Radical Cholecystectomy Research Articles

Situs inversus totalis with local metastasis of gallbladder carcinoma and variation of the common hepatic artery

BackgroundSitus inversus totalis (SIT) is a rare congenital anomaly characterized by a complete transposition of all the viscera. SIT cases were usually reported because of the presence of tumors, leading to false association between them. Therefore, any research that advances our understanding on SIT is highly required. This study firstly describes a very rare case of SIT with “jumping” metastasis to pancreas of gallbladder carcinoma.Case presentationA 69-year-old female patient presented at our hospital with complaints of one month of epigastric pain was studied. She had not sought for treatment prior the visit. Imaging examinations of this patient revealed SIT and a variation of the common hepatic artery with concomitant tumors of gallbladder and pancreas. However, there was no evidence of distant metastases beyond the abdominal cavity. She underwent a combination of radical cholecystectomy, total pancreatectomy, splenectomy and hepatic artery-splenic artery reconstruction. Histological analyses revealed metastasis of the gallbladder carcinoma in to the pancreas. Although the patient opted against chemotherapy, she survived without tumor for 16 months following the surgery. A review of the current literature on association with SIT and tumor occurrence was presented.ConclusionsIt is a great surgical challenge for the resection of multicenter hepatobiliary and pancreatic tumors in such rare SIT anatomical abnormalities with vascular variants. A reliable surgical plan based on detailed preoperative imaging and intraoperative anatomical exploration is crucial to achieving radical resection.

Does Timing of Completion Radical Cholecystectomy Determine the Survival Outcome in Incidental Carcinoma Gallbladder: A Single-Center Retrospective Analysis.

IntroductionIncidental discovery of gallbladder cancer (GBC) on postoperative histopathology or intra-operative suspicion is becoming increasingly frequent since laparoscopic cholecystectomy became the standard of care for gallstone disease. Incidental GBC (IGBC) portends a better survival than primarily detected GBC. Various factors affect the outcome of re-resection with the timing of re-intervention an important determinant of survival.MethodsAll patients of IGBC who underwent curative resection from January 2009 to December 2018 were considered for analysis. Details of demographic profile, index surgery, and operative findings on re-resection, histopathology and follow-up were retrieved from the prospectively maintained database. Patients were evaluated in three groups based on the interval between index cholecystectomy and re-resection: Early (<4 weeks), Intermediate (4-12 weeks) and Late (>12 weeks), using appropriate statistical tests.ResultsNinety-one patients were admitted with IGBC during the study period of which 48 underwent re-resection with curative intent. The median age of presentation was 55 years (31-77 years). The median duration of follow-up was 40.6 months (Range: 1.2-130.6 months). Overall and disease-free survival among the above-mentioned three groups was the best in the early group (104 and 102 months) as compared to the intermediate (84 and 83 months) and late groups (75 and 73 months), though the difference failed to achieve statistical significance (p=0.588 and 0.581). On univariate analysis, factors associated with poor outcome were node metastasis, need for common bile duct (CBD) excision and high-grade tumor. However, on multivariate analysis, poor differentiation was the only independent factor affecting survival.ConclusionEarly surgery, preferably within four weeks, possibly entails better survival in incidentally detected GBC. The grade of a tumor, however, is the most important determinant of survival in IGBC.

A Sordid Tale of Bile and Bowel

Synchronous tumors of gall bladder and colon cancer are rare, and the underlying genetic, environmental, and immunological factors could play a role in the development of such tumors. Till date, only a few cases of synchronous gall bladder and colonic malignancies have been reported. A 60-year-old lady presented with sub-acute onset of colicky pain in the abdomen and vomiting. Imaging showed the presence of thickening in the ileocecal junction along with a thickened gall bladder. A provisional diagnosis of gall bladder tumour with ileocecal tuberculosis or a synchronous colonic malignancy was made. Laparotomy revealed synchronous tumors in the gall bladder and caecum. Radical cholecystectomy with radical right hemicolectomy was performed. The final histopathology report confirmed the presence of two independent malignancies. A tailored treatment approach for both sites based on clinical findings and anticipated outcomes must be considered. Further immunohistochemical studies must be conducted to confirm the presence of dual malignancies. Metastases from one site to the other should be ruled out.

