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GALLBLADDER TUMOURS
243
with cholecystitis (Kalliafas et al ., 1998 ; Ryu et al . 2003 ; Elwood, 2008 ).
In addition, it is a well-recognized complication in the ICU setting and in
patients on parenteral nutrition where the inactivity of the gallbladder
and biliary stasis are felt to be responsible (Hakala et al ., 1997 ; Kalliafas et al .,
1998 ; Pelinka et al ., 2003 ). There also appears to be a male preponderance
(in contrast to calculous disease) and an increased incidence in patients with
diabetes and atherosclerosis (Kalliafas et al ., 1998 ; Parithivel et al ., 1999 ; Ryu
et al ., 2003 ; Wang et al . 2003 ). In patients presenting in outpatients in the
usual fashion if a thick walled gallbladder is demonstrated, or in patients
who present acutely where peri-cholecystic fluid is found, then the treatment
should be the same as for those patients with gallstones. This is important
as occasionally emphysematous cholecystitis can present acutely and it is
associated with significant morbidity and mortality (Ryu et al ., 2003 ; Wang
et al ., 2003 ). In critically ill patients, treatment should be given a high prior-
ity as gangrene ensues and perforation is associated with significant risks
(Wang et al ., 2003 ). If these patients are very unwell, we have found percu-
taneous drainage under ultrasound control very effective and with low mor-
bidity (McClain et al ., 1997 ). When patients recover it is, however, worth
rescanning their gallbladders to exclude small stones that were previously
overlooked.
Gallbladder tumours
Gallbladder tumours have a dismal reputation due their usually late presenta-
tion (Piehler and Critchlow, 1978 ; Perpetuo et al ., 1978 ). The exact incidence
is unclear and, although it is the commonest biliary tract malignancy, it is
important to place this in perspective and remember that pancreatic cancer is
about five times more common (Diehl, 1980 ). The relative paucity of other
tumours of the gallbladder apart from polyps at least simplifies the manage-
ment. The clinician can be fairly confident, when they do present, about the
pathology they are dealing with although other tumours have been described
(carcinoid, melanoma, and sarcoma) but are so unusual that the diagnosis is
almost inevitably not considered and is made on examination of the resected
gallbladder (Barron-Rodriques et al ., 1991 ; Albores-Saavedra et al ., 2000 ;
Lack, 2003 ).
Gallbladder polyps
Benign adenomas are not infrequently diagnosed on ultrasound scanning of
patients with suspected gallstones. It is believed that the malignant potential of
these lesions is low but malignancy can certainly be present if they are greater
than 10mm in size (Yang et al ., 1992 ; Shinkai et al . 1998 ; Yeh CN et al ., 2001 ;
GALLBLADDER
244
Saleh et al ., 2008 ). The present management of inadvertently discovered polyps
is as follows:
◆
Small, incidentally discovered lesions without gallstones and in an asymp-
tomatic patient should have an ultrasound performed initially at 6 months
and then yearly for 2 years. If there is no change in size and gallstones are
not seen then they are left alone. It should be noted that occasionally ade-
nomas are described as calcifi ed and these usually represent small gallstones
and should be treated as such
◆
Multiple polyps or moderate sized polyps (greater than 5mm, less than
10mm) are scanned at 6-monthly intervals. If there is any increase in size or
number cholecystectomy is recommended
◆
Polyps greater than 10mm are removed with a cholecystectomy. In these
lesions intraoperative ultrasound is essential to examine the gallbladder
prior to removal. If the appearances are suspicious and suggest malignant
change then an open cholecystectomy is performed with frozen section
biopsies and lymph node sampling.
Great care must always be taken with larger polyps as perforation of a gall-
bladder containing even an early malignancy dramatically alters the course of
the disease as these tumours have a high propensity to deposit in wounds and
the peritoneal cavity.
Gallbladder cancer ( Figs. 4.27 and 4.28 )
Gallbladder cancer presents incidentally when histology of a gallbladder
removed for stones is examined, there is a suspicious appearance on ultra-
sound scanning of patients with gallstones, and as an advanced malignancy
(Randi et al ., 2009 ). The outcome of these patients depends on the stage at
which the disease presents and for this reason, survivals are generally quoted
after diagnosis.
