NEW YORK (Reuters Health) – In selected patients with suspected early-stage gallbladder carcinoma, laparoscopy is a safe approach, Korean physicians report in the February Archives of Surgery.

“Although laparoscopic surgery is widely applied in a variety of malignant diseases, such as colon cancer, gastric cancer, and hepatoma, its application to gallbladder malignancy was not tried before, so it is considered ‘taboo,’” lead author Dr. Ho-Seong Han from Seoul National University Bundang Hospital told Reuters Health by email.

As long as oncologic principles are observed, however, “including radical resection of tumor and adequate lymph node dissection, there is no reason” that laparoscopy can’t be used for gallbladder cancer, Dr. Han added.

If the gallbladder disease turns out to be benign, patients will have been spared unnecessary open surgery, according to Dr. Han and colleagues. Even with malignant disease, they note, lymphadenectomy can be done laparoscopically, for a less invasive procedure.

In the same issue of the journal, however, Dr. Jeffrey B. Matthews from the University of Chicago argues in an invited critique that this approach is too risky. Dr. Matthews would rather see all patients with malignant disease undergo conversion to open operation. He worries that laparoscopic surgery increases the risk of “rendering a potentially curative situation incurable through operative error or inadequate tumor clearance.”

For their prospective study, Dr. Han and colleagues considered 36 patients with suspected gallbladder carcinoma at stage T2 or less, without evidence of liver invasion on computed tomography. Three patients had liver involvement revealed by endoscopic ultrasound, which ruled out laparoscopy. Another 3 had hepatic involvement on ultrasonography at the start of laparoscopy, so their surgeries were converted to open procedures.

In the remaining 30 patients, the course of surgery was based on results of intraoperative frozen biopsy. Twelve patients whose frozen sections suggested benign disease had laparoscopic cholecystectomy only. Pathology reports later showed that 2 patients had T1a carcinoma, for which cholecystectomy is considered definitive treatment.

For the 18 patients with malignant disease, the authors write, “The gallbladder, including about 2 mm of the thin liver tissue adhered to the gallbladder, was carefully resected so as not to spill the potentially malignant bile and not to expose the subserosal layer of the gallbladder…. Once the specimen had been completely detached, it was inserted into a protective bag and extracted through the umbilical port site.” This procedure was followed by locoregional laparoscopic lymphadenectomy.

There were no bile spills due to gallbladder perforation, the authors report. Median operative time for carcinoma cases was 190 minutes, and median blood loss was 50 mL. Tumors ranged from 1.4 to 7.5 cm. None of the patients required repeat resection, although 10 had stage pT2 carcinoma. Median postoperative stay was 4 days.

At a median follow-up of 27 months, all 18 cancer patients were alive without recurrence or port site metastasis.

“We are still accumulating cases at about 5 or 10 a year, therefore, totaling more than 50 cases,” Dr. Han told Reuters Health. “Among the patients who underwent this operation, all the patients survived until now, with only one recurrent case. When compared with open surgery, our survival result is good, considering the prognosis of T2 gallbladder cancer is poor.”

Two patients had complications during lymphadenectomy: a hemorrhage from a torn branch of the main portal vein, which required conversion to laparotomy, and a bile duct injury that was repaired laparoscopically.

Three postoperative complications – symptomatic fluid collection at the gallbladder fossa, transient blood drainage from an indwelling drain, and voiding difficulty – were successfully handled without radiologic intervention or reoperation.

In his comments to Reuters Health, Dr. Han pointed out that the ideal candidate for laparoscopic surgery is someone suspected of having early gallbladder cancer (stage T2 or lower). However, “if tumor has invaded the liver or the gallbladder serosa, open radical cholecystectomy should be considered, although laparoscopic liver wedge resection or S4b & S5 resection can be performed in the future.”

In response to Dr. Matthews’ critique, Dr. Han said, “He is right that we should be prudent when we start the new procedure. However, many new scientific developments have to get through due and sincere critics. Laparoscopic radical cholecystectomy using our technique is exactly the same as open surgery except that it is a minimal approach. The oncologic principle should be the same whether it is open or laparoscopic surgery.”

The article recommends that in the event of a positive margin of the gallbladder or cystic duct, or for surgeons lacking expertise in advanced laparoscopic dissection, laparoscopy should be converted to an open procedure for further resection and lymphadenectomy.

Also, the authors emphasize, if carcinoma is suspected prior to surgery, “one should pay as close attention as possible to not perforate the gallbladder and must use a protective bag during the extraction.”

Dr. Han and colleagues conclude that laparoscopic resection with lymphadenectomy is technically feasible and “the interim outcome is acceptable for highly selected patients who have early-stage gallbladder carcinoma without liver invasion.” They acknowledge, however, that long-term follow-up and randomized trials are needed to confirm their results.

Reference:

Arch Surg 2010;145:128-133.