Effect of Preoperative Duloxetine Hydrochloride on Reducing Postoperative Morphine Requirement after Open Radical Cholecystectomy in Cancer Patients: A Randomized Controlled Study.

Recently, opoids are linked with cancer recurrence. Duloxetine hydrochloride (DH), an anxiolytic may reduce total opoid requirement after cancer surgery. We assessed the efficacy of a single dose of DH in reducing the total morphine requirement after open radical cholecystectomy. We also calculated the Visual Analog Scale (VAS) score, patient satisfaction score (PSS), and time taken to the use of the first rescue analgesic. This is a prospective, randomized, double blind, controlled study conducted in the patients aged 20-70 years (American Society of Anaesthesiologists classes I-III) undergoing open radical cholecystectomy under general anesthesia for carcinoma gall bladder. The patients were divided into two groups of 32 patients each by computer-generated randomization. Group A received oral DH (60 mg); Group B received identical placebo capsules 2 h before surgery with a sip of water. Postoperatively, intravenous morphine was given using a patient-controlled analgesia pump. After 24 h, total morphine consumption, the VAS score, time to the first rescue analgesia, and PSS were recorded. Statistical Package for the Social Sciences software (SPSS version 22.0, IBM Corp., Chicago, IL, USA 2013). P value < 0.05 or 0.001 was considered statistically significant. The total morphine consumption and VAS score were significantly lower in Group A. No significant effects was observed on PSS. A single 60 mg dose of DH administered 2 h before open radical cholecystectomy reduced total morphine consumption and improved VAS score postoperatively with no effect on PSS.

Mixed neuroendocrine-non-neuroendocrine neoplasm of the gallbladder: case report and literature review

BackgroundMixed neuroendocrine–non-neuroendocrine neoplasms (MiNENs) of the gallbladder are rare malignancies. Here we presented two cases and reviewed the related literature.Case presentationOur two patients were postoperatively diagnosed with gallbladder MiNENs, which pathologically consisted of a large cell neuroendocrine carcinoma and papillary adenocarcinoma. After cholecystectomy, one patient had a survival time of 30 months, while the other remained alive through 12 months of follow-up. In the literature, a total of 72 cases of gallbladder MiNENs were identified, and with our two patients included, we calculated a male-to-female ratio of 0.22 and a mean age of 64.5 years for the 74 reported cases. About one-half of these patients were found to have gallstones and presented with abdominal pain or discomfort in a relatively early stage. The preoperative diagnosis of these 74 cases mainly relied on abdominal ultrasound, contrast-enhanced computed tomography (CT) scanning, and magnetic resonance imaging or positron emission tomography/CT. However, the final diagnosis was established based upon the pathological evidence and expression of synaptophysin (Syn) and/or chromogranin A identified by immunohistochemical staining or neurosecretory granules detected by electron microscopy. Fifty-eight patients (78.4%) underwent various operations including simple cholecystectomy (n = 14), en bloc cholecystectomy (n = 9), standard or non-standard radical cholecystectomy (n = 25), or extended radical cholecystectomy (n = 6). The mean size of the resected gallbladder masses was 50.8 ± 36.1 mm (n = 63) with regional lymph node metastasis in 37 patients (52.1%), liver invasion or staging greater than T3 in 33 patients (45.8%), and hepatic metastasis in 26 patients (35.1%). The postoperative median survival time was 36 ± 11.42 months (95% confidence interval, 13.62 to 58.38 months). The log-rank analysis did not find that postoperative adjuvant chemotherapy contributed to a longer survival time relative to that among the patients who did not receive chemotherapy (numbers of patients, 15 versus 43; survival times, 36 months versus 30 months, p > 0.05).ConclusionsOur two cases and the cases in the literature suggest that MiNENs of the gallbladder predominantly occur in women; are associated with early lymph node metastasis, local hepatic invasion, and hepatic metastasis; and can be managed by various surgeries as well as chemotherapy combined with somatostatin analogs.