The outlook, apart from incidentally discovered lesions, is very poor with
only a few patients surviving to 2 years and no survival at 5 years (Perpetuo
et al ., 1978 ; Piehler and Critchlow, 1978 ). Nevertheless, in a few recent series,
an aggressive approach has been taken and has produced long-term survivors
and even cures (Kondo et al ., 2002 ; Wakabayashi et al ., 2004 ).
Little controversy exists over the management of T1 and T4 lesions (Ogura
et al ., 1991 ; De Aretxabala et al ., 1994 ; Takayuki et al ., 2003 ). T1 lesions
are almost always managed by cholecystectomy alone although the survival
in these patients is not 100% (range from 85–100%). As a consequence there
has been some discussion as to the role of surgery in T1b (T1a tumours
are confined to the mucosa whereas T1b tumours penetrate into but not
GALLBLADDER TUMOURS
245
Fig. 4.27 Investigation of suspected gallbladder cancer.
Incidental
Histology from
laparoscopic
specimen
Suspected
gallbladder
carcinoma
Disseminated
disease vascular
invasion extensive
visceral involvement
Results of staging
investigations
Inoperable
Operable
Resection
Oncology
opinion
Laparoscopy Resection
Potentially
operable
Full assessment
for operability
Diagnosis and
staging
radiological
US/CT
Symptomatic
GALLBLADDER
246
Fig. 4.28 Management of gallbladder carcinoma.
Incidental finding
during other
procedure
? Surveillance
(see Section 4)
Extended cholecystectomy
Cholecystectomy
En Bloc resection of liver
Extended right hepatectomy
Lymphadenectomy
Excision and reconstruction
of the CBD
Excise any port sites
Cholecystectomy
Segmental
En Bloc resection
Lymphadenectomy
± Reconstruction
CBD
Biliary decompression
if required (ERCP)
Segment III bypass
Chemotherapy
Intraoperative
ultrasound if
available:
consider referral
CT/MRI
T1b
T1a
T1a
T2 T3
Fit
Unfit
T4
T1
CT/MRIJaundice
Demonstration
on histological
examination of
gallbladder
Gallbladder
carcinoma
presentation
Abnormal gallbladder
on US/CT/MRI
GALLBLADDER TUMOURS
247
through the muscular layer) lesions (Wakabayashi et al . 2004 ; Lai and Lau,
2008 ). In fit patients it seems reasonable to offer those with T1b lesions surgery
and the usual recommendation is an extended cholecystectomy (Wagholikar
et al ., 2002 ). The outcome for T4 lesions irrespective of the surgical procedure
is uniformly poor and these patients are offered palliative treatment particu-
larly to alleviate jaundice. The difficult area is the T2 and T3 lesions where we
have adopted an aggressive approach which we believe is effective. Patients
with T2 and T3 tumours may either be diagnosed after examination of the
resected specimen or suspected on preoperative imaging. It is important to
exclude disseminated diseases as far as possible and in our non-operated
patients, CT scanning and laparoscopy with intraoperative ultrasound is our
usual work-up. Additional problems may occur with referral of patients from
other centres after incidental discovery where the interval may be quite long
and in these patients we repeat the laparoscopy. Nevertheless, there are some
series reporting long-term survivors with radical surgery even in the presence
of positive lymph nodes and this has been our experience (Bartlett et al ., 1996 ;
Kondo et al ., 2002 ; Wakabayashi et al ., 2004 ; Ong et al ., 2008 ).
Surgical options
These depend on the stage of the disease as indicated by the preoperative
assessment.
The possible surgical approaches are as follows:
◆
Radical cholecystectomy with a rim of normal liver and lymphadenectomy
◆
Cholecystectomy, liver resection of Segments IV and V and lymphadenectomy
◆
Right or extended right hepatectomy with complete lymphadenectomy
and resection of the bile duct with a Roux-en-Y reconstruction to the left
of the duct.
The choice of procedure will depend on the fitness of the patient (the peak
incidence of gallbladder cancer is 70–75 years of age), stage of the tumour, and
its exact position.
Irrespective of the procedure selected, all port sites and surgical incisions
must be excised. Fundal tumours are more amenable to less radical surgery
than tumours near the cystic duct which commonly involve the bile duct.
