Gallbladder Cancer Surgical Management 2006.5.30 GI Conference Review Department of Surgery

Introduction Poor prognosis Early GB cancer vs Advanced GB cancer Except early-stage cases Aggressive malignancy, predominantly in the elderly Location of GB; liver, bile duct, major vessel invasion Extensive L/N metastasis At the time of presentation 25 % ; localized disease 35 % ; LN metastasis or adjacent organ invasion 40 % ; Already distant metastasis Radiation, chemotherapy ; not effective Early GB cancer vs Advanced GB cancer Depth of invasion Correlate with tumor spread, long term survival

Risk Factors Female gender ; F: M (2-6 : 1) Old age Ethnic, geographical variation Gallstones GB polyp Porcelain GB Biliary tract anomaly ; APBDU Exposure to carcinogen

TNM Staging

TNM Staging

Lymphatic Spread Cholecysto-celiac Cholecysto-mesenteric Cholecysto-retropancreatic

Clinical Presentation Presenting Syndrome Signs and Symptoms Percentage of Patients with GB ca. Chronic cholecystitis Postprandial RUQ pain, often recent change in character 40-45 % Acute cholecystitis Short-duration RUQ pain, N/V, Fever, Tenderness 15-20 % Malignant biliary obstruction Jaundice, Weakness, Weight loss, Anorexia, Pain 30-35 % Malignant nonbiliary tract tumor Anorexia, Weight loss, Weakness 25-30 % Other GI problem GI bleeding or obstruction <5 %

Imaging Study Ultrasonography EUS Cholangiography CT MRI Heterogenous mass replacing GB lumen Irregular GB wall EUS Depth of invasion Cholangiography Long stricture of the CHD CT Invasion into adjacent organs Adjacent vascular anatomy MRI

Clinical Groups Incidental GB cancer Apparent GB cancer discovered during or after laparoscopic or open cholecystectomy for assumed benign disease 1~2% of cholecystectomy for gallstones Apparent GB cancer suspected and confirmed after clinical or diagnostic investigation Advanced GB cancer

Surgical Management Early GB cancer Laparoscopic cholecystectomy Bile spillage(30%)  peritoneal dissemination, Port site recurrence(10-29%) Open cholecystectomy ; gold standard Simple cholecystectomy ; T1a Extended cholecystectomy GB + Liver bed + LN dissection

Incidental GB cancer

Mode of spread

Operation Rt Hepatic Duct Lt Hepatic Duct Pancreas Liver Stomach Gallbladder Cystic Duct Common Bile Duct Pancreatic Duct Common Bile Duct Duodenum

Extended cholecystectomy + PD

Apparent GB cancer

Advanced GB cancer Extended Cholecystectomy + Bile duct resection Gross bile duct invasion to facilitate LN Dissection Extended Cholecystectomy + PV resection PHA, LHA invasion ; contraindication Extended Cholecystectomy + Liver resection Extended hepatectomy after PVE Extended Cholecystectomy + Extensive LND Extended Cholecystectomy + PD Hepatopancreatoduodenectomy (HPD)

Survival

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