Differentiated surgical tactics for Mirizzi syndrome in patients with cholelithiasis

The aim of the work: to improve the results of treatment of Mirizzi syndrome by developing rational surgical tactics depending on its type. Materials and Methods. The work is based on the evaluation of the results of surgical treatment of 62 patients with cholelithiasis complicated by Mirizzi syndrome who were hospitalized in surgical departments of the Republican Specialized Scientific and Practical Center for Emergency Medical Care of the Samarkand branch for the period from 2016 to 2021. Results and Discussion. Successful radical cholecystectomy largely depends on the correctly chosen surgical tactics, which significantly affects the course of the operation and has a certain significance in the outcome of surgical treatment, affects the course of the rehabilitation period. Based on the data of the preoperative examination the patients of the main group were divided into 3 subgroups of the degree of probability of Mirizzi syndrome. The proposed program for choosing surgical tactics in patients with cholelithiasis complicated MS allowed in 8.1 % and 29.0% of cases to perform laparoscopic cholecystectomy and cholecystectomy from a mini-access, respectively, and thereby allowed to avoid damage to the bile ducts and to complete the operation with minimal risk. The developed program for choosing the tactics of surgical treatment of patients with cholelithiasis complicated MS, taking into account an integrated approach to the choice of access, allowed to improve the quality of care by reducing the frequency of immediate postoperative complications to 3.2 %, and in the long-term postoperative period, complications were reduced to zero.

Incidental finding of a large polypoidal gallbladder mass diagnosed as papillary adenocarcinoma - A case report.

Introduction and importanceLesions which project from the gallbladder wall into its lumen are known as gallbladder polyps. Nearly 5% of all adults have gallbladder polyps, the majority are pseudo-polyps with no neoplastic potential. Although gallbladder polyps are commonly found in cholecystectomy specimen, only a very few gallbladder polyps present as carcinoma in a polypoid lesion.Case presentationA 48 years old male patient came for a routine health checkup and ultrasonography (USG) of abdomen showed incidental finding of a polypoid lesion measuring 43 × 28 mm in the gallbladder. Computed tomography scan revealed a soft tissue mass of similar size almost filling the lumen of the gallbladder and showed notable enhancement in post-contrast images. The mass was concluded to be suggestive of gallbladder carcinoma. Extended radical cholecystectomy was performed and histopathological examination of the polypoid lesion showed papillary adenocarcinoma with tumor staging of T2b.Clinical discussionThe prevalence of polypoid lesions of the gallbladder are reported to be 2–12% of all cholecystectomy specimens. Gallbladder polyps are one of the common USG findings in general population. It is difficult to differentiate between the benign and malignant polypoid lesions of the gallbladder solely depending on imaging studies. A size larger than 10 mm is the best indicator of malignancy. The most common malignant gallbladder polyp is adenocarcinoma.ConclusionIn majority of the cases, gallbladder polyp is an incidental finding. Even though most of the gallbladder polyps are benign in nature, cholecystectomy is the treatment of choice if the suspicion for malignancy is high.

Descriptive analysis of incidental and operable gallbladder carcinoma cases: a UK centre experience.

SummaryObjectiveTo identify and compare significant or relevant prognostic factors in pre-operatively diagnosed, surgically resectable, gallbladder cancer and in incidentally detected gallbladder cancer cases.Material and methodsGallbladder resections (October 2009-March 2016) were identified on the histopathology Winpath database. Cases with a final histological diagnosis of gallbladder cancer (GBC) were categorised into: Group A: clinically suspected operable GBC (n = 13). Group B: incidental GBC with staged liver bed resection (n = 5). Group C: incidental GBC without staged liver bed resection (n = 15). The clinicopathological features were analysed in each group separately.ResultsThe overall incidence of primary (GBC) was 0.66% and all the cases were adenocarcinomas, of which, 6 of 33 (18.2%) were grade 1 and 15 of 33 (45.4%) were grade 3. Male to female ratio is 1:2.3. Of the 33 patients with GBC 14 (42.4%) has died of disease at 18-month follow-up. 15 of 33 had perineural invasion and 10/21 (47.6%) cases showed lymph node matastasis. Six cases had positive surgical margin and 9/15 showed direct liver invasion. Higher stage disease (T3/T4) was seen in 10/14 cases.ConclusionThe prognosis of primary GBC is poor and best clinical outcomes can be achieved with early diagnosis followed by radical cholecystectomy and staged liver resection with negative margins.

