This document discusses the management of gallbladder cancer. It covers diagnosis, staging, and surgical treatment approaches based on tumor stage. For early stage T1a tumors found incidentally after cholecystectomy, simple cholecystectomy may be adequate. For T1b and T2 tumors, radical resection including lymph node dissection is recommended due to higher risk of residual disease and lymph node involvement. For locally advanced T3/T4 or node positive cancers, radical surgery with hepatic resection or multi-organ resection is supported, though morbidity and mortality are high; N2 node involvement carries a poor prognosis. Staging laparoscopy is important to identify unresectable disease not apparent on imaging.
Gall bladder carcinoma seen in Indian popluation most common in women and presents at a very late stage .Survival is in months hence palliative treatment is being preferred .
Gall bladder carcinoma seen in Indian popluation most common in women and presents at a very late stage .Survival is in months hence palliative treatment is being preferred .
Cholangiocarcinoma: Pathology, diagnosis and treatment.Marco Castillo
A brief description with many abdominal imaging of the Cholangiocarcinoma.
Includes definition, epidemiology, pathology, classification, clinical presentation, diagnosis, staging and treatment.
Colorectal cancer is most common GI cancer
The rectum is the most frequent site involved
Adenoma-carcinoma sequence: Arises from adenoma in stepwise progression
GB cancer is the 5th most common GIT malignancy(worldwide).200 years later it is still considered to be a highly malignant disease with a poor survival rate
.Here is a brief description regarding
This Presentation gives summarized overview of Gall Bladder Carcinoma especially the management as per latest National Comprehensive Cancer Network(NCCN) Guidelines version 2.2013
In Depth review of the Surgical management of esophageal carcinoma including management overview, endoscopic management, Type of surgeries, Open, and minimally invasive, Extent of lymphadenectomy. Literature review of evidence for type of surgery and complications
Cholangiocarcinoma: Pathology, diagnosis and treatment.Marco Castillo
A brief description with many abdominal imaging of the Cholangiocarcinoma.
Includes definition, epidemiology, pathology, classification, clinical presentation, diagnosis, staging and treatment.
Colorectal cancer is most common GI cancer
The rectum is the most frequent site involved
Adenoma-carcinoma sequence: Arises from adenoma in stepwise progression
GB cancer is the 5th most common GIT malignancy(worldwide).200 years later it is still considered to be a highly malignant disease with a poor survival rate
.Here is a brief description regarding
This Presentation gives summarized overview of Gall Bladder Carcinoma especially the management as per latest National Comprehensive Cancer Network(NCCN) Guidelines version 2.2013
In Depth review of the Surgical management of esophageal carcinoma including management overview, endoscopic management, Type of surgeries, Open, and minimally invasive, Extent of lymphadenectomy. Literature review of evidence for type of surgery and complications
Presentation on New Advances in the Treatment of Liver Tumors (Laparoscopic Resections) by Dr. Kimberly Moore Dalal, Surgical Oncology & General Surgery, Peninsula Medical Center.
Il trattamento chirurgico del colangiocarcinoma - Gastrolearning®Gastrolearning
Gastrolearning II modulo/8a lezione
Il trattamento chirurgico del colangiocarcinoma
Prof. Gian Luca Grazi - Hepato-Biliary-Pancreatic Surgery National Cancer Institute Regina Elena, Roma
The presence of haematuria may be the sole symptom of an underlying disease, either benign or malignant. It is one of the most common presentations of patients with urinary tract diseases and of patients referred for urinary imaging. Painless visible haematuria (VH) is the commonest presentation of bladder cancer.
This is a general overview of options available to patients with liver dominant metastatic disease as well other focal areas of disease which may benefit from services provided by an interventional radiologist
Prix Galien International 2024 Forum ProgramLevi Shapiro
June 20, 2024, Prix Galien International and Jerusalem Ethics Forum in ROME. Detailed agenda including panels:
- ADVANCES IN CARDIOLOGY: A NEW PARADIGM IS COMING
- WOMEN’S HEALTH: FERTILITY PRESERVATION
- WHAT’S NEW IN THE TREATMENT OF INFECTIOUS,
ONCOLOGICAL AND INFLAMMATORY SKIN DISEASES?
- ARTIFICIAL INTELLIGENCE AND ETHICS
- GENE THERAPY
- BEYOND BORDERS: GLOBAL INITIATIVES FOR DEMOCRATIZING LIFE SCIENCE TECHNOLOGIES AND PROMOTING ACCESS TO HEALTHCARE
- ETHICAL CHALLENGES IN LIFE SCIENCES
- Prix Galien International Awards Ceremony
Couples presenting to the infertility clinic- Do they really have infertility...Sujoy Dasgupta
Dr Sujoy Dasgupta presented the study on "Couples presenting to the infertility clinic- Do they really have infertility? – The unexplored stories of non-consummation" in the 13th Congress of the Asia Pacific Initiative on Reproduction (ASPIRE 2024) at Manila on 24 May, 2024.
