I. Definition
Gallbladder cancer diagnosed clinically as benign gallbladder disease and performed cholecystectomy, but confirmed as gallbladder cancer by pathological examination intraoperatively or postoperatively, is called accidental gallbladder cancer. Some people think that gallbladder cancer found accidentally during or after cholecystectomy for any reason is accidental gallbladder cancer.
Incidence
Foreign literature reports that accidental gallbladder cancer accounts for about 27%-41% of gallbladder cancers treated in surgery. Among gallbladder cancers admitted to the Department of General Surgery of Shanghai Oriental Hospital from January 2004 to December 2006, accidental gallbladder cancer accounted for 49%. Since laparoscopic cholecystectomy has replaced open cholecystectomy as the standard procedure for cholecystectomy in most hospitals, accidental gallbladder cancer is now mainly detected by laparoscopic cholecystectomy. Accidental gallbladder cancer accounts for 0.3-0.5% of laparoscopic cholecystectomies in western countries, and 0.8-0.9% in Japan. In our hospital, accidental gallbladder cancer accounts for 0.71% of all cholecystectomies (including laparoscopic cholecystectomy and open cholecystectomy) (23/3235) Despite the increasing progress of various examination methods, early diagnosis of gallbladder cancer is still difficult, and most early gallbladder cancers (T1) are difficult to be detected preoperatively. In other words, early gallbladder cancer is usually an accidental gallbladder cancer. In our hospital, 11 cases of early-stage (T1a,T1b) gallbladder cancer were diagnosed in the above mentioned period, and 10 cases were accidental gallbladder cancer, among which 8 cases were detected by laparoscopic cholecystectomy for the diagnosis of gallbladder stones.
High risk group
The etiology of gallbladder cancer is still unclear. However, gallbladder stones and gallbladder polyps are closely related to the occurrence of gallbladder cancer, and more than 60% of patients with gallbladder cancer have gallbladder stones in combination. More than 60% of gallbladder cancer patients are combined with gallbladder stones. 83% of gallbladder cancer patients in our hospital are combined with gallbladder stones. Like most malignant tumors, gallbladder cancer has its own high-risk group. Those with high-risk factors should undergo cholecystectomy as early as possible. Careful pathological examination during or after surgery to detect possible unexpected gallbladder cancer: 1.
1. Elderly people with gallbladder stones. Some data show that gallbladder cancer occurs in 8% to 10% of gallbladder stone patients over 70 years old.
2.Female. There are significantly more women than men with gallbladder cancer (ratio of men to women 2.6-3:1).
3.Long history of gallbladder stones
4.Stones larger than 2cm
5.Multiple stones, especially full type stones
6, calcification of gallbladder wall, porcelain gallbladder. Some data show that the cancer rate of calcified gallbladder is as high as 50%.
7.Significant thickening of the gallbladder wall
8.Gallbladder atrophy, regardless of the presence of stones
9.Stones combined with gallbladder polyp-like lesions
10.Gallbladder polyps larger than 1 cm
IV. Treatment
So far, surgical resection is still the only effective treatment for gallbladder cancer and the only hope for long-term survival of gallbladder cancer patients. The scope of surgical resection varies for unexpected gallbladder cancer with different pathological stages.
Studies have shown that the depth of tumor invasion is the most important factor affecting the prognosis of unexpected gallbladder cancer. For early-stage gallbladder cancer (T1a) with tumor infiltration depth limited to the mucosal layer of gallbladder, if the gallbladder is completely resected, with no intraoperative gallbladder rupture, no bile leakage and negative margins, whether laparoscopic cholecystectomy or open cholecystectomy, most studies show that the 5-year survival rate after surgery is nearly 100%, therefore, most scholars believe that simple cholecystectomy is sufficient for T1a gallbladder cancer. All five cases of T1a gallbladder cancer in our hospital underwent simple cholecystectomy, and four cases have survived tumor-free for more than 3 years after surgery.
For T1b unexpected gallbladder cancer with tumor infiltration deep into the muscular layer, it is still controversial whether cholecystectomy alone is sufficient and whether reoperation to extend the resection is necessary. Most studies have shown that there is no significant difference in the 5-year survival rate after reoperation to expand the extent of resection compared with that after cholecystectomy alone. Among our 6 T1b patients, 2 died of tumor recurrence at 6 and 7 months postoperatively, respectively, and 4 had survived more than 3 years postoperatively. One case was diagnosed with recurrence within the hepatoduodenal ligament at 42 months postoperatively, and the tumor invaded the duodenal bulb and common hepatic duct, with resection of the distal stomach, duodenal bulb and part of the descending segment, extrahepatic bile duct resection, and skeletal clearance of the hepatic portal vessels. Now 1 month postoperatively, the quality of survival is good. Recurrence of T1b gallbladder cancer after surgery is not uncommonly reported in multiple groups of domestic and international studies. In view of this, our opinion is that for unexpected gallbladder cancer belonging to T1b, radical surgery for gallbladder cancer should be aggressively performed openly despite its early stage.