Node positivity in T1b gallbladder cancer: A high volume centre experience

IntroductionIdentification of early stage gallbladder cancer (GBC) is difficult with simple cholecystectomy being considered curative for T1a GBC but T1b requires radical cholecystectomy due to chances of lymph node metastasis. However there is no consensus regarding the optimal treatment strategy for T1b disease. MethodologyA retrospective review of a prospectively maintained database of GBC patients operated at our institute from March 2010 to March 2021 was conducted. Only patients with proven gallbladder adenocarcinoma on final histopathology report were included. ResultsA total of 1245 patients of suspected GBC who underwent surgery during this period with 76 patients of T1b stage were analysed. We divided the group into a node positive cohort (n = 16, 9 received neoadjuvant treatment due to uptake in periportal nodes and 7 patients were pN1) and a node negative cohort (n = 60). The median nodal harvest was 8 nodes (2–24 nodes). Considering the radiological and pathological parameters, the rate of lymph node positivity was 21% (16/76). The overall major morbidity was 5.2% and there was no mortality. After a median follow up of 47.5 months, 3-year OS and DFS of the node negative and positive cohort was 96.7%, 91.7% and 75% and 62.5% (p = 0.058). The node positive cohort had 43% recurrences whereas the node negative cohort had 8.3% with all recurrences limited to periportal lymph nodes, distant nodes or liver metastasis. ConclusionNodal positivity for T1b gall bladder cancer ranges around 21% and radical surgery with complete peri –portal lymphadenectomy should be considered as standard of care.

A216 WHEN CANCER CASTS THE FIRST STONE: A CASE REPORT OF GALLBLADDER CANCER PRESENTING AS GALLSTONE ILEUS

BackgroundGallstone ileus is a rare cause of mechanical bowel obstruction. It occurs when a biliary stone passes through a cholecystoenteric fistula and becomes impacted in the bowel lumen, most commonly at the terminal ileum or ileocecal valve.Gallbladder cancer is rare and often has a poor prognosis. Many patients present with advanced-stage disease and only 10% of patients are candidates for surgical resection. Early research has shown there is an increased incidence of gallbladder cancer among patients with gallstone ileus. To date, this relationship remains poorly understood.AimsTo present a case of an elderly female whose gallbladder cancer presented after causing a cholecystoenteric fistula and gallstone ileus.MethodsA retrospective review of a single patient case.ResultsOur patient was a 78-year-old female with a background history of hypertension, iron-deficiency anemia, osteoporosis, and treated bilateral breast cancer. She initially presented with acute cholecystitis, complicated by a concurrent pulmonary embolism. Given her need for systemic anticoagulation, she was treated non-operatively with antibiotics and an outpatient cholecystectomy was planned.She returned to hospital eight months later reporting two days of nausea and vomiting. A repeat CT scan showed a cholecystoduodenal fistula with a 3.5cm x 2.6cm gallstone impacted 20cm from the ileocecal valve. A laparoscopic-assisted enterolithotomy was performed and her postoperative course was uneventful.One month later, a CT scan was organized by her family physician to follow-up on incidental liver lesions. While the liver lesions were deemed benign, there was new lobulated soft tissue within the gallbladder, measuring 4.8cm x 4.7cm x 6.2cm, suspicious for a primary gallbladder malignancy. A follow-up MRI confirmed an intraluminal mass with direct invasion into hepatic segment III as well as marked segment III intrahepatic biliary dilatation. Endoscopy to the duodenum and cholecystoduodenal fistula was performed with a biopsy confirming gallbladder adenocarcinoma.She underwent an open radical cholecystectomy, left hepatic lobectomy, antrectomy, resection of 1st portion of duodenum, and reconstruction with a Roux-en-Y gastrojejunostomy. Final pathology and staging confirmed a pT3pN0M0 adenocarcinoma of the gallbladder with a fistula tract within the cancer extending to the duodenum. She was then referred to a cancer center to complete a six-month course of adjuvant chemotherapy with capecitabine.ConclusionsGallstone ileus is a cause of mechanical bowel obstruction and rarely, it can be the first presentation of gallbladder cancer. Gallbladder cancer has a poor prognosis with many patients presenting with late-stage disease. As a result, we recommend the consideration of post-enterolithotomy imaging in select patients to evaluate for evidence of malignancy.Funding AgenciesNone

