Abstract

We read with interest the article by Goetze and Paolucci entitled, ‘‘Use of Retrieval Bags in Incidental Gallbladder Cancer Cases’’ [1]. It reports on a multicenter study that included approximately 600 patients suffering from occult gallbladder cancer. This analysis is of substantial importance, particularly regarding the high frequency of laparoscopic cholecystectomies. With high esteem, nevertheless allow us to supply some annotations and additions. The primary goal of surgical treatment of gallbladder cancer must be the oncologic adequate resection to avoid local or general recurrence [2]. The elevated rate of trocar metastasis and peritoneal seeding, local recurrence, and distant metastasis (together 27.2 vs 38.4%) in case of intraoperative perforation during minimal invasive cholecystectomy of the gallbladder is an impressive observation. However, the meaning for overall long-term prognosis has not been analyzed and remains unclear. From our point of view, a primary open access is mandatory in any case of preoperative suspicion of malignancy (ultrasound, CT). Only a few exceptions can be made: e.g., when peritoneal carcinosis has to be counted out. In case of intraoperative suspicion, immediate or secondary conversion from minimal to open access has to be performed [3]. When gallbladder cancer is detected in the specimen after laparoscopic cholecystectomy, an oncologic adequate, open re-resection (including trocar channels) has to be performed from stage T1b on. The extension depends on the TNM stage of the disease, including lymphadenectomy and most often—even extended—liver resection. Fong et al. [4] point out the high value of aggressive re-resection for postoperatively diagnosed gallbladder cancer of all stages. They support other authors who describe no difference in long-term prognosis between patients with a primary open resection and patients who received a minimal invasive cholecystectomy followed by an open re-resection. Limiting therapy to an exclusively minimal open access is not oncologically justified in case of highly malignant gallbladder cancer (T1b or higher) [5–7]. For this reason, intraoperative suspicion of malignancy must not only cause using a retrieval bag but also be the cause for immediate or secondary conversion to open access. In the published study, we cannot extract any information about whether re-resection and what kind of reresection was performed to prevent tumor recurrence, despite that it was an item in the questionnaires. Very impressively Goetze and Paolucci showed the significantly worsened relapse rate in case of gallbladder perforation: 38.4 vs 27.2% without perforation. The usage of a retrieval bag caused no further difference in local recurrence rate but did so for the rate of trocar metastases. Concerning interpretation the question arises whether both the decision to use a retrieval bag and the event of an intraoperative perforation cannot be an expression of difficult conditions for cholecystectomy. These difficult conditions might be secondary to a more advanced tumor stage (joining cholecystitis, infiltration of neighboring tissue/ organs). Therefore, it might be that not the perforation or the use of a bag itself is the decisive factor for the worsened or improved prognosis. The observation that 30 of 174 carcinomas extracted laparoscopically by using a retrieval bag have been T3 carcinomas (additionally that of 330 laparoscopic operated incidental carcinomas 187 cases have been T2, 44 cases of U. K. Fetzner (&) K. L. Prenzel H. Alakus A. H. Holscher D. L. Stippel Department of General-, Visceraland Cancer Surgery, University of Cologne, Cologne, Germany e-mail: ulrich.fetzner@uk-koeln.de

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