Radical resection of gallbladder carcinoma (expanded radical resection of gallbladder cancer) Wang Dong, Department of Hepatobiliary Surgery, Peking University People’s Hospital
Radical resection of gallbladder carcinoma
Extended radical resection of gallbladder carcinoma
Introduction to 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, which may be caused by 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 discovered unexpectedly after cholecystectomy or surgery for benign gallbladder diseases, 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.
l For those whose lesions are confined to mucosa, simple cholecystectomy wood is performed.
l For those who have invaded the mucosal muscle layer and the whole layer, and even have metastasis to the hilar, peri-choledochal and post-duodenal lymph nodes, 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.
l 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 as appropriate.
l Extended radical resection for gallbladder cancer includes gallbladder, liver tissue adjacent to the gallbladder bed, lymph node clearance of hepatoduodenal ligament, and lymph nodes behind the head of pancreas in patients with gallbladder cancer are often metastatic and need to be cleared together.
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. In adults, the liver weighs 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
l 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, and in severe liver diseases, such as advanced cirrhosis and severe hepatitis, the detoxification function is reduced and toxic substances accumulate in the body.
l Metabolic and synthetic functions: the daily intake of protein, fat, carbohydrates, vitamins and 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.
l 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.
l the functions of hematopoiesis, blood storage and regulation of circulating blood volume
l immune defense functions.
l Regenerative function: the liver has a powerful regenerative function. The normal liver can tolerate about 70% of the volume removed, 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.
Preparation before surgery
l Appropriate daily aerobic exercise, which is beneficial for postoperative recovery, and strict abstinence from smoking.
l Blood tests, including routine blood, urine, stool, full biochemistry, electrolytes, coagulation, hepatitis B, hepatitis C, HIV, syphilis antibodies, tumor markers, etc.
l Chest X-ray, electrocardiogram, abdominal CT, MRI, PET-CT, etc.
l Relevant examinations if other systemic diseases, such as heart and lung organs, are present.
l an enema or oral laxative to cleanse the intestines the day before surgery
l a light diet the day before surgery and water abstinence from early morning on the day of surgery
l appropriate fluids and intravenous antibiotics to prevent infection before surgery.
l Gastric and urinary catheters are left in place on the morning of surgery.
Postoperative period
l After the surgery, observation in the surgical intensive care unit may be required for one day before transferring back to the general ward.
l A gastric tube is inserted into the stomach through the nostrils, and its main function is to drain digestive juices from the stomach and prevent vomiting. If there is not much drainage per day after surgery, it can be removed when the intestinal function is restored (exhaustion).
l urinary catheters are placed in the bladder for drainage of urine and are usually removed on the second to third postoperative day.
l 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, which is normally a small amount of light red or light yellow fluid and can be removed after resumption of diet.
l A T-tube may be left in place. The T-tube is placed in the common bile duct and is mainly used to drain bile, so pay attention to protection during the activity to avoid dislodgement.
l A deep venous puncture tube will be placed in the neck or upper extremity for postoperative infusion and administration of various medications, which can be removed when you resume eating.
l An elastic stocking to prevent thrombosis will be placed in the lower extremity and may be removed when you begin to move around.
l a pain pump will be connected through an intravenous or epidural catheter, allowing the patient to administer pain medication on their own. Appropriate use of pain medication will relieve pain during walking, coughing and deep breathing, and if pain is unbearable appropriate use of pain medication or seek medical help.
l You are advised to move to the floor early, generally recommended to start on the 2nd-3rd postoperative day, which can improve blood circulation, prevent thrombosis and promote recovery of gastrointestinal function.
l 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.
l Wounds are usually changed on postoperative day 3, and health care providers are advised to inform them of any abnormal bleeding and oozing.
l The need for early postoperative treatment with intravenous fluid supplementation, parenteral nutrition solution, acid-suppressing drugs, antibiotics, etc.
l usually after removal of the gastric tube can begin to eat by mouth, initially starting with drinking water, then gradually changing to liquid, semi-liquid, until the ordinary diet.
l If there is no significant appetite at the beginning, enteral nutrition solution can be given under medical advice.
l If there is obvious abdominal distension and nausea and vomiting then feeding needs to be postponed. A few patients may have obvious gastrointestinal dysfunction and be unable to eat in a short period of time, and may even have a new gastric tube.
l A small number of patients have a mild fever (temperature between 37-38 degrees Celsius), which usually resolves within 3-5 days.
l most patients experience weight loss before surgery and during recovery from surgery, which does not resolve for some time, but weight gain should be sought after discharge.
A physician or nurse needs to be contacted promptly if any of the following occur
l chills or a body temperature above 38.5°C
l redness or swelling of the incision or leakage of fluid.
l if there is a change in the color of the fluid in the drainage tube or a large increase in the amount of drainage
l when there is an increase in abdominal pain or new symptoms of pain
l nausea, vomiting, diarrhea.
l persistent constipation for more than 2-3 days
l 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 medication to be taken after discharge, and the nurse will check the medication with you. The discharge time is usually about 2 weeks after surgery.
Special precautions
l 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 less and more often, 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.
l should quit smoking, alcohol, coffee, strong tea, carbonated drinks, sour and spicy foods, chew slowly, eat light and easily digestible foods, 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.
l Patients with gallbladder cancer should eat more foods with anti-infection and anti-cancer effects, including: buckwheat, barley, bitter melon, lily of the valley, goldenseal, sea cucumber, etc.; to improve appetite, they can eat prunes, yam, radish, etc.
l 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.
l 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 that it causes constipation, which should be prevented by drinking more water and eating coarse fiber foods.
l physical exercise can help to regain strength and improve symptoms, walking is the best method, please consult your doctor before doing other more strenuous exercises, do not overdo it when exercising, have a regular life and ensure sufficient rest and sleep
l For the first 6 weeks after surgery, it is not suitable to lift heavy objects over 5 kg. 1 month after surgery, you can drive, but driving is not recommended after taking pain medication.