Axillary nodal metastasis of operated gallbladder carcinoma: remote site of aggression\u2014a case report

BackgroundGallbladder cancer is a very aggressive type of biliary tract cancer. The only curative treatment is complete surgical excision of the tumour. However, even after surgery, there is still a risk of recurrence of the cancer.Case presentationA 63-year-old gentleman presented with the complaint of a non-healing ulcer at upper abdomen for the last 1 month. He had undergone a laparoscopic cholecystectomy at a private centre 4 months ago. Investigations confirmed the diagnosis of epigastric port site metastasis from a primary from gall bladder adenocarcinoma. After undergoing completion radical cholecystectomy with wide local excision of the epigastric ulcer, he received 6 cycles of concurrent chemoradiotherapy. Eighteen months later, he presented to us with bilateral axillary swellings. Investigations confirmed isolated bilateral axillary metastasis and the patient underwent a bilateral axillary lymphadenectomy (Level 3). However, PET scan after 6 months showed widespread metastasis and the patient succumbed to the illness 1 month later.ConclusionAxillary metastasis probably occurs due to the presence of microscopic systemic metastasis at the time of development of port site metastasis. An R0 resection of the malignancy is the only viable option for effective therapy. The present case highlights the rare involvement of isolated bilateral axillary lymph nodes as a distant metastatic site with no evidence of disease in the locoregional site. However, the prognosis after metastasis remains dismal despite multiple treatment modalities.

Robot-assisted radical cholecystectomy for gallbladder cancer – A review

Radical cholecystectomy (RC) is recommended for Gallbladder cancer (GbC) patients with resectable T1b or higher stage. Traditionally, open RC is preferred over minimally invasive approach. Robotic surgery is increasingly gaining popularity and there are reports of robotic RC (RRC) for GbC. RRC is still new and mostly performed in high-volume centers with access to robotic technology. This study aims to review the current literature on the safety and feasibility of RRC for GbC. We performed a systematic review of RRC for GbC using PubMed and Embase until December 2020. The primary endpoint was major complications, while the secondary endpoints were conversion to open, R0 resection, and early recurrence. Seven studies with 74 patients were included in the study. Overall, four patients (5.41%) required open conversion. Five out of 74 patients (6.76%) experienced post-operative complications. There was no post-operative mortality. Among the patients with surgical margins reported (n = 63), 61 patients had negative margins (96.8%) and only two patients had positive margins. Two-year survival outcomes were reported as 60.5-100%. This is the first review that summarizes the current evidence on RRC for GbC. The endpoints suggest that RRC is feasible and safe in selected patients and when done in experienced centers. Understanding the strengths and limitations of RRC compared to other established therapeutic options may potentially aid surgeons in formulating the optimal treatment plan for GbC patients.

Nodal Metastases Impacts Residual Disease Status Following Definitive Oncological Resection of Gallbladder Cancer

Introduction: Most of gallbladder cancer (GBCA) cases are diagnosed incidentally following cholecystectomy. Due to the high recurrence rate following re-resection of incidental GBCA, the OPT-IN trial is examining the benefit of doublet neoadjuvant chemotherapy for patients with incidental T2/T3 GBCA. The aim of this study is to predict demographic and clinicopathological factors that influence residual disease (RD) status following definitive oncological resection. Methods: This is a retrospective study of patients who underwent radical resection for GBCA between 2012-2020. Multivariate logistic regression was performed to predict factors affecting R1 resection following initial procedure and RD status following re-resection. Results: A total of 43 patients underwent initial resection for GBCA including cholecystectomy (n=36) and radical cholecystectomy (n=7). Thirty-five (81.4%) were diagnosed incidentally. R1 resection was found in 14 patients (33%). Pathological T3 (pT3) stage was associated with a higher rate of R1 resection following the initial procedure (8 out of 11 patients; p=0.001). On multivariate analysis, pT3 stage demonstrated an odd ratio (OR) of 41.05 for R1 resection (p=0.046) in this group. Thirty-three patients eventually underwent definitive oncological resection following cholecystectomy. Nodal disease was significantly associated with RD in final specimens on both univariate (83.3%, p=0.002) and multivariate analyses (OR:17.12; p=0.009). Conclusion: Following initial resection, pT3 stage is a significant predictor of R1 resection for both incidental and non-incidental GBCA. RD after definitive resection correlates with the presence of nodal metastases. Patients with incidental GBCA may benefit from systemic chemotherapy prior to definitive resection as being examined in the OPT-IN trial.

