Laparoscopic approach to suspected T1 and T2 gallbladder carcinoma

AIM To evaluate a laparoscopic approach to gallbladder lesions including polyps, wall-thickening lesions, and suspected T1 and T2 gallbladder cancer(GBC).METHODS We performed 50 cases of laparoscopic whole-layer cholecystectomy(LCWL) and 13 cases of laparoscopic gallbladder bed resection(LCGB) for those gallbladder lesions from April 2010 to November 2016. We analyzed the short-term and long-term results of our laparoscopic approach. RESULTS The median operation time was 108 min for LCWL and 211 min for LCGB. The median blood loss was minimal for LCWL and 28 ml for LCGB. No severe morbidity occurred in either procedure. Nine patients who underwent LCWL and 7 who underwent LCGB were postoperatively diagnosed with GBC. One of these patients had undergone LCGB for pathologically diagnosed T2 GBC after LCWL. All of the final surgical margins were negative. Three of these 15 patients underwent additional open surgery. The mean follow-up period was 26 mo, and only one patient developed recurrence.CONCLUSION LCWL and LCGB are safe and useful procedures that allow complete resection of highly suspected or earlystage cancer and achieve good short-term and longterm results.

Incidental gallbladder cancer during laparoscopic cholecystectomy:Managing an unexpected finding

AIM:To evaluate the impact of incidental gallbladder cancer on surgical experience.METHODS:Between 1998 and 2008 all cases of cholecystectomy at two divisions of general surgery,one university based and one at a public hospital,were retrospectively reviewed.Gallbladder pathology was diagnosed by history,physical examination,and laboratory and imaging studies [ultrasonography and computed tomography(CT)].Patients with gallbladder cancer(GBC) were further analyzed for demographic data,and type of operation,surgical morbidity and mortality,histopathological classification,and survival.Incidental GBC was compared with suspected or preoperatively diagnosed GBC.The primary endpoint was diseasefree survival(DFS).The secondary endpoint was the difference in DFS between patients previously treated with laparoscopic cholecystectomy and those who had oncological resection as first intervention.RESULTS:Nineteen patients(11 women and eight men) were found to have GBC.The male to female ratio was 1:1.4 and the mean age was 68 years(range:45-82 years).Preoperative diagnosis was made in 10 cases,and eight were diagnosed postoperatively.One was suspected intraoperatively and confirmed by frozen sections.The ratio between incidental and nonincidental cases was 9/19.The tumor node metastasis stage was:pTis(1),pT1a(2),pT1b(4),pT2(6),pT3(4),pT4(2);five cases with stageⅠa(T1 a-b);two with stageⅠb(T2 N0);one with stage Ⅱa(T3 N0);six with stage Ⅱb(T1-T3 N1);two with stage Ⅲ(T4 Nx Nx);and one with stage Ⅳ(Tx Nx Mx).Eighty-eight percent of the incidental cases were discovered at an early stage(≤Ⅱ).Preoperative diagnosis of the 19 patients with GBC was:GBC with liver invasion diagnosed by preoperative CT(nine cases),gallbladder abscess perforated into hepatic parenchyma and involving the transversal mesocolon and hepatic hilum(one case),porcelain gallbladder(one case),gallbladder adenoma(one case),and chronic cholelithiasis(eight cases).Every case,except one,with a T1b or more advanced invasion underwent Ⅳb + Ⅴ wedge liver resection and pericholedochic/hepatoduodenal lymphadenectomy.One patient with stage T1b GBC refused further surgery.Cases with Tis and T1a involvement were treated with cholecystectomy alone.One incidental case was diagnosed by intraoperative frozen section and treated with cholecystectomy alone.Six of the nine patients with incidental diagnosis reached 5-year DFS.One patient reached 38 mo survival despite a port-site recurrence 2 years after original surgery.Cases with non incidental diagnosis were more locally advanced and only two patients experienced 5-year DFS.CONCLUSION:Laparoscopic cholecystectomy does not affect survival if implemented properly.Reoperation should have two objectives:R0 resection and clearance of the lymph nodes.