Resection of Gallbladder Cancer, Including Surgical Staging

Resection of Gallbladder Cancer, Including Surgical Staging

Rebecca Taylor, Yuman Fong

Introduction

Gallbladder cancer was first described in 1777. The average age at diagnosis is 65years, with women being three times more affected than men. In gallbladder cancer, 90% of the cancers are adenocarcinomas. Gallstones and chronic inflammation of the gall- bladder are associated with malignant disease. It is estimated that 1% of patients under- going cholecystectomy for gallstones are found to have cancer. Twenty percent to 60%

of gallbladders with calcifications (porcelain gallbladder) will develop cancer.

Natural History

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Patients with incompletely resected gallbladder cancer have a 5-year survival rate of less than 5%

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Completely resected patients have a 5-year survival rate of 17–90% depending on stage of disease

Indications and Contraindications for Resectional Procedures Indications

Gallbladder cancer with T1–4, N0/1 and M0

Relative Contraindications

Lymph node metastases to N2 compartment

Contraindications

Peritoneal carcinomatosis or other distant metastases (M1)

Presentation

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Mass in segment 4/5 associated with gallbladder

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During surgery for presumed cholelithiasis or as pathologic finding after cholecystectomy for presumed gallstone disease

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One-third of patients will present with jaundice

Preoperative Investigations and Preparation for the Procedure

History: Biliary colic, jaundice, itching, weight loss, previous gallbladder or biliary surgery

Physical examination: Right upper quadrant mass

Imaging

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Ultrasound

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Contrast-enhanced CT scan (CT angiogram is preferred)

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Magnetic resonance cholangiopancreatography (MRCP)

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Cholangiography [if invasive cholangiography is necessary, percutaneous cholan- giography (PTC) is preferred over endoscopic retrograde cholangiopancreatography (ERCP)]

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Direct arteriography (rarely needed)

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Important anatomic details: porcelain gallbladder, mass, enlarged/necrotic lymph nodes, arterial involvement, portal venous involvement, adjacent organ (colon, duodenum) involvement, peritoneal metastasis

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Gallbladder polyp [solitary, sessile, large (>1cm) polyps are worrisome for cancer]

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Look at anomalous pancreaticobiliary duct junction, choledochal cyst, and of course hepatic arteries

Extent of Resection According to Stage

Patients presenting with gallbladder mass on imaging or operative exploration:

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T2/3, N0/1, M0: radical cholecystectomy and lymph node dissection

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Unilateral vascular involvement: extended lobectomy and lymph node dissection

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T4, N0/1, M0: extended lobectomy and lymph node dissection, possible adjacent organ resection

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N2 or M1: no curative surgery, possible palliation by biliary or gastric bypass

Patients with cancer discovered as an incidental finding after cholecystectomy for presumed cholelithiasis:

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T1 with negative liver and cystic duct margin: no further therapy

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T1 with positive cystic duct margin: re-resection of cystic duct or common bile duct to negative margins

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T2/3/4, M0: extended lobectomy, common bile duct resection, lymph node dissection, and resection of laparoscopic port sites

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N2 or M1: no curative surgery (palliation)

Procedure

A radical cholecystectomy (including segments 4b and 5) resection will be described. If an extended lobectomy is necessary because of the bulk of the tumor or because of vascular invasion, the dissection of the porta hepatis and hilar areas is performed as described below. With gallbladder cancer, when an extended resection is necessary, it is usually an extended right lobectomy. The liver resection is then performed as described in Sect.3,“Liver,” after the vasculature to the left side is dissected free and protected and the left hepatic duct has been divided.

Incision

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No previous surgery: A low right subcostal (hockey stick) incision is favored (see Sect.1, chapter “Positioning and Accesses” for descriptions of incisions and division of falciform)

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Previous cholecystectomy: Subcostal incision to incorporate excision of previous open or laparoscopic port incisions plus separate excision of umbilical port

STEP 1 Surgical exploration

Exposure and exploration: installation of the retractor (see Sect.1, chapter “Retractors and Principles of Exposure”) and inspection of possible port site and peritoneal metastasis

Ultrasound to evaluate location of the primary tumor in relation to vascular structures (portal vein, hepatic artery, hepatic vein) and to rule out discontiguous liver metastases

Careful inspection of vascular variation

STEP 2 Area resected by radical cholecystectomy, and regional lymph node and connective tissue dissection

The two segments (4b and 5) contiguous with the gallbladder bed are resected.

