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Peep Before You Enter – Laparoscopy in Gall Bladder Ca
Journal of Cancer Science and Research

Journal of Cancer Science and Research
Open Access

ISSN: 2576-1447

+44 1478 350008

Short Communication - (2018) Volume 0, Issue 0

Peep Before You Enter – Laparoscopy in Gall Bladder Cancer.

Vinay K Kapoor*
Professor of Surgical Gastroenterology, Sanjay Gandhi Postgraduate Institute of Medical Sciences (SGPGIMS) Lucknow, Uttar Pradesh, India
*Corresponding Author: Vinay K Kapoor, Professor of Surgical Gastroenterology, Sanjay Gandhi Postgraduate Institute of Medical Sciences (SGPGIMS) Lucknow, Uttar Pradesh, India, Tel: +91(800)4904751 Email:

Keywords: Gall bladder cancer; Laparoscopy; Cholecystectomy; Metastases

Short Communication

Gall bladder cancer (GBC) is the commonest biliary tract cancer worldwide. It is diagnosed clinically based on symptoms (dull continuous pain in the right upper abdomen, jaundice, vomiting, anorexia and weight loss) and signs (firm to hard gall bladder mass). This is ‘obvious’ GBC (Kapoor 2006) - which, in a large majority of cases, is advanced; a careful search should be made for clinically obvious metastases e.g. liver nodule, ascites, pelvic deposits, umbilical nodule and left supraclavicular lymph nodes which, if present, need to be confirmed by fine needle aspiration cytology (FNAC) - usually image (US/ CT) guided. If there is no clinical evidence of metastases, the patient needs to be investigated further for staging and resectability of the disease; this is invariably in the form of a triple-phase contrastenhanced computed tomography (CT). In addition to looking for liver metastases and ascites, attention should be paid to enlarged distant (celiac, superior mesenteric and aorto-caval) lymph nodes which, if positive on CT-guided FNAC, carry as poor prognosis as distant metastasis and contraindicate resection; even extended retroperitoneal lymphadenectomy does not help in improving survival in presence of these lymph nodes (Kondo 2000). Resectability assessment on CT includes involvement of adjacent organs such as pancreas and vessels (hepatic artery and portal vein) in the hepato-duodenal ligament [1-4]. Positron emission tomography (PET) scan has been reported to complement CT in detecting metastases (Leung 2014).

Cuschieri was the first to report the use of laparoscopy for diagnosis and staging of pancreatic cancers. Jarnagin reported staging laparoscopy in patients with primary and secondary hepato-biliary cancers. Weber described staging laparoscopy in 100 patients with extrahepatic biliary cancers. We were the first to report staging laparoscopy in GBC; out of 91 patients who were thought to have resectable disease on CT, staging laparoscopy revealed metastases in 34 patients and extensive unresectable disease in 6 patients thus avoiding an unnecessary laparotomy in as many as 38% patients (Agrawal 2005). Agarwal reconfirmed the value of staging laparoscopy in GBC in a much larger experience with 409 patients [5-8].

In GBC, if CT shows possibly resectable disease, laparoscopy should be performed to look for small metastatic deposits on the surface of the liver, omentum, parietal and visceral peritoneum which are not usually seen on CT and/ or PET. This is staging laparoscopy; NOT diagnostic laparoscopy as called by Russolillo. If these metastatic deposits are not present, laparoscopic sampling of aorto-caval lymph nodes can be done. Laparoscopic US can help better assess local infiltration into pancreas and vessels (hepatic artery and portal vein) in the hepatoduodenal ligament [9-12]. Addition of US to laparoscopy can increase the overall yield (from 38% to 52%) and accuracy (from 62% to 85%) in detecting unresectable disease (Russolillo 2016). It has also been shown to be cost effective (Nadeem 2014). Port site metastases are common after laparoscopic cholecystectomy is done in patients in whom GBC was not diagnosed preoperatively (Paolucci 2001). Whether staging laparoscopy alone increases the risk of port site metastases is not known; handling/dissection of the primary tumor in the GB, however, should be avoided to reduce this risk.

Patients with GBC who have jaundice need preparation with preoperative biliary drainage to bring the serum bilirubin down and portal vein embolization to induce atrophy hypertrophy before a major liver resection can be done (Kapoor 2015). Staging laparoscopy should preferably be performed once before and again after portal vein embolization just before surgery [13,14].

A significant number of GBCs are diagnosed at histopathological examination of the GB removed with a presumptive diagnosis of gall stones - incidental GBC. Most patients with incidental GBC will require reoperation for completion extended cholecystectomy (CEC) (Behari 2013). In addition to a metastatic work up which includes chest X-ray/ CT and abdomen CT, staging laparoscopy should be performed before laparotomy, especially if the time interval between the incidental cholecystectomy and reoperation is long. MSKCC group reported very low yield of staging laparoscopy in 136 patients with incidental GBC and recommended its selective use in patients with T3, poorly differentiated and margin positive cases only (Butte 2011).

