Surgery For Gallbladder Cancer Research Articles

Impact of the COVID-19 pandemic on disease progression in patients with hepatobiliary and pancreatic cancer.

e16246 Background: The COVID-19 pandemic has posed challenges to healthcare systems, notably impacting cancer care. For patients with Hepatobiliary and Pancreatic Cancer, there has been a reported decline in median survival. The etiology of this decline, whether it is attributed to an escalation in disease severity or to delays in diagnosis and treatment remains unclear. Methods: This retrospective study analyzed the National Cancer Database (NCDB 2004-2020) data from 2018 to 2020. We compared time from diagnosis to initial treatment, AJCC (2017) TNM clinical stage distribution, and pathological variables suggestive of tumor aggression between the pre-pandemic and pandemic periods, as well as within COVID-19 positive (C19+) and negative (C19-) patients. Results: The study included 17,429 liver cancer (LC), 37,185 pancreatic cancer (PC), 1,684 gallbladder cancer (GC), and 3,651 intrahepatic biliary cancer (IBC) patient’s pre-pandemic, and 14,420 LC and 35,456 PC, 1,457 GC, and 3,792 IBC patients during the pandemic. The time to initial treatment did not significantly differ in the before and during the pandemic groups for all types of cancer. However, for GC, there was a significant increase in days to definitive surgery during the pandemic 54 ±73 days compared to pre-pandemic 28±53 days (p < 0.01). There was also a notable increase in the time to initial treatment and definitive surgery for pancreatic cancer in C19+ patients (46±51, 118±104 days) compared to C19- patients (35±37, 97±89 respectively) (p < 0.01). For LC and GC, there was a significant increase in late-stage diagnoses during the pandemic period. LC (stage III: 23.67% and stage IV: 21.10%) compared to pre-pandemic (stage III: 22.71% and stage IV: 19.02%, p < 0.01). GC (stage IV: 77.0%) compared to pre-pandemic (stage IV: 71.85%, p < 0.01). Lympho-vascular invasion rates and node positivity ratios in HC, GC, and IBC patients remained unchanged. For PC there was no change in late stage distribution and IBC there were no significant differences in overall stage distribution or lympho-vascular invasion rates. However, a significant increase in node positive/node harvested ratio was observed in stage III C19+ PC patients (0.308±0.322) compared to C19- (0.134±0.181, p < 0.01). Conclusions: Cancer screening delays during the pandemic led to an increase in late-stage diagnoses for LC and GC but stage distributions for PC and IBC were largely unchanged. However, the pandemic's impact was subtly observed in the form of increased node positivity in stage III C19+ pancreatic cancer patients possibly due to their delay in initial treatment and surgery. There was also an increase in time to definitive surgery in gallbladder cancer. These findings underscore the importance of maintaining robust cancer care pathways, particularly for high-risk groups, to prevent adverse stage migration and ensure timely management, even in the face of global health emergencies.

Can laparoscopic surgery be the preferred strategy for gallbladder cancer?

Gallbladder cancer, notoriously known for its high malignancy, predominantly requires radical surgery as the treatment of choice. Although laparoscopic techniques have become increasingly prevalent in abdominal surgeries in recent years, the progress of laparoscopic techniques in gallbladder cancer is relatively slow. Due to the anatomical complexity, technical difficulty, and biological features of gallbladder cancer that is prone to metastasis and dissemination, traditional open surgery is still the main surgical approach. This study aims to reappraisal the current state of laparoscopic surgery for gallbladder cancer by appraising clinical practice and research evidence. Laparoscopic surgery for various stages of gallbladder cancer, including early, advanced, incidental, and unresectable gallbladder cancer were discussed. The promise and limitations of laparoscopic techniques are systematically explored.

Open vs minimally invasive liver surgery for gallbladder cancer, an Italian registry-based analysis

Open vs minimally invasive liver surgery for gallbladder cancer, an Italian registry-based analysis

Extensive lymphadenectomy in radical surgery for gallbladder cancer: immediate and long-term results in a series of 246 cases

Extensive lymphadenectomy in radical surgery for gallbladder cancer: immediate and long-term results in a series of 246 cases

Open versus minimally invasive liver surgery for gallbladder cancer, an IgoMILS (Italian Group of Minimally Invasive Liver Surgery) registry-based analysis

Open versus minimally invasive liver surgery for gallbladder cancer, an IgoMILS (Italian Group of Minimally Invasive Liver Surgery) registry-based analysis