These simplified slides by Dr. Sidra Arshad present an overview of the non-respiratory functions of the respiratory tract.
Learning objectives:
1. Enlist the non-respiratory functions of the respiratory tract
2. Briefly explain how these functions are carried out
3. Discuss the significance of dead space
4. Differentiate between minute ventilation and alveolar ventilation
5. Describe the cough and sneeze reflexes
Study Resources:
1. Chapter 39, Guyton and Hall Textbook of Medical Physiology, 14th edition
2. Chapter 34, Ganong’s Review of Medical Physiology, 26th edition
3. Chapter 17, Human Physiology by Lauralee Sherwood, 9th edition
4. Non-respiratory functions of the lungs https://academic.oup.com/bjaed/article/13/3/98/278874
Ethanol (CH3CH2OH), or beverage alcohol, is a two-carbon alcohol
that is rapidly distributed in the body and brain. Ethanol alters many
neurochemical systems and has rewarding and addictive properties. It
is the oldest recreational drug and likely contributes to more morbidity,
mortality, and public health costs than all illicit drugs combined. The
5th edition of the Diagnostic and Statistical Manual of Mental Disorders
(DSM-5) integrates alcohol abuse and alcohol dependence into a single
disorder called alcohol use disorder (AUD), with mild, moderate,
and severe subclassifications (American Psychiatric Association, 2013).
In the DSM-5, all types of substance abuse and dependence have been
combined into a single substance use disorder (SUD) on a continuum
from mild to severe. A diagnosis of AUD requires that at least two of
the 11 DSM-5 behaviors be present within a 12-month period (mild
AUD: 2–3 criteria; moderate AUD: 4–5 criteria; severe AUD: 6–11 criteria).
The four main behavioral effects of AUD are impaired control over
drinking, negative social consequences, risky use, and altered physiological
effects (tolerance, withdrawal). This chapter presents an overview
of the prevalence and harmful consequences of AUD in the U.S.,
the systemic nature of the disease, neurocircuitry and stages of AUD,
comorbidities, fetal alcohol spectrum disorders, genetic risk factors, and
pharmacotherapies for AUD.
Flu Vaccine Alert in Bangalore Karnatakaaddon Scans
As flu season approaches, health officials in Bangalore, Karnataka, are urging residents to get their flu vaccinations. The seasonal flu, while common, can lead to severe health complications, particularly for vulnerable populations such as young children, the elderly, and those with underlying health conditions.
Dr. Vidisha Kumari, a leading epidemiologist in Bangalore, emphasizes the importance of getting vaccinated. "The flu vaccine is our best defense against the influenza virus. It not only protects individuals but also helps prevent the spread of the virus in our communities," he says.
This year, the flu season is expected to coincide with a potential increase in other respiratory illnesses. The Karnataka Health Department has launched an awareness campaign highlighting the significance of flu vaccinations. They have set up multiple vaccination centers across Bangalore, making it convenient for residents to receive their shots.
To encourage widespread vaccination, the government is also collaborating with local schools, workplaces, and community centers to facilitate vaccination drives. Special attention is being given to ensuring that the vaccine is accessible to all, including marginalized communities who may have limited access to healthcare.
Residents are reminded that the flu vaccine is safe and effective. Common side effects are mild and may include soreness at the injection site, mild fever, or muscle aches. These side effects are generally short-lived and far less severe than the flu itself.
Healthcare providers are also stressing the importance of continuing COVID-19 precautions. Wearing masks, practicing good hand hygiene, and maintaining social distancing are still crucial, especially in crowded places.
Protect yourself and your loved ones by getting vaccinated. Together, we can help keep Bangalore healthy and safe this flu season. For more information on vaccination centers and schedules, residents can visit the Karnataka Health Department’s official website or follow their social media pages.
Stay informed, stay safe, and get your flu shot today!
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New Directions in Targeted Therapeutic Approaches for Older Adults With Mantl...i3 Health
i3 Health is pleased to make the speaker slides from this activity available for use as a non-accredited self-study or teaching resource.
This slide deck presented by Dr. Kami Maddocks, Professor-Clinical in the Division of Hematology and
Associate Division Director for Ambulatory Operations
The Ohio State University Comprehensive Cancer Center, will provide insight into new directions in targeted therapeutic approaches for older adults with mantle cell lymphoma.
STATEMENT OF NEED
Mantle cell lymphoma (MCL) is a rare, aggressive B-cell non-Hodgkin lymphoma (NHL) accounting for 5% to 7% of all lymphomas. Its prognosis ranges from indolent disease that does not require treatment for years to very aggressive disease, which is associated with poor survival (Silkenstedt et al, 2021). Typically, MCL is diagnosed at advanced stage and in older patients who cannot tolerate intensive therapy (NCCN, 2022). Although recent advances have slightly increased remission rates, recurrence and relapse remain very common, leading to a median overall survival between 3 and 6 years (LLS, 2021). Though there are several effective options, progress is still needed towards establishing an accepted frontline approach for MCL (Castellino et al, 2022). Treatment selection and management of MCL are complicated by the heterogeneity of prognosis, advanced age and comorbidities of patients, and lack of an established standard approach for treatment, making it vital that clinicians be familiar with the latest research and advances in this area. In this activity chaired by Michael Wang, MD, Professor in the Department of Lymphoma & Myeloma at MD Anderson Cancer Center, expert faculty will discuss prognostic factors informing treatment, the promising results of recent trials in new therapeutic approaches, and the implications of treatment resistance in therapeutic selection for MCL.