N1 lymph nodes (blue): those in the hepatoduodenal ligament (No.12) and common hepatic (No.8) and celiac arteries (No.9) are resected. Positive N2 nodes (red), retropan- creatic nodes (No.13), perigastric nodes or aortocaval nodes indicate incurable disease.

Nerve plexuses around the hepatic artery should be dissected.

Full kocherization allows inspection of these nodal stations and facilitates subsequent

dissection.

STEP 3 Excision of the highest peripancreatic lymph node

After kocherization, the highest peripancreatic lymph node is excised. This node is sent

for frozen section histologic analysis. After excision of this node, retraction of the bile

duct anteriorly allows visualization of the portal vein and facilitates safe dissection of

nodal and connective tissues. Frozen section staging using this node also guides the

operative procedure. If this node is positive and the patient is at high medical risk, then

the radical resection is usually abandoned. A radical resection performed in the setting

of a positive node should include a retropancreatic nodal dissection and aortocaval

nodal dissection, with or without a pancreaticoduodenectomy.

STEP 4 Common bile duct resection

Except in the very thin patient, it is very difficult to adequately excise the nodal tissue in the porta hepatis without resecting the common bile duct. This is particularly true if the patient has recently had a cholecystectomy, so that the scars from such surgery further complicate identification of nodal tissue and tumor. Resecting the common bile duct also allows the most certainty of resection of the cystic duct–common duct junction.

Furthermore, resecting the common duct allows the safest dissection and inspection of the portal vein and hepatic arteries behind the tumor and in the hilar area.

The bridge of liver tissue between segments 4b and 3, overlying the base of the

falciform, is divided (A) to allow access to the left portal pedicle. The common bile duct

is divided immediately above the pancreas and reflected upward (B). The resection

margin must be examined by frozen section. All nodal and connective tissues, including

the celiac, hepatoduodenal, and portal-caval nodes, are dissected with the common duct,

leaving behind only the skeletonized portal vein and hepatic artery.

STEP 5 Assessment of the portal vein and hepatic artery

With the common duct and portal nodal tissue reflected upward, the main, left, and right portal veins and arteries are dissected. If the main portal vein is involved, a portal vein resection and reconstruction may be necessary (see below). If the right hepatic artery and/or right portal vein are involved, an extended right liver resection is warranted. Once the arterial anatomy and possible arterial variations are clearly identified, the right or left hepatic artery is skeletonized distally to the right and left extremes of the hilar plate. In doing so, the left and right hepatic ducts are dissected free.

STEP 6 Transection of the left and right hepatic ducts

The left hepatic duct is then identified and transected at the base of the umbilical fissure.

Unlike the dissection for a hilar cholangiocarcinoma, the junction of the left and right

hepatic ducts can usually be freed from the liver. Retraction of the left hepatic duct

stump upward then allows a good look at the right hepatic duct from the posterior-infe-

rior aspects. A stay suture is then placed on this duct before transection.

STEP 7 Liver resection

After transection of the right hepatic duct, tissue from both the left and right ductal

margins is sent for frozen section analysis. The entire gallbladder bed including

segments 4b and 5 is then resected along the dotted lines shown. The portal veins and

hepatic arteries are protected under direct vision. Liver parenchymal transaction is as

described in Sect.3, chapters “Liver Resections” and “Left Hemihepatectomy,” usually

with inflow occlusion by the Pringle maneuver, and with central venous pressure (CVP)

maintained below 3cm H

O (see Sect.3, chapter “Extended Hemihepatectomies”).