The value of the preoperative Naples prognostic score in predicting prognosis in gallbladder cancer surgery patients

PurposeThe Naples prognostic score (NPS) is a comprehensive prognostic model that includes inflammatory and nutrition-related indicators and is increasingly used as a prognostic score for various malignant tumors. Given its predictive effect on prognosis in patients with gallbladder cancer, it is currently unclear. This study aimed to investigate the role of preoperative NPS in predicting prognosis in gallbladder cancer surgery patients.Patients and methodsA retrospective analysis was performed for 135 patients who underwent radical surgery for gallbladder cancer without preoperative treatment between March 2011 and January 2020. NPS was calculated by measuring the preoperative total cholesterol value, serum albumin value, neutrophil–lymphocyte ratio (NLR), and lymphocyte-monocyte ratio (LMR). They were then divided into 3 groups (groups 0, 1, and 2) based on NPS scores. Survival analysis was performed using the Kaplan–Meier method and log-rank test. Univariate and multivariate Cox proportional hazards models were used to identify independent prognostic factors. Plot time-dependent receiver operating characteristic (ROC) curves to compare the prognostic value of scoring systems. Finally, a nomogram model was developed with independent prognostic factors.ResultsMultivariate analysis showed that NPS was an independent risk factor affecting OS (HR = 3.417, p < 0.05). The time-dependent ROC curve results showed that NPS had a better predictive value on survival prognosis than other indicators. The nomogram constructed according to independent factors such as NPS has a good predictive ability for OS.ConclusionAs a simple and reliable tool, the NPS has important predictive value in the survival prognosis of gallbladder cancer patients. The nomogram model constructed by NPS will help determine prognosis and make individualized treatment decisions.

Improved long-term outcomes after innovative preoperative evaluation and conception of precise surgery for gallbladder cancer.

Three-dimensional visualization preoperative evaluation (3D-VPE) and enhanced recovery after surgery (ERAS) have been suggested to improve outcomes of cancer surgery in patients, yet little is known regarding their clinical benefit in patients with gallbladder cancer (GBC). We hypothesized that the combination of 3D-VPE and ERAS would improve the outcome of patients undergoing surgery for GBC. This study aimed to determine if 3D-VPE and ERAS can improve the outcomes and overall survival in patients with GBC, establishing a novel patient management strategy for GBC. A total of 227 patients with GBC were recruited and divided into two groups: those who received traditional treatment between January 2000 and December 2010 (n = 86; the control group) and those who underwent 3D-VPE and ERAS between January 2011 and December 2017 (n = 141). Univariate and multivariate analyses were employed to assess the relationship among disease stages, lymph node invasion, and cell differentiation between the two groups. Cox regression analysis was used to investigate patient survival in these groups. Patients who underwent 3D-VPE and ERAS showed a significantly higher R0 resection rate (67.4% vs. 20.9%, p < 0.001) and dissected lymph node number (26.6 ± 12.6 vs. 16.3 ± 7.6 p < 0.001) compared to the control group. The median survival was 27.4 months, and the 1- and 3-year survival rates were 84.4% and 29.8%, respectively, in patients who received combined management; in the control cohort, the median survival was 12.7 months, and the 1- and 3-year survival rates were 53.5% and 15.1%, respectively. In addition, some postoperative complications and risk factors were diminished relative to the traditionally treated patients. The implementation of 3D-VPE and ERAS can significantly improve the prognosis and outcomes of patients with GBC and should be considered for wide use in clinical practice.

Practice patterns in diagnostics, staging, and management strategies of gallbladder cancer among Nordic tertiary centers.

Gallbladder cancer (GBC) is a rare malignancy in the Nordic countries and no common Nordic treatment guidelines exist. This study aimed to characterize the current diagnostic and treatment strategies in the Nordic countries and disclose differences in these strategies. This was a survey study with a cross-sectional questionnaire of all 19 university hospitals providing curative-intent surgery for GBC in Sweden, Norway, Denmark, and Finland. In all Nordic countries except Sweden, neoadjuvant/downstaging chemotherapy was used in GBC patients. In T1b and T2, majority of the centers (15-18/19) performed extended cholecystectomy. In T3, majority of the centers (13/19) performed cholecystectomy with resection of segments 4b and 5. In T4, majority of the centers (12-14/19) chose palliative/oncological care. The centers in Sweden extended lymphadenectomy beyond the hepatoduodenal ligament, whereas all other Nordic centers usually limited lymphadenectomy to the hepatoduodenal ligament. All Nordic centers except those in Norway used adjuvant chemotherapy routinely for GBC. There were no major differences between the Nordic centers in diagnostics and follow-up. The surgical and oncological treatment strategies of GBC vary considerably between the Nordic centers and countries.