Target Audience
Hematology/oncology fellows, attending faculty, and other health care professionals involved in the treatment of patients with mantle cell lymphoma (MCL).
Learning Objectives
1.) Identify clinical and biological prognostic factors that can guide treatment decision making for older adults with MCL
2.) Evaluate emerging data on targeted therapeutic approaches for treatment-naive and relapsed/refractory MCL and their applicability to older adults
3.) Assess mechanisms of resistance to targeted therapies for MCL and their implications for treatment selection
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Pulmonary Thromboembolism - etilogy, types, medical- Surgical and nursing man...VarunMahajani
Disruption of blood supply to lung alveoli due to blockage of one or more pulmonary blood vessels is called as Pulmonary thromboembolism. In this presentation we will discuss its causes, types and its management in depth.
Ozempic: Preoperative Management of Patients on GLP-1 Receptor Agonists Saeid Safari
Preoperative Management of Patients on GLP-1 Receptor Agonists like Ozempic and Semiglutide
ASA GUIDELINE
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Ozempic: Preoperative Management of Patients on GLP-1 Receptor Agonists
Gall bladder cancer management
1. Management of Gall bladder cancer
Dr. Romil Jain
Department of Surgical Gastroenterology and Liver transplant
Sir Ganga Ram Hospital
New Delhi
2. Headings
• Diagnosis of carcinoma gall bladder
• Jaundice as a presenting sign.
• Techniques of standard radical
cholecystectomy and related controversies
• Neoadjuvant and adjuvant treatment
• Summary
3. Diagnosis of carcinoma gall bladder
Clinical scenarios –
• Preoperatively
• Intraoperatively - at the time of surgical exploration for
abdominal symptoms attributable to another disease
process
• Postoperatively- examination of the gallbladder specimen
typically removed for cholecystectomy due to cholelithiasis.
4. Risk factors
• Gall stone disease: present in 70 to 90% of the
patients. However overall incidence in GB cancer in
gall stone patients is 0.3 to 3%. Risk increases with
size >3cm and longer duration
• Porcelain GB: intramural calcification of wall, risk
reported to be upto 50%, modern series reported less
than 10% (Khan et al 1.1%). More risk with the
selective or incomplete calcification. (Stephen &
Berger)
• Gall bladder polyp : age >60, size>1 cm (> 0.8 cm in
PSC), associated gall stones have increased risk.
5. • Chronic inflammatory states
Chronic infection with salmonella and helicobacter
Primary sclerosing cholangitis
APBDJ
Drugs : Isoniazide, OC pills, methyl dopa
Obesity
Occupational – oil, paper, textile and shoe industry
workers
.
6. Pre operative suspicion
Patients with right upper abdominal pain, and particularly
those with jaundice or signs of duodenal obstruction
More typically have locally advanced disease that may
be identified preoperatively.
Patients with early gallbladder cancer are often
asymptomatic, or may have nonspecific symptoms that
mimic, or are due to cholelithiasis or cholecystitis. So
malignancy not typically suspected preoperatively.
7. Incidental detection
Found in 0.3 to 3.0 percent in patients undergoing
laparoscopic cholecystectomy.
Duffy A et al. Gallbladder cancer (GBC): 10-year experience at Memorial
Sloan-Kettering Cancer Centre (MSKCC). J Surg Oncol 2008
Cavallaro A et al. Incidental gallbladder cancer during laparoscopic
cholecystectomy: managing an unexpected finding. World J Gastroenterol
2012
• At surgical exploration (open or laparoscopic)
• Commonly in final histopathology report.
8. Intraoperative incidental detection
• Two possibilities:
• an obvious GB mass seen or
• mass seen on cut open specimen.
• Rule out distant metastasis
• Talk to patients relatives
• Conversion to open
• Cholecystectomy and frozen section tumor ? cystic duct
margin?
• Look for celiac lymph nodes and inter aortocaval nodes
• Inform anesthetist
• Radical cholecystectomy with liver non anatomical
(wedge) or anatomical resection with lymphdenectomy
9. Incidental detection on pathology
What will be the approach?
• Managed by an expert in hepatobiliary surgery
History and physical examination
Preoperative symptoms and signs
Preoperative imaging
Reassess histopathology by an expert - T stage, N stage, cystic
duct margin?
Talk to surgeon –bile spillage? retrieval bag? Any doubtful
lesion? location?
Patient’s performance status and comorbidity
Restaging- CT scan (chest, abdomen and pelvis) + MRI / PET
CT scan
Staging laparoscopy – around 20% yield
Interaortocaval lymph node sampling: 18% yield.