In tumours near the bile duct especially with lymph node involvement, only
the most radical procedure is likely to produce clearance. Present policy is as
follows:
◆
Incidentally discovered lesions at cholecystectomy, or on preoperative
imaging where lymph nodes are negative and the tumours is at the fundus,
are treated by radical cholecystectomy and lymphadenectomy
GALLBLADDER
248
◆
Tumours with lymph node metastases or situated near the cystic duct are
assessed at surgery. If no other disease can be demonstrated (lymph nodes
in the hepatoduodenal ligament) and there is no bile duct involvement then
a segmental resection of Segments IV and V is undertaken with a complete
lymphadenectomy and excision of all lymphatic and nervous tissue in the
hepatoduodenal ligament
◆
Where there are nodes in the hepatoduodenal ligament or involvement of
the CBD, then radical surgery is offered. This is a right or preferably an
extended right hepatectomy (when the size of Segments II and III and the
fi tness of the patient permit this) with excision of the bile ducts from the
pancreas to the falciform ligament. After excision of all tissue apart from
the left hepatic artery and portal vein the biliary tract is reconstructed with
a Roux loop. Any previous port sites or surgical incisions are also excised
( Fig. 4.29 – 4.32 ).
The surgical procedure (also see Figs. 4.29 – 4.32 )
Surgery for gallbladder cancer utilizes features of segmental or classical liver
resection together with the reconstruction following resection of cholangi-
ocarcinoma. The differences arise in respect of the lymphadenectomy and
attempts to prevent local recurrence.
A bilateral subcostal incision is used with a vertical midline extension cepha-
lad if required. All port sites or previous incisions are included or excised
separately. It is necessary to include the scar and the tract with a 1–2cm clear-
ance. Laparotomy begins with a limited incision and the peritoneal cavity
examined very carefully. The right upper quadrant is also explored and any
abnormal serosal or peritoneal areas excised and sent for frozen section exam-
ination. The gallbladder (if in situ ) or gallbladder fossa, cystic duct or remnant,
bile duct, and hepatoduodenal ligament are carefully examined to determine
the most appropriate procedure. If the disease is confined to the gallbladder
fossa, nodes, and the hepatoduodenal ligament, then surgery is potentially
curative.
Lymphadenectomy is a common element of the procedure irrespective of
the approach to the liver and the bile duct. It is simpler if the bile duct is also
excised but irrespective of this the lymphadenectomy must be complete. All
lymphatic and neural tissue together with obvious nodes must be removed
from the superior border of the pancreas to the hilum. After gallbladder sur-
gery, nodes are often palpable but frozen sections frequently reveal only
inflammatory changes. It is important to remember that these are postopera-
tive patients and histological proof of nodal metastases is required. At the end
GALLBLADDER TUMOURS
249
of the procedure, the hepatoduodenal ligament has essentially ceased to exist.
The only remaining structures will be:
◆
The portal vein, hepatic artery, and bile duct when Segments IV and V are
to be resected but the bile duct preserved
◆
The left portal vein and left hepatic artery when a right or extended
right hepatectomy, together with the bile duct, is required. The decision
about the extent of the hepatectomy depends on the size of Segments II and
III, the patient’s age, and the presence of an accessory left hepatic artery.
This artery is very valuable in extended right hepatectomy and the postop-
erative course is generally uneventful with more rapid regeneration and less
disturbance of the liver function.
The liver resection and reconstruction are identical to those proce-
dures described in Sections 2 and 5 but care must be taken during the lym-
phadenectomy to ligate all tissue divided even if this is felt to be nervous tissue.
Fig. 4.29 Gallbladder cancer in the fundus with involved hepatoduodenal lymph
nodes.
Fig. 4.30 Gallbladder is removed and all the structures in the hepatoduodenal
ligament skeletonized.
Fig. 4.31 Right hepatectomy performed with bile duct divided above the pancreas
and to the left of the confluence.
GALLBLADDER TUMOURS
251
Failure to do this can produce a significant lymphatic leak which can be
relatively prolonged. This approach is effective and the procedure associ-
ated with few problems, a low mortality, and surprisingly good survivals
(Ong et al ., 2008 ).
Fig. 4.32 Roux-en-Y with anastomosis to the left bile duct.
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