Tumors that invade to connective tissue outside the muscular layer but do not invade the plasma layer or the liver are T2 gallbladder cancer. Most scholars believe that for patients with T2 gallbladder cancer, open radical surgery is necessary and can significantly improve the overall prognosis of patients in this stage.
Tumors that invade the whole gallbladder, or the liver, or an adjacent organ are considered T3 gallbladder cancer. T3 and T4 gallbladder cancers are more likely to combine with lymph node metastasis (N1,N2) or distant metastasis (M1). For unexpected gallbladder cancer with distant metastases, surgical intervention is not effective in treating the tumor and cannot prolong the patient’s survival, except for the elimination of coexisting biliary system infections or other complications.
For T3 and T4 unexpected gallbladder cancer without distant metastasis (M0), the traditional view is that the prognosis of this type of gallbladder cancer is extremely poor and palliative treatment should be the mainstay. Currently, most scholars believe that for T3, T4 gallbladder cancer with local progression and no distant metastasis, radical resection can prolong the survival of patients. However, there are still controversies about the definition of radical resection, the amount of liver to be resected, and whether it is necessary to remove extrahepatic bile ducts.
The definition of radical cholecystectomy in classical domestic and foreign surgical textbooks is usually.
(1) Complete removal of the gallbladder.
(2) Skeletonization within the gallbladder triangle and hepatoduodenal ligament.
(3) wedge-shaped resection of liver tissue up to 2 cm deep in the gallbladder bed.
Extended radical surgery for gallbladder cancer refers to partial resection of the involved organs or additional pancreaticoduodenectomy on top of radical surgery depending on the tumor involvement of the organs. It is easy to see that most scholars believe that if radical resection can be performed for gallbladder cancer, standard radical resection should be performed as far as possible, including skeletal clearance of the hepatoduodenal ligament, or even combined with extrahepatic bile duct resection. In other words, skeletal clearance of the hepatoduodenal ligament does not necessarily require resection of the extrahepatic bile duct.
If the extrahepatic bile duct system is completely skeletonized like a blood vessel, it will lead to ischemic atrophy, sclerosis or even necrosis, while to preserve the nourishing blood supply of the bile duct, it is necessary to preserve some of the fatty connective tissue outside the bile duct. Therefore, the extrahepatic biliary system cannot be truly “skeletonized”. In addition, we have studied the hepatoduodenal ligament cleanup specimens and found that microscopically, focal cancerous tissues or small nests of cancerous glands in the hilar or hepatoduodenal ligament were seen around the nerves, and some showed small foci involving the adipose tissue at the hilar, or small lymphatic tracts, or perivascular infiltrates and intravascular tumors. Obviously, the only way to completely remove the fat and connective tissues in the hepatoduodenal ligament is to remove the extrahepatic bile ducts, so as to remove the lymphatic ducts and nerve tissues that may have been involved and achieve the purpose of radical resection. In a Japanese study, among 30 cases of gallbladder cancer with microscopic tumor invasion of the hepatoduodenal ligament, 25 cases had cancer cells in the extrahepatic bile duct wall. Apparently, preservation of the extrahepatic bile duct may lead to residual tumor within the bile duct wall.
Our opinion is as follows.
I. It is meaningful to actively perform radical surgery for T3,T4 stage gallbladder cancer with local progression and no distant metastasis.
The term “hepatoduodenal ligament skeletonization” should clearly refer to vascular skeletonization in the hepatoduodenal ligament, i.e. hepatic portal vascular skeletonization. Only hepatoportal vascular skeletonization is possible to achieve the purpose of radical resection.
Therefore, hepatic hilar vascular skeletonization is an important basis for achieving better results in radical resection of T3 and T4 gallbladder cancer, which is of great significance in the surgical treatment of gallbladder cancer and should become one of the routine steps in the surgical treatment of gallbladder cancer. If the adjacent organs such as stomach, colon, duodenum and pancreas are involved, they should also be removed together.