Renal cell carcinoma with gallbladder metastasis: a case report

Renal cell carcinoma (RCC) is the most frequent renal neoplasm, with a high rate of metastasis, especially in the lungs and bones. The gallbladder is one of the rare metastatic sites. We report an 80-year-old woman who presented with chronic right flank pain for the last six months. A computer tomography scan revealed a heterogeneous right renal mass measuring 86 ×76× 68 mm and multi lithiasis in the gallbladder. A right radical nephrectomy, lymphadenectomy, and cholecystectomy were performed. The postoperative clinical course was uneventful, without any complications. The histological results showed a clear RCC with metastasis to the gallbladder. After 12-months follow-up, the patient is free from disease. In conclusion, even though the coexistence of metastatic gallbladder from clear RCC is rare, the possibility of concurrence should be considered if suspected findings in the gallbladder are identified intraoperatively.

Pre-operative diagnosis of Xanthogranulomatous Cholecystitis

Background: The primary objective of our study was to review the portfolio of patients with xanthogranulomatous cholecystitis and their outcomes. Methods: Retrospective analysis of information on 64 patients was done to examine age, clinical symptoms and findings, preoperative screening, operational results, surgical history, length of hospital stay, and postoperative problems. Result: There were 44 women and 56 males, with a mean age of 55 ±11.4 years. Out of 100 patients, 57 had gallbladder stones, 12 had adenomyomatosis plus stones, and 3 had polyps, according to preoperative ultrasonography. 4 individuals had acute cholecystitis, while 14 had chronic cholecystitis. 5 of the 11 individuals who underwent abdominal computed tomography had thickening of the gallbladder wall. In 4 cases, frozen section exams were performed, 1 patient underwent a radical cholecystectomy because of probable malignancy. Conclusion: Diagnosis of xanthogranulomatous cholecystitis on the basis of preoperative or intraoperative diagnosis of is challenging, and pathologic evaluation is the only method that may provide a conclusive answer.

Node Positivity in T1b Gallbladder Cancer: A High Volume Centre Experience

Introduction: Identification of early stage gallbladder cancer is difficult which is why about half of the patients are diagnosed post simple cholecystectomy . Simple cholecystectomy is considered adequate for T1a gall bladder cancer, however T1b requires radical cholecystectomy due to chances of lymph node metastasis. Methods: A retrospective review of a prospectively maintained database of gall bladder cancer patients operated at our institute from March 2010 to March 2021 was conducted. Only patients with proven gallbladder adenocarcinoma on final histopathology report were included. Results: There were a total of 1,245 patients of upfront and revision surgery for gall bladder cancer in this period. There were 76 patients of T1b stage of which 11 patients underwent upfront surgery and 65 patients were diagnosed as incidental gall bladder carcinoma. Neoadjuvant treatment was given to 9 patients due to uptake in periportal nodes and they were excluded from final analysis. The median age was 50 years (28-72 years). The median nodal harvest was 8 nodes (2-24 nodes). Positive nodes were found in 7 (10.44%) out of 67 patients with pT1b in final histopathology report. After a median follow up of 47.5 months (range 2-120 months), 7 (10.4%) patients had succumbed due to disease, 2 were alive with disease and 3 were lost to follow up with an OS of 89% and DFS of 86%. Conclusion: Nodal positivity for T1b gall bladder cancer ranges around 10% and radical surgery with complete peri –portal lymphadenectomy should be considered as standard of care.

Robotic Radical Cholecystectomy Experience from a Single Tertiary Referral Center

Gallbladder adenocarcinoma is most often diagnosed at an advanced age, and a minimally invasive approach has potential to significantly reduce the morbidity of resection. There is little data regarding the safety and adequacy of a robotic radical cholecystectomy. We sought to evaluate the outcomes of our experience with robotic resection at our institution.