10.
11.
12. Preoperative imaging
• When surgery is being considered, preoperative imaging
is important to identify patients with absolute
contraindications to resection.
• Imaging is less sensitive for peritoneal disease, present
in a significant number of patients and requires
diagnostic staging laparoscopy.
• However, there are no definitive guidelines for imaging
prior to surgery.
13. • USG
• Doubtful features are, mural thickening or calcification, a mass
protruding into the lumen, a fixed mass in the GB.
• Endoscopic USG: more accurate but data are conflicting.
• Compared with transabdominal US, EUS more often correctly
predicted the histologic diagnosis (97 versus 76 percent)
14. EUS is a useful to assess
• the depth of tumor invasion into the GB wall and
• for defining lymph node involvement
• bile for cytologic analysis, sensitivity of 73 percent for the
diagnosis of GBC.
• EUS guided FNA
• Sadamoto Y,Kubo H, Harada N, et al. Preoperative diagnosis and staging of gallbladder
carcinoma by EUS. Gastrointest Endosc 2003; 58:536.
• Mohandas KM, Swaroop VS, Gullar SU, et al. Diagnosis of malignant obstructive jaundice by bile
cytology: results improved by dilating the bile duct strictures. Gastrointest Endosc 1994; 40:150.
15. • On CT, GBC can appear as
• a polypoid mass protruding into the lumen or completely
filling it, a focal or diffuse thickening of the gallbladder
wall, or a mass in the gallbladder fossa; liver invasion,
suspected nodal involvement, or distant metastases.
• Difficult to differentiate inflammation with malignancy
• Pilgrim CH, Groeschl RT, Pappas SG, Gamblin TC. An often overlooked diagnosis:
imaging features of gallbladder cancer. J Am Coll Surg 2013
• Liang JL, Chen MC, Huang HY, et al. Gallbladder carcinoma manifesting as acute
cholecystitis: clinical and computed tomographic features. Surgery 2009
16. Yoshimitsu k, Honda H et al. CT evaluation according toTNM staging in operated patients GB cancer. Am J
Roentgenol 2002
17. Loading…
• Dynamic MRI and MR cholangiopancreatography (MRCP)
can help to differentiate benign from malignant gallbladder
lesions in equivocal cases.
• MRI is particularly useful for visualizing invasion into the
hepatoduodenal ligament, portal vein encasement, and lymph
node involvement
• Yoshimitsu K, et al. J Magn Reson Imaging 1997
• Schwartz LH, Black J, Fong Y,et al.. J Comput Assist Tomogr 2002
• Jung SE, Lee JM, Lee K, et al.. Eur Radiol 2005
18. Kim JH, Tim KH et al.preoperative evaluation of GB cancer by MRCP , MRI and contrast
MRI. J Magn Rason Imaging 2002, 16;676-69
19. PET scan
• Most GB cancers are PET avid
• Help differentiate between benign and malignant tumors
and diagnose extrahepatic spread (Petrowsky et al., 2006).
• Limited in differentiating between inflammatory states and
malignancy (Corvera et al, 2008)
• More accurate in diagnosing metastatic disease than CT
scan.
• PET/CT had a sensitivity of 100% compared to 25% with
CT alone (P < .001), and PET alone changed surgical
management in 17% of cases (Petrowsky et al, 2006).
• Petrowsky H, et al: Impact of integrated positron emission tomography and
20. Radiological approach
• The usual first test for gallbladder symptoms is ultrasound
• Duplex ultrasound adds information in terms of local
vasculature involvement
• When GBC is proven or suspected preoperatively, imaging
with CT or MRI should provide adequate data on local extent
of tumor and assess for metastases.
• PET can be a valuable adjunct in searching for metastatic
disease when CT or MRI provides an equivocal information.
• Invasive cholangiography indicated only when a therapeutic
intervention, such as stenting, is anticipated.
21. Preoperative pathologic
diagnosis
Preoperative histologic diagnosis is unnecessary with disease
that is amenable to resection
Tendency to seed the peritoneum, biopsy tracts, and surgical
wounds
Significant false-negative rates in smaller lesions.
For a patient with unresectable or metastatic disease, a
percutaneous
biopsy is indicated.
Bile cytology has been proposed as a way of making the
diagnosis, sensitivity reported 75%, but a deliberate attempt to
make the diagnosis this way is unwarranted.
22. Diagnostic staging laparoscopy
• Diagnostic staging laparoscopy frequently identifies metastatic
disease or other findings that contraindicate tumor resection
that may not be apparent on preoperative imaging
studies. (30% and 20% after primary non curative
cholecystectomy)
• Butte JM, Gönen M, Allen PJ, et al. The role of laparoscopic staging in patients
with incidental gallbladder cancer. HPB (Oxford) 2011; 13:463.
• Gaujoux S, Allen PJ. Role of staging laparoscopy in peripancreatic and
hepatobiliary malignancy. World J Gastrointest Surg 2010; 2:283.
