Gallbladder carcinoma and surgical treatment

Gallbladder carcinoma shows an unusual geographic and demographic distribution. It is relatively uncommon in Europe, but more frequent in Israel, Chile, Bolivia and in Southwestern Native Americans in the United States. Chronic cholecystitis, choledochal cysts, high body mass index, female gender, age, nicotine and industrial exposure to carcinogens are associated risk factors. The frequency of gallbladder cancer in all operations of the biliary tract is about 1–3%, reflecting the commonest biliary tract malignancy. Preoperative imaging, including ultrasound and computed tomography (CT), may reveal signs indicative of the presence of malignancy. However, most patients are not diagnosed prior to surgical intervention. Survival depends on the ability to achieve a curative resection, including hepatectomy and lymph node dissection in patients with local extended tumour according to the stage of the disease. Overall, the curative resection rates for gallbladder carcinoma range from 10% to 30%. Regional and para-aortic lymphadenectomy provides no survival benefit for patients with para-aortic disease, which has a negative influence on prognosis equivalent to that of distant metastases. A survival benefit is seen only in selected patients with metastases limited to the regional nodes. Taking a sample biopsy of the para-aortic nodes before starting surgery is recommended because these nodes are involved more frequently than expected. For those patients with unresectable cancer, palliative surgical, endoscopic or radiological bypass procedures can improve quality of life. Other approaches to the management of advanced tumours include systemic chemotherapy or combined chemo-radiotherapy and need further evaluation. Early-stage tumours are often discovered as an incidental finding during (laparoscopic) cholecystectomy or on histological examination of the gallbladder, mostly necessitating relaparotomy and extensive resection. In the following, management of patients with gallbladder cancer at different stages and situations is discussed.