ASO Visual Abstract: Benchmarks and Geographic Differences in Gallbladder Cancer Surgery: An International Multi-center Study.

ASO Visual Abstract: Benchmarks and Geographic Differences in Gallbladder Cancer Surgery: An International Multi-center Study.

Surgical outcomes of gallbladder cancer: the OMEGA retrospective, multicentre, international cohort study

Gallbladder cancer (GBC) is rare but aggressive. The extent of surgical intervention for different GBC stages is non-uniform, ranging from cholecystectomy alone to extended resections including major hepatectomy, resection of adjacent organs and routine extrahepatic bile duct resection (EBDR). Robust evidence here is lacking, however, and survival benefit poorly defined. This study assesses factors associated with recurrence-free survival (RFS), overall survival (OS) and morbidity and mortality following GBC surgery in high income countries (HIC) and low and middle income countries (LMIC). The multicentre, retrospective Operative Management of Gallbladder Cancer (OMEGA) cohort study included all patients who underwent GBC resection across 133 centres between 1st January 2010 and 31st December 2020. Regression analyses assessed factors associated with OS, RFS and morbidity. On multivariable analysis of all 3676 patients, wedge resection and segment IVb/V resection failed to improve RFS (HR 1.04 [0.84-1.29], p=0.711 and HR 1.18 [0.95-1.46], p=0.13 respectively) or OS (HR 0.96 [0.79-1.17], p=0.67 and HR 1.48 [1.16-1.88], p=0.49 respectively), while major hepatectomy was associated with worse RFS (HR 1.33 [1.02-1.74], p=0.037) and OS (HR 1.26 [1.03-1.53], p=0.022). Furthermore, EBDR (OR 2.86 [2.3-3.52], p<0.0010), resection of additional organs (OR 2.22 [1.62-3.02], p<0.0010) and major hepatectomy (OR 3.81 [2.55-5.73], p<0.0010) were all associated with increased morbidity and mortality. Compared to LMIC, patients in HIC were associated with poorer RFS (HR 1.18 [1.02-1.37], p=0.031) but not OS (HR 1.05 [0.91-1.22], p=0.48). Adjuvant and neoadjuvant treatments were infrequently used. In this large, multicentre analysis of GBC surgical outcomes, liver resection was not conclusively associated with improved survival, and extended resections were associated with greater morbidity and mortality without oncological benefit. Aggressive upfront resections do not benefit higher stage GBC, and international collaborations are needed to develop evidence-based neoadjuvant and adjuvant treatment strategies to minimise surgical morbidity and prioritise prognostic benefit. Cambridge Hepatopancreatobiliary Department Research Fund.

Impact of acute cholecystitis comorbidity on prognosis after surgery for gallbladder cancer: a propensity score analysis

BackgroundCholecystitis can represent a comorbidity during gallbladder cancer surgery; nonetheless, the prognostic impact of acute cholecystitis comorbidity remains unclear. This study aimed to evaluate the impact of acute cholecystitis comorbidity on prognosis after gallbladder cancer surgery, with adjustment for background factors using propensity score analysis.MethodsA total of 218 patients who underwent gallbladder cancer surgery at our institute between 1986 and 2022 were retrospectively included in the analysis. Patients were divided into two groups according to the presence or absence of acute cholecystitis at the time of surgery. Background factors were adjusted by including intraoperative bile leakage as a covariate in propensity score calculation. Overall survival and recurrence-free survival were compared between the two groups using one-to-one propensity score matching and inverse probability weighting.ResultsOf the 218 patients, 37 had coexisting acute cholecystitis. In one-to-one propensity score matching, the overall survival time in the acute cholecystitis group tended to be shorter than that in the non-acute cholecystitis group, although not significantly (hazard ratio, 2.41; 95% confidence interval, 0.96–6.06). Other analyses using inverse probability weighting showed significantly poor overall survival in the acute cholecystitis group. Regarding recurrence-free survival in propensity score matching, the acute cholecystitis group showed a significantly shorter duration than the non-acute cholecystitis group (hazard ratio, 6.69; 95% confidence interval, 1.46–30.6). The inverse probability weighting-adjusted analysis also indicated a significantly higher risk of recurrence in the acute cholecystitis group.ConclusionsAcute cholecystitis comorbidity at the time of gallbladder cancer surgery may have a negative impact on gallbladder cancer prognosis.