23. A large prospective study of 409 patients undergoing
staging laparoscopy for gallbladder cancer, 23 percent
of patients had disseminated disease.
Agarwal AK et al. Ann Surg 2013
Laparoscopic ultrasound should be employed as
adjunctive imaging.
Shoup M, Fong Y. Surgical indications and extent of resection in gallbladder
cancer. Surg Oncol Clin N Am 2002
24. Contraindications to resection
Absolute contraindications to surgery for gallbladder cancer
• include liver metastasis, peritoneal metastases,
• involvement of N2 nodes,
• malignant ascites,
• extensive involvement of the hepatoduodenal ligament, and
• encasement or occlusion of major vessels.
Surgery should only be considered to palliate specific
problems.
25. • Direct involvement of colon, duodenum, or liver does
not represent an absolute contraindication.
• There is no role for a palliative radical surgery, for the
purpose of debulking.
• Although not proven, debulking simple cholecystectomy
is recommended by some to prevent future episodes of
cholecystitis in patients with locally unresectable
disease.
26. General approach
An open rather than laparoscopic procedure is generally
recommended, although some data suggest the feasibility of a
planned laparoscopic approach for an early-stage (T1a)
gallbladder cancer.
Reddy YP et al.. Eur J Surg Oncol 2000
Cho JY, Han HS, Yoon YS, et al. Laparoscopic approach for suspected early-stage
gallbladder carcinoma. Arch Surg 2010
However, preoperative staging is not entirely reliable at
identifying patients with T1a disease, and improperly staged
tumors are at risk for inadequate resection and subsequent
27. • An open approach is more often chosen to minimize the risk
for bile spillage.
• Open surgery is usually performed through a right subcostal
incision.
• Frozen section to evaluate the margins of the specimen.
Comment on cystic duct margin is important.
• A negative margins to be obtained.
28. • If the cystic duct stump is negative, only regional lymph
node dissection is performed (except T1a tumors).
• And if it is positive, extrahepatic bile duct resection is also
undertaken.
• For incidentally detected cancer, the surgical
management is similar to primary resection of gallbladder
cancer.
29. Specific considerations
T1a tumor- it means its involving lamina
propria
• Cystic duct margin negative
• Cure rates following simple cholecystectomy range
from 73 to 100 percent in case series.
• Suzuki K, Kimura T, Ogawa H.
• Surg Endosc 2000; 14:712. Yildirim E, Celen O, Gulben K, Berberoglu U. The
surgical management of incidental gallbladder carcinoma. Eur J Surg Oncol 2005;
31:45.
30. • Re resection for T1a tumors does not appear to
provide an overall survival benefit.
• Coburn NG, Cleary SP, Tan JC, Law CH. Surgery for gallbladder
cancer: a populationbased analysis. J Am Coll Surg 2008; 207:371
• .
• You DD, Lee HG, Paik KY, et al. What is an adequate extent of resection for
T1 gallbladder cancers? Ann Surg 2008; 247:835.
31. T1b tumor- involving muscular layer
• The optimal approach to T1b disease is more controversial.
• Initial reports have showed no significant difference in
overall survival.
• But presently re resection was supported because,
1.
2.
3.
4.
Higher incidence of lymph nodes mets (15 vs 2.5%)
High loco regional recurrence 50 to 60%
High rates of liver involvement 0 to 13%
Increased median survival (9.5 Vs 6.4 years)
Abramson MA, et al. Radical resection for T1b gallbladder cancer:
a decision analysis. HPB 2009
Pawlik TM et al. J Gastrointest Surg 2007
32. T2 tumor- involvement of peri muscular connective tissue.
• Extended cholecystectomy is indicated.
• As high chances of residual disease 40 to 76%
• High chances of liver (10%) and lymph nodal involvement
(30% to 60%)
• High rates of local recurrence after simple cholecystectomy.
Shimada H, Endo I, Togo S, et al. The role of lymph node dissection in the treatment of
gallbladder carcinoma. Cancer 1997
Kapoor VK. Incidental gallbladder cancer. Am J Gastroenterol 2001
33. • 5 year survival is 24 to 40 % without re resection , may
approaches up to 80 to 100% after resection
• Toyonaga T, Chijiiwa K, Nakano K, et al. Completion radical surgery after
cholecystectomy for accidentally undiagnosed gallbladder carcinoma. World J Surg 2003;
27:266
• Survival in patients with T2 lesions is related to the number of
lymph nodes removed.
• Downing SR, Cadogan KA, Ortega G, et al. Early-stage gallbladder cancer in the
Surveillance, Epidemiology, and End Results database: effect of extended surgical
resection. Arch Surg 2011
• One report suggests that for gallbladder cancer to be considered
node negative, at least six lymph nodes should have been
removed.
• Ito H, Ito K, D'Angelica M, et al. Accurate staging for gallbladder cancer: implications for
surgical therapy and pathological assessment. Ann Surg 2011;
34. Resectable T3, T4 and node positive cancer.
• In the past, surgeons were reluctant to operate on patients
with locally advanced (T3/4) disease because of an
overall poor prognosis.
