Immediate Radical Re-Resection of Incidental T1b Gallbladder Cancer and the Problem of an Adequate Extent of Resection (Results of the German Registry Incidental Gallbladder Cancer)

Introduction: Gallbladder cancer is suspected preoperatively in only 30% of all patients, while the other 70% of cases are discovered incidentally by the pathologist (incidental or occult gallbladder cancer or IGBC). If gallbladder cancer is suspected preoperatively, an open cholecystectomy must be performed. The increasing rate of cholecystectomies via laparoscopy has lad to the detection of more gallbladder cancers in an early stage. Extended resection with regional lymph node dissection for T2 carcinomas and for more advanced cancer has been suggested. If IGBC is detected postoperatively by the pathologist after simple cholecystectomy, radical re-resection in cases of T2 tumours and more advanced stages is recommended. However, it has been argued that T1b cancers may have spread regionally or systemically at presentation and, thus, it remains debatable whether T1b cancers should be treated by simple cholecystectomy or by radical resection. Patients/Material and Method: This investigation was based on the German Registry of Incidental Gallbladder Cancer of the German Society of Surgery. In the present study, we evaluated whether T1 carcinoma patients do profit from a radical re-resection and if the different techniques of liver resection have comparable results in T1 carcinomas. Results: We analysed 684 cases of IGBC including 124 patients with T1 cancer with a 5-year survival of 48%. An extended re-resection increased the 5-year survival up to 68% for T1-IGBC. The analysis shows no advantage for re-resection of T1a cancer. In contrast, the current analysis shows a statistically significant survival benefit for re-resection of T1b cancers from 34% to 75%. The Registry data show a trend of better survival for the patients treated with the wedge resection technique compared to other resection techniques. Conclusion: For T1a cancer a simple cholecystectomy is sufficient. An immediate re-resection is highly recommended for patients with IGBC in T1b stage. The wedge resection technique combined with a locoregional lymphadenectomy of the hepatoduodenal ligament seems to be the strategy of choice for T1b cancer. An extended re-resection is necessary to determine the nodal status exactly, and to determine an exact definite staging for patients with T1b dcancer.