Adverse Outcomes After Bile Spillage in Incidental Gallbladder Cancers

Abstract

Objective: To determine the effect of bile spillage during cholecystectomy on oncological outcomes in incidental gallbladder cancers. Background: Gallbladder cancer (GBC) is rare, but lethal. Achieving complete resection offers the best chance of survival. About 30% of GBCs are discovered incidentally after cholecystectomy for benign pathology. There is an anecdotal association between peritoneal dissemination and bile spillage during the index cholecystectomy. However, no population-based studies are available that measure the consequences of bile spillage on patient outcomes. Methods: We conducted a retrospective cohort comparison of patients with incidental GBC. All cholecystectomies and cases of GBC in Alberta, Canada, from 2001 to 2015, were identified. GBCs discovered incidentally were included. Operative events leading to bile spillage were reviewed. Patient outcomes were compared between cases of bile spillage versus no contamination. Results: In all, 115,484 cholecystectomies were performed, and a detailed analysis was possible in 82 incidental GBC cases. In 55 cases (67%), there was bile spillage during the index cholecystectomy. Peritoneal carcinomatosis occurred more frequently in those with bile spillage (24% vs 4%; P = 0.0287). Patients with bile spillage were less likely to undergo a radical re-resection (25% vs 56%; P = 0.0131) and were less likely to achieve an R0 resection margin [odds ratio 0.19, 95% confidence interval (CI) 0.06–0.55]. On Cox regression modeling, bile spillage was an independent predictor of shorter disease-free survival (hazard ratio 1.99, 95% CI 1.07–3.67). Conclusion: For incidentally discovered GBC, bile spillage at the time of index cholecystectomy has measureable adverse consequences on patient outcomes. Early involvement of a hepatobiliary specialist is recommended where concerning features for GBC exist.

Intraoperative bile spillage is associated with worse survival in gallbladder adenocarcinoma

“…Drain placement at the time of cholecystectomy and minimally invasive approach were independently associated with decreased OS. Our results support other series’ findings that intraoperative bile spillage is a negative prognostic factor for gallbladder adenocarcinoma . A recent population‐level study of incidentally identified gallbladder malignancy mirror our results, finding bile spillage was associated with lower rates of completion radical cholecystectomy, higher rates of peritoneal relapse, and decreased PFS .…”

“…Our results support other series’ findings that intraoperative bile spillage is a negative prognostic factor for gallbladder adenocarcinoma . A recent population‐level study of incidentally identified gallbladder malignancy mirror our results, finding bile spillage was associated with lower rates of completion radical cholecystectomy, higher rates of peritoneal relapse, and decreased PFS . Taken together, our findings highlight the critical nature of appropriate documentation of spillage and drain placement in managing and counseling these patients.…”

“…Intraoperative bile spillage has been considered a potential hazard of laparoscopic cholecystectomy because the early days of laparoscopy, and it remains a feared event that may subject patients with unsuspected malignancy to upstaged disease and a worse outcome . More contemporary series have examined intraoperative spillage, with some showing it to be associated with decreased survival while others did not demonstrate a correlation . The occurrence of bile spillage may itself be an indicator of locally advanced disease, which may compromise gallbladder wall integrity during laparoscopic dissection and perhaps lead to a higher rate of subtotal cholecystectomy …”

Prognostic value and risk stratification of residual disease in patients with incidental gallbladder cancer

“…It was therefore a true local disease. It has been suggested that the worsening of the prognosis related to RD could be due to disruption of the natural barriers between the tumor and the lymphatic network in the gallbladder bed or in the serosa layer, or to an intraoperative gallbladder perforation [18,19].…”

Robotic surgery of gallbladder cancer

“…The historically reported data are perhaps related to an inappropriate surgical technique carried out in the early years of the learning curve of laparoscopic cholecystectomy for presumed benign disease and were probably associated with gallbladder perforation, bile spillage and no use of protective bag for specimen extraction. The key role of bile spillage during index cholecystectomy for incidentally diagnosed GBC has been addressed in a population-based study by Horkoff et al [17] who highlighted in a retrospective cohort comparison the negative prognostic impact of bile spillage and its role in the development of peritoneal carcinomatosis. The occurrence of incidentally diagnosed GBC after cholecystectomy is assumed to vary between 0.19% and 3.3% [18] with a slight increase after the advent of laparoscopic cholecystectomy.…”