Radical surgery for de novo gallbladder carcinoma-Single-center analysis of prognostic factors and survival outcomes from an endemic region.

Gallbladder cancer (GBC) is an aggressive malignancy where curative resection is possible in few and survival is poor. There are limited data on outcomes in patients with de novo GBC from endemic regions undergoing surgery for curative intent. We report survival outcomes in this group of patients from a region with high incidence of disease. We reviewed the records of all GBC patients (2014-2018) and included those who underwent radical cholecystectomy (RC) for de novo GBC. Univariable and multivariable analyses were performed to identify factors influencing recurrence and survival. A total of 649 patients with GBC were evaluated for surgery and curative intent surgery was attempted in 246 (38%) patients. Of these 246 patients, RC was performed in 115 patients, with histologically confirmed de novo GBC. Locally advanced disease (≥stage IIIB) was present in 52 (45.2%) patients. Median time to recurrence and overall survival (OS) were 31 and 36 months, respectively. Lymph node positivity (p = 0.005) and grade significantly influenced OS on multivariable analysis. Satisfactory survival outcomes are possible after RC for de novo GBC. Extended resections performed in high volume centers combined with appropriate adjuvant treatment can offer significant survival benefits, with acceptable morbidity and mortality rates.

Focal neuroendocrine carcinoma mixed with adenocarcinoma of the gallbladder with aggressive lymph node metastasis in a patient who did not meet the mixed neuroendocrine\u2013non-neuroendocrine neoplasm criteria

A 70-year-old Japanese woman who was treated for interstitial pneumonia (IP) with steroid therapy developed cholecystitis. A serial computed-tomography (CT) imaging showed irregular thickness of the fundus wall of the gallbladder and two rapidly enlarged lymph nodes (LNs): number (no.) 12 and no. 8a. Positron-emission tomography-computed tomography (PET-CT) scan showed an abnormal uptake at the site of the gallbladder tumor and those LNs. We subsequently performed open radical cholecystectomy and LN dissection of the no. 12 and 8a LNs, following complete remission of IP. The histology showed gallbladder adenocarcinoma, with a single focus of neuroendocrine carcinoma (NEC) component of less than 30%; Ki-67 index > 80%, synaptophysin (Syn) (+), chromogranin A (CgA) (+), and clusters of differentiation (CD) 56 (+) (T2bN1M0, Stage IIIB). LN no. 8a was diffusely metastatic with NEC components. LN no. 12c, which was adjacent to the cystic duct, revealed necrosis without apparent tumor cells, but was highly suspicious for tumor necrosis. The final diagnosis was adenocarcinoma of the gallbladder with focal NEC (< 30%), which did not meet the criteria for mixed neuroendocrine–non-neuroendocrine neoplasm (MiNEN). Postoperatively, she completed 4 cycles of adjuvant chemotherapy for NEC (Cisplatin plus Etoposide), and no recurrence was observed after 12 months.

Robotic Resection of Gallbladder Cancer: A Single-Center Retrospective Comparative Study to Open Resection.

Minimally invasive surgery is gaining support for resection of gallbladder cancer (GBC). This study aims to compare operative and early outcomes of robotic resection (RR) to open resection (OR) from a single institution performing a high volume of robotic HPB surgery. Twenty patients with GBC underwent RR from January 2013 to August 2019. Outcomes were compared to a historical control of 23 patients with OR. Radical cholecystectomy for suspected GBC and completion operations for incidental GBC after routine cholecystectomy were both included. Robotic resection had lower blood loss compared to OR (150 vs 350mL, P = .002) and shorter postoperative length of stay (2.5 vs 6days, P < .001), while median operative time was similar (193 vs 208min, P = .604). There were no statistical differences in 30-day major complications or readmissions. No 30-day mortalities occurred. There was no statistical difference in survival trend (P = .438) or median lymph node harvest (5 vs 3, P = .189) for RR compared to OR. Robotic resection of GBC is safe and efficient, with lower length of hospital stay and blood loss compared to OR. Technical benefits of robotic-assisted surgery may prove advantageous though larger studies are still needed.