• Cubertafond P, Mathonnet M, Gainant A, Launois B. Radical surgery for gallbladder cancer.
Results of the French Surgical Association Survey. Hepatogastroenterology 1999
• Support for radical surgery with reports indicating long term
survival in patients with T3 and T4 tumors, 15 to 63 percent
and 7 to 25 percent of patients, respectively.
• Kayahara M, Nagakawa T. Recent trends of gallbladder cancer in Japan: an analysis of 4,770 patients.
Cancer 2007; 110:572.
35. Some advocate even more extensive resection
involving hepatectomy, pancreaticoduodenectomy,
colectomy, and even nephrectomy for potentially
resectable disease.
A median survival time of 17 months.
Dixon E, Vollmer CM Jr, Sahajpal A, et al. Ann Surg 2005;
But morbidity and mortality rates are high (48 to 54,
and 15 to 18 percent, respectively).
In general, patients with lymph node metastases
outside the hepatoduodenal ligament should not
undergo resection.
36. Results with radical lymphadenectomy are less favorable
with N2 disease.
Tashiro S, Konno T, Mochinaga M, et al. Treatment of carcinoma of the gallbladder in
Japan. Jpn J Surg 1982;
If preoperative FNA confirms involvement of N2 nodes,
surgery should be performed only for palliation of specific
problems.
In a series of 104 patients treated at Memorial Sloan-
Kettering over a 12-year period, major hepatectomy,
resection of adjacent organs other than the liver, and
common bile duct excision increased perioperative
morbidity and were not associated with better survival.
D'Angelica M, Dalal KM, DeMatteo RP, et al. Analysis of the extent of resection for
37. Managing an incidental gallbladder cancer found on pathology
Timing of re resection
A retrospective analysis from the US Extrahepatic Biliary
Malignancy Consortium (JAMA Surg,2017)
Those who underwent reoperations between four and
eight weeks from the date of the original cholecystectomy
had better overall survival.
Due to reduced inflammation and full appreciation of
subclinical diseases (compared with reoperating <4
weeks) but does not allow too much time for disease
dissemination.
Ethun CG, Postlewait LM, Le N, et al. Association of Optimal Time Interval to
38. Managing an incidental GBC found intraoperatively
The surgeon should maintain a high index of suspicion in
patients with risk factors.
If an obviously malignant lesion is encountered, it is best not to
sample the lesion laparoscopically to reduce the hazard of
seeding.
The procedure should be converted to an open resection, if
resection will be undertaken.
39. Options include the following:
• Completing the cholecystectomy and obtaining a frozen
section, if positive, do extended cholecystectomy.
• For surgeons unfamiliar with complex hepatobiliary
surgery, closing the patient with or without simple
cholecystectomy and referral to a high-volume center.
40. • Fong et al from MSKCC found no difference in long term
complications and survival.
• Fong Y,Jarnagin W, Blumgart LH. Gallbladder cancer: comparison of patients presenting initially
for definitive operation with those presenting after prior noncurative intervention. Annals of
surgery. 2000 Oct 1;232(4):557-69..
41. Gall bladder cancer with jaundice
• Suggests porta hepatis involvement.
• Reported as advanced disease with dismal
prognosis.
• Many western authors consider jaundice as a
contraindication.
42. Loading…
• In 240 patients at MSKCC who presented with gallbladder
cancer, 82 (34%) were jaundiced and were more likely to have
advanced stage disease
• Only six underwent resection with curative intent, and only four
had an R0 resection.
• The median disease-specific survival of patients with jaundice
was 6 months, significantly worse than those without jaundice
(16-month disease-specific survival; P < .0001).
• None from the jaundiced group survived 2 years.
• Hawkins WG, Dematto RP, Jarnagin WR et al. jaundice predicts advanced disease and mortality in
patients with gall bladder cancer. Ann Surg Oncol; 2004;11:310- 15.
43. • Study by Agrawal et al, suggested that biliray obstruction is
not a sign of inoperability.
• In their study, total 51 patients with jaundice
• Total 27% underwent resection.
• Median survival - 26 months.
• 7 patients survive more then 2 years.
• They suggested that on the basis of jaundice only, patients
should not be deferred for resection.
• Agarwal AK, Mandal S, Singh S, Bhojwani R, Sakhuja P,Uppal R. Biliary obstruction in gall bladder
cancer is not sine qua non of inoperability. Annals of surgical oncology. 2007
44. • A retrospective study by Varma and colleagues (2009)
reported that although jaundice was associated with a higher
stage at presentation, it did not preclude resection.
• Total 120 patients 89 (54%) had jaundice.
• Half of those patients 44 patients who presented with
jaundice underwent R0 resections.
• Varma V,Gupta S, Soin AS, Nundy S. Does the presence of jaundice and/or a lump in a patient with
gall bladder cancer mean that the lesion is not resectable?. Digestive surgery. 2009
45. Bile spillage
Bile spillage is likely to be an association with an
incomplete resection and systemic recurrences.
