Open Radical Cholecystectomy with Partial Hepatectomy for Gallbladder Cancer

Gallbladder cancer (GBCA) is a relatively uncommon disease with dismal prognosis. As the symptoms associated with GBCA are vague and non-specific, most patients present when the disease is at an advanced stage and the majority are diagnosed when the disease is beyond the possibility of resection. On the other hand, GBCA can be discovered incidentally and appropriate oncologic surgery provides a great chance of cure for patients with GBCA. We present a case of incidentally-diagnosed GBCA and describe the surgical management for operable GBCA with a focus on the operative technique and perioperative management. A 60-year-old male presented with incidentally-discovered GBCA during a follow-up imaging study for his previously treated bladder cancer. The patient had been asymptomatic, and CT showed a growing mass in the gallbladder without evidence of metastatic disease. GBCA was suspected, and resection was recommended. He underwent extended cholecystectomy including cholecystectomy en bloc with partial hepatectomy at segment IVb and 5 and portal lymphadenectomy. His postoperative course was uneventful, and histologic examination confirmed the diagnosis of GBCA, pT3N1M0, stage IIIB.

The patient is a 60-year-old male who presented with a gallbladder mass. The mass was discovered during regular follow-up for recently treated bladder cancer. He underwent total cystectomy with ileal conduit following neoadjuvant chemotherapy two years prior and had been followed by serial CT scan every 6 months. The most recent CT showed a gallbladder mass, which had been growing compared with the prior scan 6 months before. Thus, gallbladder cancer was suspected, and resection was recommended.

The patient was asymptomatic and did not have any specific findings on physical exam. His abdomen was soft and flat with well healed scar at the lower midline and ileal conduit at the right lower quadrant.

CT showed a 2-cm mass at the fundus gallbladder, consistent with GBCA. It was contrast-enhanced, and there was no definitive sign of liver invasion, lymphadenopathy, or distant metastasis. MRI ruled out liver metastasis.

For patients with suspected GBCA, like the patient shown here, surgical resection should be considered when the staging work-up does not detect the evidence of metastatic disease. Unlike other types of gastrointestinal cancer that can be accessible endoscopically, histologic confirmation by biopsy is usually unavailable, and thus thorough explanation to the patient about the possibility that the suspected lesions may turn out to be benign in the histopathologic examination after radical operation is critical. The standard oncologic resection includes cholecystectomy en bloc with partial liver resection (around the gallbladder fossa) and portal lymphadenectomy. The resection of common bile duct is necessary only when it is involved by the tumors by preoperative imaging studies or the cystic duct stump margin is proved positive for cancer by intraoperative frozen section. Laparoscopic cholecystectomy should be avoided when cancer is highly suspected preoperatively because of the risk of violation of the plane between the tumor and the liver, and the risk of port site seeding. On the other hand, if the preoperative diagnosis is unclear, initial laparoscopic cholecystectomy is a reasonable option for diagnostic purpose. When the diagnosis of GBCA is histologically confirmed, additional partial liver resection and lymphadenectomy (either open or laparoscopically depending on the surgeon’s skill and expertise) should be completed simultaneous to cholecystectomy or as a separate staged operation later.

Our patient had a gallbladder mass that kept growing in the past several months, and gallbladder cancer was highly suspected. As there was no metastatic disease detected on the preoperative imaging studies including CT and MRI, resection was planned without confirming histological diagnosis.

When the patient has elevated tumor marker CA19-9, staging laparoscopy has been shown to have a high yield to identify the occult metastatic disease and to allow the patients to avoid non-beneficial laparotomy.³ The serum CA19-9 level for our patient was within normal range and staging laparoscopy was not performed.

The goal of oncologic surgery is to remove all cancer cells potentially spread in the regional area, and thus definitive resection for GBCA should include not only gallbladder, but also part of the liver bed around the gallbladder fossa (segment 4b and 5 at least) and all regional lymph nodes around the hepatoduodenal ligament and retropancreatic area (#8, 12, 13 lymph node stations). Bile duct resection was not performed for this patient as the tumor was located away from the neck and the cystic duct margin was proved negative for cancer.

