Should suspected early gallbladder cancer be treated laparoscopically?

Abstract

Early gallbladder cancer (EGC), defined as T1 and T2 disease, is frequently curable when completely excised without bile spillage. The objective of the present study was to determine what effect initial laparoscopic cholecystectomy has on outcome in patients with EGC. Of 89 patients referred to our institution with gallbladder cancer over an 11-year period, 26 had undergone initial laparoscopic cholecystectomy. Sixteen of the 26 patients had T1 or T2 disease and are the subjects of this report. These patients were reviewed retrospectively to assess preoperative diagnosis, intraoperative bile spillage, and outcome (recurrence and survival). In addition, the Western literature was reviewed to determine the impact of initial laparoscopic cholecystectomy on recurrence and survival of patients with EGC. Six patients had a preoperative ultrasound consistent with a mass in the gallbladder wall. Seven (44%) had documented bile spillage during the laparoscopic cholecystectomy. T stage based on the laparoscopic cholecystectomy was T1 (n = 1) and T2 (n = 15). Twelve patients underwent reexploration of whom seven underwent further radical excision (gallbladder liver bed resection and extensive lymphadenectomy). After a mean follow-up of 20.1 months (range 4 to 39 months), 69% of patients have had a recurrence or died. Three patients had a port-site recurrence. Five (71%) of seven patients with bile spillage at laparoscopic cholecystectomy have had a recurrence or died of disease. A review of the Western literature on EGC initially removed by laparoscopic cholecystectomy (including the present series) yielded 21 patients with T1 and 42 patients with T2 disease. One-year Kaplan-Meier survival (T1 = 89%, T2 = 71%) and 3-year Kaplan-Meier survival (T1 = 47%, T2 = 40%) of these patients is worse than prior reports for open cholecystectomy. An initial laparoscopic cholecystectomy with its potential for bile spillage can convert potentially curable EGC to incurable disease. Patients with preoperative findings suspicious for gallbladder cancer should undergo open exploration with intent to perform a radical cancer operation as a primary procedure if the diagnosis is confirmed intraoperatively.