Am Surg 2011 Clinical implication of bile spillage in patients undergoing
laparoscopic cholecystectomy for gallbladder cancer. Lee JM al.
46. Surgical techniques
Staging laparosocpy
Inter aortocaval lymph node sampling
Frozen section
Extent of lymph nodal resection
Bile duct excision
Hepatic resection
Port site excision
Hepatopancreatoduodenectomy
Laparoscopic radical surgery role
47. Inter aorto caval lymph node
sampling
• Interaortocaval (16b1) lymph node (LN) involvement in
gallbladder cancer (GBC) is a sign of advanced disease with
a dismal prognosis equivalent to that of distant metastasis
• Kaneoka Y,Yamaguchi A, Isogai M, Harada T, Suzuki M. (2003) World J Surg 27:260–265.
• Kondo S, Nimura Y, Hayakawa N, Kamiya J, Nagino M, Uesaka K. (2000). Br J Surg
87:418–422.
48. • CT indicator - (size >10 mm and heterogeneous internal
architecture) of the 16b1 LN. But positive predictive value is
less.
• And that is why detection of 16b1 LNs, intraoperative biopsy
and frozen-section analysis of these nodes have been
proposed
• Noji T, Kondo S, Hirano S, Tanaka E, Ambo Y,Kawarada Y et al. (2005) CT
evaluation of para-aortic lymph node metastasis in patients with biliary cancer. J
Gastroenterol
49. • Patients with aortocaval lymh node positive had a
high preoperative CA19-9 , CEA and jaundice.
• Agarwal AK, Kalayarasan R, Javed A, Sakhuja P.. HPB: The Official Journal of the
International Hepato Pancreato Biliary Association. 2014;16
50. Frozen
section
• Although single most important factor to decide about further
treatment, there is paucity of literature regarding role of
frozen section.
• Aoki et al did study on 990 lap cholecystectomy and found that
sensitivity 64% and specificity 100%.
• Low sensitivity was due to inability to find pTis and T1
lesion.
• Aoki T, Tsuchida A, Kasuya K, et al. Is frozen section effective for diagnosis of
unsuspected gallbladder cancer during laparoscopic cholecystectomy? Surg Endosc
2002;16(1):197-200
51. • Another study, in consecutive 1793 lap cholecystectomy,
frozen done in suspicious lesion.
• Sensitivity was 90% and specificity was 100%
• Kwon AH, Imamura A, Kitade H, Kamiyama Y.Unsuspected gallbladder cancer diagnosed during
or after laparoscopic cholecystectomy. Journal of surgical oncology. 2008 Mar 1;97(3):241-5
52. Extent of lymph
nodal excision
• The lymphatic drainage of the gallbladder is via several pathways
and does not always follow a predictable drainage pattern.
• In some cases, lymph nodes associated with gallbladder cancer
can first be seen posterior to the pancreas or portal vein.
• Shirai Y,Yoshida K, Tsukada K, et al.. Br J Surg 1992; 79:659.
• Uesaka K, Yasui K, Morimoto T, et al. J Am Coll Surg 1996; 183:345.
• Ito M, Mishima Y,Sato T.. Surg Radiol Anat 1991; 13:89.
53.
54. • LN involvement seen in 35 to 80 % with ≥T2.
• LN dissection is still indicated for >T1a even when lymph node
involvement is not obvious intraoperatively.
• LN involvement is one of the best predictors of a poor outcome
after surgery (five year survival of 57% without vs 12 % with
LN metastases)
55. • D1 lymphadenectomy removes N1 lymph nodes (cystic artery,
hepatic artery, portal vein, and common bile duct)
• D2 removes additional N2 lymph nodes (periaortic, celiac
artery, superior mesenteric artery, and inferior vena cava nodes)
• Optimal extent of lymphdenectomy controversial.
• N2 lymph nodal removal is not associated with increased
survival, but it provides accurate staging.
56. • The latest edition of the American Joint Committee on Cancer
staging manual requires that at least 3 lymph nodes be removed
for proper staging of gallbladder cancer.
• American Joint Committee on Cancer Staging Manual, 7th, Edge SB, Byrd DR, Compton
CC, et al (Eds),Springer, New York 2010. p.211.
• Other experts(MSKCC) advocate removal of more (at least 6)
lymph nodes.
• Ito H, Ito K, D'Angelica M, et al. Accurate staging for gallbladder cancer: implications
for surgical therapy and pathological assessment. Ann Surg 2011; 254:320.
57. Because an extended lymphadenectomy allows for better
prognostic stratification of patients, it is suggested to
perform a D2 rather than a D1 lymphadenectomy for
gallbladder cancer when it can be performed without
substantially increasing postoperative complications.
58. Bile duct excision
• When the tumor extends into the common bile duct, or
frozen section analysis of the cystic duct margin is positive,
extrahepatic bile duct resection should be performed.
• Jayaraman S, Jarnagin WR. Management of gallbladder cancer. Gastroenterol Clin
North Am 2010; 39:331.
