Degree of biliary tract violation during treatment of gallbladder adenocarcinoma is independently associated with development of peritoneal carcinomatosis

Abstract

Background Gallbladder cancer (GBC) is often incidentally diagnosed after cholecystectomy. Intra‐operative biliary tract violations (BTV) have been recently associated with development of peritoneal disease (PD). The degree of BTV may be associated with PD risk, but has not been previously investigated. Methods We reviewed patients with initially non‐metastatic GBC treated at our institution from 2003 to 2018. Patients were grouped based on degree of BTV during their treatment: major (e.g., cholecystotomy with bile spillage, n = 27, 29%), minor (e.g., intra‐operative cholangiogram, n = 18, 19%), and no violations (n = 48, 55%). Overall survival (OS) and peritoneal disease‐free survival (PDFS) were evaluated with Kaplan‐Meier and Cox proportional hazards modeling. Results Ninety‐three patients were identified; the median age was 64 years (range 31–87 years). Seventy‐six (82%) were incidentally diagnosed. The median follow‐up was 23 months; 20 (22%) patients developed PD. The 3‐year PDFS for patients with major, minor, and no BTV was 52%, 83%, and 98%, respectively (major vs. none: p < 0.001; minor vs. none: p < 0.01). BTV was not associated with 5‐year OS (HR 1.53, p = 0.16). Conclusion Increasing degree of BTV is associated with higher risk of peritoneal carcinomatosis in patients with GBC and should be considered during preoperative risk stratification. Reporting biliary tract violations during cholecystectomy is encouraged.

Practices in the Management of Incidental Gallbladder Cancer

“…2) were able to correctly define true iGBC (Question 24). ►Supplementary Table 3 describes the inci-dence of iGBC and knowledge and practices of management of these cases among the responding surgeons (Questions 19 and [25][26][27][28][29]. When asked about the survival of a patient in whom no reoperation was done for iGBC (Question 30), the median longest survival reported was 4.5 years (mean: 3.3. years; range: 2 months to 20 years).…”

“…24 Bile spill is associated with development of peritoneal dissemination. 25 In a recent study, bile spillage at prior cholecystectomy was an independent factor associated with a poor prognosis on multivariate analysis. 26 Bile spill has been shown to shorten the disease-free survival as well as overall survival in many studies 27,28 hence, utmost care should be taken to prevent it and in case bile spill has occurred, it should always be mentioned in the operative findings by the surgeon, as it helps in further decision making, management, and prognosticating the patients.…”