Gallbladder carcinoma surgical therapy. An overview

Carcinoma of the gallbladder is the most frequent tumor of the extrahepatic biliary tract, and the fourth commonest upper gastrointestinal malignancy. Despite advances in preoperative diagnostic and surgical techniques, carcinoma of the gallbladder is still associated with a poor prognosis because it generally presents late with a short history of non-specific abdominal symptoms, and direct extension to adjacent vital organs frequently occurs at presentation. Some recent reports suggest an improved prognosis in a minority of patients with early tumors that are diagnosed incidentally on pathological examination of cholecystectomy specimens. This is the case of “incidental” or fortuitous gallbladder carcinoma. The TNM classification and stage grouping criteria are useful to predict survival and decide therapy. Gallbladder cancer can be diagnosed 1) before operation, 2) at the time of cholecystectomy, or 3) on pathological examination of cholecystectomy specimen. Patients diagnosed incidentally on pathological examination of cholecystectomy specimens have an improved survival and should be considered for further radical re-resection. Their prognosis is significantly better compared to the prognosis of patients whose gallbladder cancer was diagnosed preoperatively or at the time of cholecystectomy. Patients undergoing radical resection and patients in whom a cholecystectomy alone was considered curative (“incidental” gallbladder carcinoma) have a better outcome (5-year survival 35-38%) than those who did not undergo curative surgery (median survival 5 months). For more radical operations including “en bloc” resections and pancreatoduodenectomy a real survival benefit is controversial. The postoperative prognosis is highly conditioned by the first surgical approach that must be as correct as possible. Patients with unresectable gallbladder cancer may undergo palliative surgical treatment (cholecystectomy; cholecystectomy + cholangiojejunostomy; segment III bypass) or medical treatment: endoscopic or percutaneous biliary stenting; chemotherapy with fluorouracil or mitomicin C or epirubicin or gemcitabine (median survival rate 8 months); radiotherapy. The best surgical therapy of gallbladder cancer is its prevention. Therefore, patients with symptomatic gallstones, anomalous biliary or pancreatobiliary junction, cystic disorders of the biliary tree or gallbladder polypoid lesions greater than 1 cm must undergo cholecystectomy.