The diagnosis of gallbladder
cancer is made in two distinct clinical fashions: Preoperatively, those
patients who have suspicious lesions found with laboratory work or imaging
based on history and physical. And incidental, (most common) those patients in
whom diagnosis is made by pathology after laparoscopic cholecystectomy or those
with gallbladder features concerning for carcinoma intraoperatively. Due to the
relative low incidence of gallbladder cancer and lack of distinct symptoms,
gallbladder cancer can be found at advanced stages and diagnosis is still
usually made postoperatively.
For lesions found incidentally, a
laparoscopic approach was thought to be a disadvantage primarily because of
increased biliary leak rates, delay in the ability to perform an unexpected
extended resection, and port site metastasis. Early
laparoscopic intraoperative biliary leak rates reached 26-36% potentially
transforming early lesions to T4 disease with major impact on survival: 75%
5 year survival rate in T1a/ T1b to 10% 3 year survival in T4. Furthermore,
early publications on laparoscopic cholecystectomy even for localized disease
showed generalized worse outcomes.
Adding to the concern was the
argument that an initial laparoscopic approaches found to have unexpected,
advanced tumors upon entry into the abdomen or gallbladders with concerning
appearance (thickened or infiltrated gallbladder walls) would require extended
resection. Thus, these patients would require referral to a center where
extended resection could be performed, resulting in treatment delay and
potential disease advancement.
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