Système gastro-intestinal et digestif

Abstrait

Radical Surgery for Incidental Gallbladder Carcinoma. Which Subset of Patients is Really Suitable for?

Dario Borreca, Francesco Balcet, Alberto Bona, Maurizio Bossotti and Paolo De Paolis

Background: There is a wide consensus on the fact that surgical treatment of incidental gallbladder carcinoma should be based according to T stage: while simple cholecystectomy is considered an adequate treatment for confined carcinomas to the lamina propria (T1a), it is still being discussed in the case of cancer limited to muscularis mucosae (T1b), and a secondary extended resection is the only curative option for tumors invading the perimuscolar connective tissue (T2), and seems to improve survival in selected advanced cases. However, it is still not clear which subset of patients is really suitable for aggressive reoperations, and their effective impact on the prognosis of incidental neoplasm. The purpose of this study is to evaluate these aspects in a retrospective review of gallbladder carcinomas diagnosed during or after 9284 cholecystectomies performed with a benign indication. Methods: From January 1995 to December 2014, 46 cancers were found. In 35 of these, an invasion beyond the lamina propria was detected. Due to clinical reasons, 17 out of these 35 patients had no further operation after cholecystectomy. Among the 18 reoperated patients, 11 had no residual disease at final pathologic examination. Results: Considering only T2 and T3 cancers, survival was improved in patients undergone a re-resection, but this result is statistically significant (p=0.01) only if a macroscopic residual disease was absent. Conclusions: If an acceptable mortality and morbidity are evaluated, an additional radical operation is justified, inasmuch as it is the best chance for long-term relapse-free survival. Nevertheless, the subset of patients which have a real benefit from this treatment is small and the better prognosis of incidental gallbladder carcinoma is probably still due to the large number of initial disease (T1a: 25% in our case series) rather than to secondary aggressive resection.