The technique of laparoscopic and robotic extended cholecystectomy for gallbladder cancer

The application of minimally invasive surgery for gallbladder cancer (GBC) is yet controversial. This article discusses the techniques of laparoscopic and robotic extended cholecystectomy. A 69-year-old male diagnosed with cT1-2N0 GBC underwent laparoscopic surgery, and a 55-year-old male with cT2N1 GBC underwent robotic surgery after preoperative chemotherapy. Nonanatomical partial hepatectomy with lymphadenectomy was performed. Liver parenchymal dissection was performed using Cavitron Ultrasonic Surgical Aspirator laparoscopically and Maryland bipolar dissector and Harmonic scalpel robotically. The operation time was 180 and 220 minutes, and the estimated blood loss was 140 and 130 mL, respectively. The final pathologies were pT1bN0 and pT2aN1, for which patients received adjuvant chemotherapy. There was no evidence of recurrence at 33 and 18 months without complications. Both laparoscopic and robotic extended cholecystectomy can be safely performed with the robotic surgical system as an effective alternative for GBC requiring liver resection with radical lymphadenectomy.

Robotic portal lymphadenectomy: A standardized approach

Background: Portal lymphadenectomy is a mandatory component of oncologic surgery for gallbladder cancer and other biliary malignancies. Minimally invasive surgical approaches for oncologic hepatobiliary malignancies are becoming more common. Although there is a paucity of descriptions of standardized approaches for portal lymphadenectomy.

A Systemic Review and Meta-analysis of Laparoscopic Surgery Versus Open Surgery for Gallbladder Cancer.

Laparoscopy in gallbladder cancer (GBC) has a possible role in staging, radical cure, and palliation in gallbladder cancer. However, a few studies have advocated the use of laparoscopic approach and concluded the safety of this approach. This present study was undertaken to determine the safety and feasibility between open and laparoscopic cholecystectomy in patients with the non-metastatic GBC. A systematic database search was performed in MEDLINE, Embase, and Google Scholar for relevant articles. As a result, a list of such studies, clinical trials, published in English up to May 2021, was obtained,14 studies were included and statistical analysis was conducted using RevMan software 5.3 (The Nordic Cochrane Centre). The 5-year survival rate was reported in 13 out of 14 studies (1388 patients), and all compared laparoscopic and open approach. There was no significant heterogeneity in between the studies (chi-square, 10.66; df, 12; I2, 0%). There was significant higher overall survival in open group (389/850 vs 194/538 or 1.45, 95% CI (1.12-1.88), P value, 0.005). There was no significant difference in recurrence rate, operative time, blood loss, lymph node yield, and postoperative complication in between open and laparoscopic groups. Our present study demonstrates that overall survival is significantly increased with open approach when compared with laparoscopic approach. There is no difference in recurrence rate, operative time, blood loss, lymph node yield, and postoperative complications between the open and laparoscopic cholecystectomy groups.

Surgical treatment and Survival of Gallbladder Cancer Patients: A Systematic Review

Objective: To assess the outcome and overall survival of surgery for gallbladder cancer. Methods: A systematic literature search was performed in PubMed. The review question was structured in PICO format. Then, the search was conducted according to a certain research strategy and certain limitations. The titles and abstracts of all retrieved citations were assessed by two medical consultants, who decided which articles to read in full text. The selected full text articles were independently screened by the researcher and the two colleagues. In a consensus meeting, it was determined which articles fulfilled the pre-defined inclusion criteria and eligibility. Results: A total of four citations were identified as fulfilling the predetermined eligibility criteria (two prospective cohort studies and two retrospective studies), while 630 studies which did not fulfill the inclusion criteria were excluded. Conclusions: Optimal treatment of gallbladder cancer is still evolving. Radical surgery in combination with standardized lymph node dissection constitutes the cornerstone of the surgical treatment. Patients’ overall survival depends upon their tumor stage, levels of CA199, and tumor location in gallbladder. Key Words: Gallbladder cancer, Surgery, Survival, Systematic Review.