Because of its propensity to spread to regional lymph nodes at an early stage and high rate of locoregional recurrence, adjuvant chemotherapy and/or chemoradiotherapy seems a rational therapeutic option for patients with GBCA. However, the rarity of gallbladder cancer and further limitation of patients who can undergo complete resection makes the randomized trial difficult to conduct and data to support its efficacy remains limited. While there is no conclusive evidence for the efficacy of adjuvant chemotherapy to date, chemotherapeutic regimen with combination of gemcitabine and cisplatin is often used for selected patients with high risk of recurrence (such as patients with N1 disease) as this regimen was shown to improve the survival of patients with unresectable metastatic biliary cancers including GBCA.⁴

The histological examination for resected specimen for our patient confirmed the diagnosis of GBCA, 5.5 cm, mixture of poorly differentiated adenocarcinoma and neuroendocrine carcinoma, pT3, pN1 (1/14), stage II. Our patient elected not to receive adjuvant chemotherapy because of its histologic type.

As symptoms associated with GBCA are in general vague and non-specific, most patients with GBCA presents when the disease is at an advanced stage and the majority of patients are diagnosed when the disease is beyond the borders of resection.^{5, 6} In fact, while obstructive jaundice is one of the most common symptoms associated with gallbladder cancer, it is well recognized as predictor of worse outcomes regardless of the types of treatment received.⁶ On the other hand, for most of patients with “incidental” GBCA, which is discovered by imaging study for unrelated disease, or cholecystectomy for suspected benign biliary symptoms, appropriate oncologic resection has a much greater impact on their long-term outcomes and radical surgery should not be discouraged for patients with locoregional disease without distant spread. Tumors beyond T2 (tumor invading to the muscular layer) are not cured by simple cholecystectomy; 30% of patients staged T2 based on the primary cholecystectomy specimen (incidental diagnosis) were reported to have residual liver disease after reoperation with definitive resections and one-third of them were found to have metastasis in the regional lymph nodes resected.^{2, 7}

The extent of liver resection required depends on the extent of direct liver invasion and involvement of major hepatic vessels. While the wedge resection of gallbladder fossa should suffice to achieve negative margin for the tumor at the fundus with minimal liver invasion, when the right portal pedicle is involved by the tumor at the neck of gallbladder, right hemihepatectomy or even extended right hepatectomy may be necessary. When major liver resection is deemed necessary, preoperative portal vein embolization to increase the future remnant liver volume is often useful to decrease the risk of postoperative liver failure.⁸

Although the therapeutic role for regional lymphadenectomy is not yet established, systematic lymphadenectomy and histological evaluation are critical to provide accurate N staging. The study demonstrated that the outcomes for patients with N0 disease based on total lymph node count less than 6 was significantly worse than the outcome for those with N0 disease based on total lymph node count 6 or greater.² Thus, it is recommended in current AJCC staging system that a minimum of 6 lymph nodes should be removed and examined histologically for accurate N staging. The optimal extent of lymphadenectomy has not been well defined, it is the author’s practice to remove the lymph nodes in the hepatoduodenal ligaments (#12), around the common hepatic artery (#8), and at the retropancreatic area (#13). The outcomes for patients with lymphadenopathy beyond this area, for example around the celiac artery or the aorta has been reported dismal. Radical resection will be unlikely beneficial for such patients and should not be performed.

The direct invasion to adjacent organs including duodenum, colon, and pancreas is not uncommon for advanced GBCA, and it is not considered as an absolute contraindication for resection. While some authors reported prolonged survival after en bloc organ resection,^{9, 10} such operations are often associated with higher risk of morbidity and mortality, and the application for aggressive radical operative for far advanced GBCA should be carefully considered individually.

Nothing to disclose.

The patient referred to in this video article has given their informed consent to be filmed and is aware that information and images will be published online.