STEP 8 Biliary reconstructions

Before bilioenteric anastomosis, the left and right hepatic ducts can be joined by inter-

rupted, absorbable sutures (4-0 or 5-0 Vicryl or PDS) to minimize the number of the

anastomosis. Alternatively, the two ducts can be anastomosed separately. A 70-cm

Roux-en-Y jejunal loop is lifted through the shortest route that allows for no tension

on the anastomosis: retrocolic or retrogastric. For details on the biliary anastomosis,

please see this section, chapters “Intrahepatic Biliodigestive Anastomosis Without

Indwelling Stent” and “Reconstruction of Bile Duct Injuries.” If a plastic biliary stent has

been placed before surgery, it is removed and not replaced. If a metal stent has been

placed, it is usually safest to cut across the metal stent at a site believed to be free of

cancer. The jejunal loop is then sewn to the duct and the stent.

STEP 9 Portal vein reconstruction

Tumors that occupy the neck of the gallbladder or the cystic duct often invade into the right portal vein or the main portal vein. Patients presenting with jaundice are at partic- ularly high risk for portal invasion. If the left portal vein and artery are free of tumor, these vascularly invasive tumors may often be resectable by combined extended lobec- tomy, portal lymphadenectomy, and portal vein resection and reconstruction.

Splitting the liver along the umbilical fissure, on the line of the extended lobectomy,

provides access to the hilar area and allows for easier control of the portal vein and safer

reconstruction. After cutting the left hepatic duct, this duct is reflected to the patient’s

left. The right hepatic artery is then transected to allow for unobstructed access to the

portal vein. Vascular clamps are then placed on the main portal vein and the left portal

vein (A-1). After transection, anastomosis of the main and left portal vein is accom-

plished with a running, nonabsorbable suture (e.g., 5-0 Proline) (A-2).

STEP 10 Liver resection and biliary reconstruction

An extended right hepatic resection is then performed as described in Sect.3, chapter

“Extended Hemihepatectomies.” The figure illustrates the subsequent reconstruction utilizing a retrocolic Roux-en-Y hepaticojejunostomy.

STEP 11 Drainage after reconstruction

After completing hemostasis in the surgical field, closed drains are placed in the right upper quadrant near the biliary anastomosis. If a percutaneous transhepatic stent has been removed, a drain should also be placed near the site of the stent entry site on the liver surface. We do not usually use stents for the anastomosis. Nasogastric tube decom- pression of the gastrointestinal tract is usually continued until return of bowel function.

This is particularly important if the bile duct used for anastomosis is small. Nasogastric

decompression prevents swelling of the Roux-en-Y limb and possible disruption of the

anastomosis.

Postoperative Tests

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Postoperative surveillance in an intensive or intermediate care unit (for extended procedures)

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Coagulation parameters and hemoglobin for at least 48hours

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Liver function test and electrolytes (including phosphorus) for at least 48hours

Postoperative Complications

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General:

– Pleural effusion – Pneumonia

– Deep vein thrombosis – Pulmonary embolism

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Abdominal:

– Intra-abdominal bleeding – Infected collection/abscess

– Liver failure (extended procedures) – Bile leak with biloma formation

– Leakage of biliodigestive anastomosis (procedures with common bile duct resection)

– Portal vein thrombosis

Tricks of the Senior Surgeon

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If the patient presents with a radiologic T3 or T4 gallbladder cancer, laparoscopic staging is warranted because of the high incidence of peritoneal metastases.

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For surgical planning, any patient with a tumor in the neck of the gallbladder or in the cystic duct, or presenting with jaundice, should be scrutinized on preoperative scans for signs of right hepatic arterial involvement. If the right artery is encased, a minimum of an extended lobectomy is necessary for resection.

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Accessory or replaced left hepatic arteries do not reside in the porta hepatis, but rather pass across the lesser omentum and enter the base of the umbilical fissure.

Patients with these anomalous vessels can therefore often be resected even when extensive involvement of the porta exists.

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Stay sutures should be placed before dividing the intrahepatic bile duct;

otherwise the small segmental duct can slip away and retract within the liver parenchyma.

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The lymphatic vessels throughout this dissection should be tied to prevent

postoperative lymphorrhea.