A Propensity Score Analysis of Chemotherapy Use in Patients With Resectable Gallbladder Cancer

Gallbladder cancer is uncommon but highly fatal. Surgery remains the only potentially curative treatment for localized or locoregionally advanced gallbladder cancer. The rate of use of neoadjuvant and adjuvant chemotherapy in resectable gallbladder cancer is unknown. To assess factors associated with the use of neoadjuvant and adjuvant chemotherapy in patients with resectable gallbladder cancer and survival outcomes. The National Cancer Database was used to identify 6391 adults who underwent definitive surgical resection for gallbladder cancers between January 1, 2004, and January 1, 2016. Data analysis was performed from January 15 to February 15, 2020. Patients with localized or locoregionally advanced gallbladder cancers (ie, categories cTx-cT4, cN0-2, and cM0) were categorized as receiving neoadjuvant chemotherapy, adjuvant chemotherapy, or surgery alone. Categorical variables were compared using the χ2 test, with 1:3 nearest-neighbor propensity score matching based on neoadjuvant chemotherapy. Survival outcomes between groups were compared using Kaplan-Meier and Cox proportional hazards regression analyses. The use and survival outcomes of adjuvant and neoadjuvant chemotherapy. Of 6391 patients who underwent definitive surgery for gallbladder cancer, 4559 were women (71.3%); median age was 68 (IQR, 59-77) years. A total of 3145 patients (49.2%) received adjuvant chemotherapy, 3145 patients (49.2%) underwent surgery without chemotherapy, and 101 patients (1.6%) received neoadjuvant chemotherapy. Neoadjuvant chemotherapy use was associated with treatment at an academic facility (61 patients [60%] vs 38 patients [38%] treated in a nonacademic facility; P < .001) and in those with private insurance (65 patients [65%] vs 11 patients [11%] with Medicaid insurance; P < .001). Surgery alone was frequently used in older patients (median age, 72 [IQR, 63-81] years vs 59 [IQR, 52-66] years in patients with neoadjuvant chemotherapy; P < .001), those with Medicare insurance (1925 patients [57%] vs 1438 patients [43%] with adjuvant chemotherapy; P < .001), and patients with a higher comorbidity index score (326 patients [62%] vs 197 patients [38%] with adjuvant chemotherapy; P < .001). Adjuvant or neoadjuvant chemotherapy was used more frequently than surgery in patients with node-positive cancer (1482 [67.2%] vs 53 [65.4%] vs 912 [49.7%]). On propensity score matching analysis, adjuvant chemotherapy was associated with longer survival than surgery alone (22 vs 18 months, hazard ratio [HR], 0.78; 95% CI, 0.63-0.96); survival with neoadjuvant chemotherapy was not statistically significant compared with surgery alone and adjuvant chemotherapy groups (27 months, HR, 0.78; 95% CI, 0.58-1.04). However, in patients with node-positive gallbladder cancer, neoadjuvant therapy was associated with longer median overall survival (30 months [95% CI, 24-36 months] vs 14 months [95% CI, 11-17] in patients with surgery alone; P = .002). In this cohort study, use of adjuvant and neoadjuvant chemotherapy was low in patients with surgically resected gallbladder cancers. Chemotherapy was used more frequently than surgery in lymph node-positive disease compared with lymph node-negative disease. Adjuvant chemotherapy was associated with a survival advantage in resectable gallbladder cancer, and neoadjuvant chemotherapy was associated with increased survival in node-positive gallbladder cancers. These findings suggest that adjuvant chemotherapy and neoadjuvant chemotherapy should be considered in treatment of gallbladder cancer.

Locally advanced gallbladder cancer treated with effective chemotherapy and subsequent curative resection: a case report

