Introduction of Gallbladder Cancer
The exact cause of gallbladder cancer is still unclear, but it is generally believed to be related to chronic cholecystitis and gallbladder stones, probably due to long-term chronic stimulation of stones, resulting in mucosal hyperplasia and degeneration of gallbladder and then cancer. Gallbladder cancer mostly occurs in the body of gallbladder, and invasive adenocarcinoma is the most common, with high malignancy, rapid growth, early and extensive metastasis.
Unexpected gallbladder carcinoma (UGC) refers to gallbladder cancer found unexpectedly after cholecystectomy for benign gallbladder diseases or after surgery, which has attracted increasing clinical attention.
Since patients with gallbladder cancer are often not in early stage when they are diagnosed, according to the analysis of large number of cases, only about 23% of gallbladder cancers can be radically resected, and the overall median survival of gallbladder cancer patients is short. In recent years, due to the development of extended radical surgery for gallbladder cancer, the 5-year survival rate after surgery has been significantly improved.
Clinical staging of gallbladder cancer
Currently, Nevein and Maron’s clinical staging is based on the depth of tumor invasion and spread of gallbladder wall.
Stage I: cancerous tissue confined to the mucosa, i.e. carcinoma in situ.
Stage II: Invasion of the muscular layer.
Stage III: cancerous tissue invading the entire wall of the gallbladder.
Stage IV: invasion of the entire wall of the gallbladder combined with metastasis of the surrounding lymph nodes.
Stage V: direct invasion of the liver or metastasis to other organs or distant metastasis.
Surgical treatment of gallbladder cancer
The specific surgical treatment depends on the specific condition.
For lesions confined to the mucosa, simple cholecystectomy wood is performed.
For those who have invaded the mucosal muscle layer and the whole layer, and even have metastasis to the hilar, peri-bile duct and post-duodenal lymph nodes, an extended resection is required, which requires resection of 3-5 cm of adjacent liver tissue, and removal of suspected metastatic lymph nodes and fatty tissue near the hilar area.
If the liver has metastasis, gallbladder resection and wedge resection of the liver, or resection of the right half of the liver, or even the right trilobe, will be performed depending on the situation.
Extended radical surgery for gallbladder cancer includes removal of gallbladder, liver tissue adjacent to gallbladder bed, lymph nodes of hepatoduodenal ligament, and lymph nodes behind the head of pancreas in patients with gallbladder cancer, which need to be removed together; if there is cancer residue in the cut edge of gallbladder duct after gallbladder resection, common bile duct resection with bile-intestinal drainage is also required, which is one of the most complicated surgeries in general surgery.
Gallbladder morphology and function
The main function of the gallbladder is to store and concentrate the bile synthesized by the liver. When fasting, the bile enters the gallbladder and when eating, the gallbladder contracts and the bile enters the intestine through the cystic duct and common bile duct.
Location and shape of the liver
The liver is located in the right upper abdomen, hidden under the right diaphragm and deep surface of the rib cage. Most of the liver is covered by the rib arch, and if the liver is palpated under the rib arch, it is mostly pathological hepatomegaly.
The normal liver is reddish-brown in color and soft in texture. The weight of the liver in adults is equivalent to 2% of body weight. The right lobe of the liver is adjacent to the right pleura and right fundus of the lung above, the left lobe of the liver is attached to the heart above, a small portion is adjacent to the anterior abdominal wall, the right lobe of the liver is adjacent to the colon in front, the posterior lobe is adjacent to the right adrenal gland and right kidney, and the left lobe of the liver is adjacent to the stomach below.
Functions of the liver
Detoxification function: The liver has a “detoxification function” for many non-nutritive substances from the body and outside the body, such as various drugs, poisons and certain metabolites in the body.
Metabolic and synthetic functions: the daily intake of protein, fat, carbohydrates, vitamins, minerals and other nutrients are sent to the liver after digestion and absorption, where they are broken down and synthesized into various substances needed by the body, including albumin, clotting factors, etc.
Bile secretion: bile is produced by hepatocytes and excreted through the bile ducts inside and outside the liver and stored in the gallbladder, which automatically contracts when eating and excretes bile to the small intestine through the cystic duct and common bile duct to help digest and absorb food.
The functions of hematopoiesis, blood storage and regulation of circulating blood volume.
Immune defense functions.
Regenerative function: the liver is so powerfully regenerative that a normal liver can tolerate resection of about 70% of its volume, and the remaining hepatocytes proliferate and are able to continue to maintain normal liver function.
Incision
Radical surgery for gallbladder cancer usually involves an oblique incision under the right upper abdominal rib cage or a reverse “L” incision.
Extent of resection
The scope of radical gallbladder cancer resection mainly includes gallbladder removal, partial liver resection and lymph node dissection. The lymph node dissection depends on the route of confluence and metastasis, generally to the next station of metastatic lymph nodes.
Pre-surgery preparation
Appropriate daily aerobic exercise, which is beneficial for postoperative recovery, and strict abstinence from smoking.
Blood tests, including routine blood, urine, stool, full biochemistry, electrolytes, coagulation, hepatitis B, hepatitis C, HIV, syphilis antibodies, tumor markers, etc.
