, Rocco N, Iannone L, Amato B: Developing guidelines in geriatric surgery: role of the grade system. BMC Geriatrics. 2009, 9 (SUPPL.1): A99-

    Google Scholar 

  11. Kayahara M, Nagakawa T, Nakagawara H, Kitagawa H, Ohta T: Prognostic Factors for Gallbladder Cancer in Japan. Ann Surg. 2008, 248: 807-14. 10.1097/SLA.0b013e31818a1561.

    Article  PubMed  Google Scholar 

  12. Konstantinidis IT, Deshpande V, Genevay M, Berger D, Fernandez-del Castillo C, Tanabe KK, et al: Trends in Presentation and Survival for Gallbladder Cancer During a Period of More than 4 Decades. A Single-Institution Experience. 2009, 144 (5): 441-7. Arch Surg

    Google Scholar 

  13. Reddy SK, Clary MM: Surgical Management of Gallbladder Cancer. Surg Oncol Clin N Am. 2009, 18: 307-24. 10.1016/j.soc.2008.12.004.

    Article  PubMed  Google Scholar 

  14. Liang JW, Dong SX, Zhou ZX, Tian YT, Zhao DB, Wang CF, et al: Surgical management for carcinoma of the gallbladder: a single- institution experience in 25-years. Chin Med J. 2008, 121: 1900-5.

    PubMed  Google Scholar 

  15. Solej M, Martino V, Mao P, Enrico S, Rosa R, Fornari M, Destefano I, Ferrarese AG, Gibin E, Bindi F, Falcone A, Ala U, Nano M: Early versus delayed laparoscopic cholecystectomy for acute cholecystitis. Minerva Chirurgica. 2012, 67 (5): 381-387.

    CAS  PubMed  Google Scholar 

  16. Ferrarese A, Martino V, Mao P: Elective and emergency laparoscopic cholecystectomy in the elderly: early or delayed approach. BMC Geriatrics. 2011, 11 (Suppl 1): A14-10.1186/1471-2318-11-S1-A14.

    Article  PubMed Central  Google Scholar 

  17. Ferrarese A, Martino V, Falcone A, Solej M, Destefano I: Perforated duodenal diverticulum: case report and short review of the literature. In press su Chirurgia.

  18. Ferrarese A, Martino V, Mao P: Wound defects in the elderly: our experience. BMC Geriatrics. 2011, 11 (Suppl 1): A15-10.1186/1471-2318-11-S1-A15.

    Article  PubMed Central  Google Scholar 

Download references

Declarations

Funding of this supplement has come from personal funds.

This article has been published as part of BMC Surgery Volume 13 Supplement 2, 2013: Proceedings from the 26th National Congress of the Italian Society of Geriatric Surgery. The full contents of the supplement are available online at http://0-www-biomedcentral-com.brum.beds.ac.uk/bmcsurg/supplements/13/S2

Author information

Authors and Affiliations

Authors

Corresponding author

Correspondence to Alessia G Ferrarese.

Additional information

Competing Interests Statement

The authors declare that they have no competing interests.

Authors' contributions

AGF: conception and design, interpretration of data, given final approval of the version to be published.

SE: conception and design, interpretration of data, given final approval of the version to be published.

MS: acquisition of data, drafting the manuscript, given final approval of the version to be published.

AF: acquisition of data, drafting the manuscript, given final approval of the version to be published.

SC: acquisition of data, drafting the manuscript, given the final approval of the version to be published.

GP: acquisition of data, drafting the manuscript, given the final approval of the version to be published.

SM: critical revision, interpretation of data, given final approval of the version to be published

VM: critical revision, interpretation of data, given final approval of the version to be published

Mario Solej, Stefano Enrico, Alessandro Falcone, Silvia Catalano, Giada Pozzi, Silvia Marola and Valter Martino contributed equally to this work.

Rights and permissions

This article is published under license to BioMed Central Ltd. This is an open access article distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/2.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

Reprints and permissions

About this article

Cite this article

Ferrarese, A.G., Solej, M., Enrico, S. et al. Diagnosis of incidental gallbladder cancer after laparoscopic cholecystectomy: our experience. BMC Surg 13 (Suppl 2), S20 (2013). https://0-doi-org.brum.beds.ac.uk/10.1186/1471-2482-13-S2-S20

Download citation

  • Published:

  • DOI: https://0-doi-org.brum.beds.ac.uk/10.1186/1471-2482-13-S2-S20

Keywords