BackgroundSurgical resection of gallbladder cancer with negative margins is the only potentially curative therapy. Most patients with gallbladder cancer are diagnosed in an advanced stage and, despite the availability of several chemotherapies, the prognosis remains dismal. We report a case of locally advanced gallbladder cancer that was successfully treated with effective cisplatin plus gemcitabine, followed by curative resection.Case presentationA 55-year-old Japanese female was hospitalized with right hypochondrial pain. Enhanced computed tomography revealed a 49 × 47 mm mass at the neck of the gallbladder, with suspected invasion of the liver and right hepatic artery. Endoscopic retrograde cholangiopancreatography demonstrated displacement of the upper bile duct. Intraductal ultrasonography showed irregular wall thickening and disappearance of the wall structure in bile ducts from the B4 branch to distal B2 and B3. Percutaneous transhepatic biliary biopsy revealed a poorly differentiated carcinoma. The patient was diagnosed with unresectable gallbladder cancer (T4N0M0 stage IVA). Cisplatin plus gemcitabine chemotherapy was initiated. After six courses of chemotherapy, enhanced computed tomography showed that the mass in the neck of the gallbladder had shrunk to 30 mm, Endoscopic retrograde cholangiopancreatography showed improvement of the hilar duct stenosis. A biopsy of the bile duct mucosa showed no malignant cells in the branch of the left and right hepatic ducts, the left hepatic duct, or the intrapancreatic ducts. The patient underwent conversion surgery with right and segment 4a liver resection, extrahepatic duct resection, and cholangiojejunostomy. The histopathologic diagnosis showed that the tumor cells had shrunk to 2 × 1 mm, and that R0 resection of the T2aN0M0 stage IIA tumor was successful.ConclusionAlthough conversion surgery for gallbladder cancer is rarely possible, curative resection may offer a better prognosis, and it is important to regularly pursue possibilities for surgical resection even during chemotherapy.

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.

Impact of enhanced recovery pathway in 408 gallbladder cancer resections

Gallbladder cancer (GBC) is the sixth most common gastrointestinal malignancy with poor prognosis. Enhanced Recovery Pathway (ERP) is associated with improved outcomes following abdominal surgical procedures. Currently, there is no study evaluating ERP in patients undergoing GBC surgery. The objective was to assess compliance with ERP elements and evaluate its impact on postoperative outcomes. Prospective study conducted from February 2014-2019, including elective GBC surgery. Team was educated prior to ERP implementation. Compliance with the protocol, functional gastrointestinal (GI) recovery, mobilisation, and postoperative outcomes were recorded. Impact of degree of compliance (more or less than 80%) with ERP and postoperative outcomes was evaluated. In 408 patients, compliance with ERP was 84.6% (53.8-100%). Compliance >80% with ERP elements was observed in 245 patients (60%). Patients with >80% compliance had lower rate of minor (18.8% vs. 27%, p=0.050) and significantly less major (0.8% vs. 6.1%, p=0.002) and postoperative stay (5.84±4.86 vs. 7.55±6.6 days, p<0.001) and earlier functional GI recovery. Intraoperative blood loss more than 600ml, lower compliance (<80%) with ERP and preoperative albumin independently predicted postoperative complications. This study demonstrates safety and efficacy of enhanced recovery pathway in gallbladder cancer. Higher compliance with the pathway was associated with significantly improved postoperative outcomes following gallbladder cancer surgery.

Comparison of Clinical Outcomes between Minimally Invasive (Laparoscopic and Robotic) and Open Extended Cholecystectomy

Background: Minimally invasive surgery (MIS), both laparoscopic and robotic surgery for gallbladder cancer (GBC) has rapidly increased recently, however, there is a lack of large multicenter studies of its safety and long-term outcome. Methods: Patients diagnosed with clinically suspected GBC who underwent EC from 2007 to 2020 in 3 large volume hepatobiliary centers were studied. EC was defined as a wedge resection of liver bed including cholecystectomy and regional lymphadenectomy Clinicopathologic data of O-EC and MIS-EC was analyzed and propensity score matching was performed to compare the short-term and long-term outcomes. Subgroup analysis of laparoscopic and robotic surgery was evaluated. Results: A total of 377 patients were included, O-EC and MIS-EC groups (laparoscopic EC: 40, robotic EC: 29) were 308 and 69 patients, respectively. Though MIS-EC group had a longer operative time (188.9 vs 238.1 minutes, p<0.001), shorter length of hospital stay (9.0 vs7.2 days, p=0.007), there was no difference in operative blood loss, complication rate, 30-day mortality rate. More lymph nodes were retrieved in O-EC (8.5 vs 7.1, p=0.044) and there was no significant difference in 3-year overall survival. In subgroup analysis of MIS-EC, laparoscopic EC had a longer operative time (264.4 vs 202.0 min, p=0.001), however, other perioperative outcomes and 3-year survival outcomes were comparable. Conclusion: MIS-EC is feasible with advantages of decreased length of stay and comparable survival to O-EC in GBC. Both laparoscopic and robotic EC had comparable perioperative and oncologic outcomes so it can be chosen according to the preference of the surgeon.