Chest X-ray, electrocardiogram, abdominal CT, MRI, PET-CT, etc.
Relevant examinations if other systemic diseases are present, such as heart and lung organs.
An enema or oral laxative to cleanse the intestines the day before surgery
A light diet the day before surgery and water abstinence from early morning on the day of surgery
appropriate fluids and intravenous administration of antibiotics to prevent infection prior to surgery
placement of a gastric tube and urinary catheter on the morning of surgery.
Postoperative period
After the surgery, observation in the surgical intensive care unit may be required for one day before being transferred back to the general ward.
a gastric tube is inserted into the stomach through the nostrils and its main purpose is to drain digestive juices from the stomach and prevent vomiting; if there is not much drainage per day after surgery, it may be removed when intestinal function is restored (exhaustion)
a urinary catheter is placed in the bladder for drainage of urine and is usually removed on the second to third postoperative day
1-2 abdominal drainage tubes will be left in the abdomen to facilitate the flow of fluid from the abdominal cavity, please record the flow and color of the drainage daily, normal is a small amount of light red or light yellow fluid and can be removed after resumption of diet
there may be an indwelling T-tube, which is placed in the common bile duct and is mainly used for bile drainage; pay attention to protection during the activity to avoid dislodgement
a deep venous puncture tube will be placed in the neck or upper extremity for postoperative infusion and administration of various medications, which may be removed when you resume eating
an elastic stocking to prevent thrombosis will be placed in the lower extremity and may be removed when you begin to move around.
an analgesic pump will be connected via an intravenous or epidural catheter allowing the patient to administer their own pain medication, which can be used appropriately to relieve pain during walking, coughing and deep breathing, or to seek medical help if the pain becomes unbearable
you will be advised to move off the floor early, generally recommended that this can be started on the second to third postoperative day, which will improve blood circulation, prevent thrombosis and promote recovery of gastrointestinal function
patients will be asked to initiate coughing and deep breathing exercises, along with the use of a nebulized inhalation device, to prevent pulmonary atelectasis and lung infections
Wounds are usually changed on postoperative day 3, and health care providers are advised to be informed of any abnormal bleeding and oozing.
the need for early postoperative treatment with intravenous fluid supplementation, parenteral nutrition fluids, acid-suppressing drugs, and antibiotics
(b) Usually, transoral feeding can be started after removal of the gastric tube, initially starting with water and then gradually changing to a liquid, semi-liquid diet until a regular diet.
If there is no significant appetite at first, enteral nutrition solution may be administered under medical advice
delayed feeding if there is significant abdominal distention and nausea and vomiting; a small number of patients may develop significant gastrointestinal dysfunction and be unable to eat within a short period of time, and may even be reintroduced to a gastric tube
a small number of patients have a mild fever (temperature between 37-38 degrees Celsius), which usually resolves within 3-5 days
most patients experience weight loss before surgery and during recovery from surgery; this does not resolve for some time, but weight gain should be sought after discharge from the hospital
A physician or nurse needs to be contacted promptly if any of the following occur
chills or a body temperature above 38.5°C
Redness or swelling of the incision or leakage of fluid.
A change in color of fluid from the drainage tube or a large increase in drainage volume
increased abdominal pain or new symptoms of pain.
Nausea, vomiting, diarrhea.
Persistent constipation for more than 2-3 days.
Other new or unexplained symptoms of discomfort.
Discharge from hospital
Discharge can be considered when normal diet is resumed, normal bowel function, no comorbidities appear, as well as no significant discomfort. Before discharge, the doctor will give you discharge advice, prescribe the medications to be taken after discharge, and the nurse will check the medications with you. The discharge time is usually about 2 weeks after surgery.
Special Precautions
The most common uncomfortable symptoms after surgery are loss of appetite, bloating and easy feeling of fullness, this situation will improve with time, please eat small and frequent meals, do not worry about slow weight recovery, the most important thing is to ensure a balanced daily nutrition, to take in enough calories to prevent further weight loss.
Should abstain from smoking, alcohol, coffee, strong tea, carbonated drinks, sour and spicy foods, chew slowly, eat light and easily digestible food, avoid full and hard food, limit fat intake, especially not too much animal fat at one time, avoid too much cold food, and not too much exercise after meals.
Patients with gallbladder cancer should eat more foods with anti-infection and anti-cancer effects, including: buckwheat, barley, bitter gourd, lily, goldenseal, sea cucumber, etc.; to improve appetite, they can eat prunes, yam, radish, etc.
Another common discomfort symptom is easy fatigue after surgery, partly due to surgery and partly due to weight loss before surgery, which will improve with time and can be helped by gradually increasing the intensity of activities.
wound pain may still be felt while recuperating at home, and pain medication may be taken if needed, but one of the side effects of pain medication is constipation, which should be prevented by drinking more water and eating coarse fiber foods
physical exercise can help restore strength and improve symptoms, walking is the best method, consult your doctor before undertaking other more strenuous exercises, do not overdo it when exercising, have a regular life and ensure adequate rest and sleep
For the first 6 weeks after surgery, it is not suitable to lift heavy objects over 5 kg. You can drive 1 month after surgery, but driving is not recommended after taking pain medication.