The standard surgical procedure for resectable GBC is extended cholecystectomy which includes the gall bladder, a 2 cm wedge/ segments IVB+V of liver and lymphadenectomy. Few groups have reported laparoscopic extended cholecystectomy (Agarwal 2015) and even laparoscopic bisegmentectomy (IVb+V) (Machado 2015) but results in the form of recurrence (especially port site metastases) and long term survival are awaited before it can be recommended. Yoon (2015) performed laparoscopic surgery (extended cholecystectomy=32, simple cholecystectomy=13) in 45 patients with suspected early GBC (T1=20, T2=25) and reported 5 year survival of 79%.

A thick walled GB on US raises a suspicion of GBC. We have described anticipatory extended cholecystectomy (AEC) which includes the gall bladder and a 2 cm wedge of liver followed by frozen section histopathological examination in such cases (Kapoor 2016); whether AEC can (should) be performed laparoscopically remains to be seen [15-18].

GBC is an aggressive cancer - resection in presence of metastases (irrespective of their site, size and number) is worthless. Every attempt must be made to detect a metastasis in every patient with GBC. National Comprehensive Cancer Network (NCCN) guidelines mention ‘strong consideration’ for performing laparoscopy (before laparotomy) for staging of GBC; we make ‘strong recommendation’ for staging laparoscopy before laparotomy in every patient with GBC – ‘peep before you enter’.

References

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  2. Agarwal AK, Javed A, Kalayarasan R, Sakhuja P (2015) Minimally invasive versus the conventional open surgical approach of a radical cholecystectomy for gallbladder cancer: a retrospective comparative study. HPB (Oxford) 17: 536-541. 
  3. Agrawal S, Sonawane RN, Behari A, Kumar A, Sikora SS, et al. (2005) Laparoscopic staging in gallbladder cancer. Dig Surg 22: 440-445. 
  4. Behari A, Kapoor VK (2013) Incidental gall bladder cancer. Adv Surg 47: 227-249.
  5. Butte JM, Gönen M, Allen PJ, D'Angelica MI, Kingham TP, et al. (2011) The role of laparoscopic staging in patients with incidental gallbladder cancer. HPB (Oxford) 13: 463-472. 
  6. Cuschieri A, Hall AW, Clark J (1978) Value of laparoscopy in the diagnosis and management of pancreatic carcinoma. Gut 19: 672-677.
  7. Jarnagin WR, Bodniewicz J, Dougherty E, Conlon K, Blumgart LH, et al. (2000) A prospective analysis of staging laparoscopy in patients with primary and secondary hepatobiliary malignancies. J Gastrointest Surg 4: 34-43.
  8. Kapoor VK (2015) Gallbladder cancer: a global perspective. J Surg Oncol 93: 607-609.
  9. Kapoor (2015) Jaundice in Gall Bladder Cancer – The Yellow Signal. Clinical Medicine Reviews in Oncology 5: 1-3.
  10. Kapoor VK, Singh R, Behari A, Sharma S, Kumar A, et al. (2016) Anticipatory Extended Cholecystectomy - The ‘Lucknow’ Approach for Thick Walled Gall Bladder with Low Suspicion of Cancer. Chin Clin Oncol 5: 8-13.
  11. Kondo S, Nimura Y, Hayakawa N, Kamiya J, Nagino M, et al. (2000) Regional and para-aortic lymphadenectomy in radical surgery for advanced gallbladder carcinoma. Br J Surg 87: 418-422.
  12. Leung U, Pandit-Taskar N, Corvera CU, D'Angelica MI, Allen PJ, et al. (2014) Impact of pre-operative positron emission tomography in gallbladder cancer. HPB (Oxford) 16: 1023-1030. 
  13. Machado MA, Makdissi FF, Surjan RC (2015) Totally Laparoscopic Hepatic Bisegmentectomy (s4b+s5) and Hilar Lymphadenectomy for Incidental Gallbladder Cancer. Ann Surg Oncol 3: S336-S339. 
  14. Nadeem H, Jayakrishnan TT, Groeschl RT, Zacharias A, Clark Gamblin T, et al. (2014) Cost effectiveness of routine laparoscopic ultrasound for assessment of resectability of gallbladder cancer. Ann Surg Oncol 21: 2413-2419.
  15. Paolucci V (2001) Port site recurrences after laparoscopic cholecystectomy. J Hepatobiliary Pancreat Surg 8: 535-543.
  16. Russolillo N, D'Eletto M, Langella S, Perotti S, Lo Tesoriere R, et al. (2016) Role of laparoscopic ultrasound during diagnostic laparoscopy for proximal biliary cancers: a single series of 100 patients. Surg Endosc 30:1212-1218.
  17. Weber SM, DeMatteo RP, Fong Y, Blumgart LH, Jarnagin WR (2002) Staging laparoscopy in patients with extrahepatic biliary carcinoma. Analysis of 100 patients. Ann Surg 235: 392-399.
  18. Yoon YS, Han HS, Cho JY, Choi Y, Lee W, et al. (2015) Is Laparoscopy Contraindicated for Gallbladder Cancer? A 10-Year Prospective Cohort Study. J Am Coll Surg 221: 847-853.
Citation: Kapoor VK (2017) Peep Before You Enter – Laparoscopy in Gall Bladder Cancer. J Can Sci Res 3:13.

Copyright: © 2017 Kapoor VK. This is an open-access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.
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