Surgical Management of Incidental Gallbladder Cancer: Who, When, and How? Open Access

Ethun, Cecilia Grace (2017)

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Current recommendation is to perform re-resection for select patients with incidentally-discovered gallbladder cancer (IGBC), based on T-stage alone. Residual disease at re-resection, however, is the most important factor in predicting outcomes, and the optimal time-interval to re-resection is not known. Furthermore, current data on the utility of port-site resection during re-resection in the US are conflicting and limited to single-institution series. The purpose of this study was to utilize a large, U.S.-based, multi-institutional database to: 1) develop an association model to estimate the risk of finding locoregional residual (LRD) and/or distant disease (DD) at the time of re-resection, and to estimate survival in patients with IGBC; 2) assess the association between time-interval from initial cholecystectomy to reoperation with overall survival (OS) and identify a time-interval that yields the best overall survival; and 3) compare practice patterns of port-site management over time and assess the association of port-site resection with OS. All patients with IGBC who underwent reoperation at 10 institutions from 2000-2015 were evaluated by retrospective chart review (n=266). Advanced T-stage, grade, lymphovascular and perineural invasion were associated with increased LRD and DD, and decreased OS. Each characteristic was assigned a value, which added to a total score from 3-10, and were separated into 3 risk-groups (Low:3-4; Intermediate:5-7; High:8-10). Each progressive group was associated with increased incidence of LRD and DD, and reduced OS. Patients underwent re-operation at 3 different time-intervals: Group A:<4wks; B: 4-8wks; C: >8wks. Patients who underwent reoperation between 4-8 weeks had the longest median OS compared to those who underwent early or late reoperation. Group A (HR 2.63) and Group C (HR 2.07) time-intervals (vs Group B) were associated with decreased OS on multivariable Cox regression analysis. The rate of port-site resection remained similar over time. On multivariable Cox regression, port-site resection was not associated with improved OS. In conclusion, by accounting for variations within each T-stage, the proposed risk score better stratifies patients with IGBC. Between 4 and 8 weeks appears to be the optimal time-interval to reoperation. Port-site resection is not independently associated with improved survival, and is not routinely recommended.

Table of Contents

AIM 1 5
Methods 5
Results 6
Discussion 9
Conclusion 12
AIM 2 13
Methods 13
Results 14
Discussion 16
Conclusion 19
AIM 3 20
Methods 20
Results 21
Discussion 22
Conclusion 25
Table 1.1 34
Table 1.2 36
Table 1.3 37
Table 1.4 38
Table 1.5 39
Table 2.1 40
Table 2.2 42
Table 3.1 43
Table 3.2 45
Figure 1.1 46
Figure 1.2a-c 47
Figure 1.3a-b 48
Figure 2.1a-c 49
Figure 3.1 50
Figure 3.2 51
Figure 3.3 52

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