• Misra S, Chaturvedi A, Misra NC, Sharma ID. Carcinoma of the gallbladder. Lancet
Oncol 2003; 4:167
• Reconstruction with Roux en Y hepaticojejunosotmy.
59. • In a study by Pawlik et al, 42 percent of patients had residual
disease in the common bile duct when the cystic duct stump had
a positive margin on frozen section.
• Pawlik TM, Gleisner AL, Vigano L, et al. Incidence of finding residual disease for incidental
gallbladder carcinoma: implications for reresection. J Gastrointest Surg 2007; 11:1478.
• Some have advocated routine resection of the extrahepatic bile
ducts, regardless of the result of the cystic duct stump frozen
section, as a means to achieving a more complete
lymphadenectomy
• Shimizu Y,Ohtsuka M, Ito H, et al. Should the extrahepatic bile duct be resected for locally advanced
gallbladder cancer? Surgery 2004; 136:1012.
60. • However, several retrospective series have not shown a
survival benefit for this approach in the management of
gallbladder cancer
• Shih SP, Schulick RD, Cameron JL, et al. Gallbladder cancer: the role of laparoscopy and
radical resection. Ann Surg 2007; 245:893.
• Further supporting this view, a retrospective study found that
common duct resection does not necessarily yield a greater
lymph node count.
• Pawlik TM, Gleisner AL, Vigano L, et al. J Gastrointest Surg 2007; 11:1478.
61. Hepatic resection
The basic principle is achieving a negative surgical margin, while
preserving the maximal amount of liver parenchyma.
The rational of resection includes:
Resection of liver invaded or likely to be invaded
directly by the tumor.
To remove micro-metastasis in segment 4b + 5 as a
result of direct venous drainage of gallbladder through
cystic vein to these segments,
To resect en bloc Glisson’s sheath because of potential
invasion of hepatoduodenal ligament.
62. In extended cholecystectomy -removal of at least a 2 cm
margin of liver adjacent the gallbladder bed.
Veins from the gallbladder drain mostly into the middle hepatic
vein provide support for anatomic IVb/V resection over
nonanatomic resection, but no randomised data available to
support the fact.
Also anatomic approach reduces the risk for bleeding or bile
leakage.
Scheingraber S, Justinger C, Stremovskaia T, et al. The standardized surgical approach
improves outcome of gallbladder cancer. World J Surg Oncol 2007
63. At present either non anatomical or anatomical resection can
be done.
The standard resection is an anatomic resection of segments
IVb and V, but it is possible to do a smaller wedge resection
for early-stage cancers with no radiographic disease in the
liver.
Blumgart’s Surgery of liver, biliary tract and pancreas 6th
edition
64. • Right extended hemihepatectomy should be performed, if
possible, for tumors of the body or neck that involve the
right portal triad or with inflammation distinction between
tumor and scar is obscured .
• Bartlett DL. Gallbladder cancer. Semin Surg Oncol 2000
65. • Horiguchi et al. compared these two methods of Gb bed
resection and segment 4b and 5 resection
• They analyzed 85 patients with pT2N0 GBC with a median
follow-up of 85 months:
• No difference in 5-year survival rate (p = 0.53) and disease
free survival rate (p = 0.23). No difference in incidence of
recurrence in two groups (p = 0.39).
• Horiguchi A, Miyakawa S, Ishihara S, et al.. J Hepatobiliary Pancreat Sci
2013
• Araida et al. conducted a questionnaire-based retrospective study
of 4243 cases of GBC reporated same.
Araida T, Higuchi R, Hamano M, et al. J Hepatobiliary Pancreat Surg 2009;16(2):204-15.
66. • K.reddy et al did a study on extended hepatectomy.
– Portal vein embolization.
• estimated volume of the future liver remnant - 25%.
– 22 curative hepatic resection - 11 extended hepatectomy - 4 of 11
preoperative PVE
– 3-year overall and recurrence-free survival - 72% and 68%.
Reddy SK, et al. Extended hepatic resection for gallbladder cancer. The American Journal of
Surgery. 2007
67. Port site
excision• After laproscopic manipulation, port site recurrences have been
described.
• Maker AV,Butte JM, Oxenberg J, et al. Is port site resection necessary in the surgical
management of gallbladder cancer? Ann Surg Oncol 2012; 19:409.
• Nowadays radical resection does not require resection of
the previous laparoscopy port sites.
68. • If tumor is found in the port sites, is a marker for peritoneal
spread and removal of the port sites will not be curative.
• Port site resection is not associated with overall survival or
recurrence-free survival.
• Yamaguchi K, Chijiiwa K, Ichimiya H, et al. Gallbladder carcinoma in the era of
laparoscopic cholecystectomy. Arch Surg 1996; 131:981.
• Giuliante F,Ardito F, Vellone M, et al. Portsites excision for gallbladder cancer
incidentally found after laparoscopic cholecystectomy. Am J Surg 2006;
191:114.18.
69. Hepatopancretoduodenecto
my
• The philosophy of achieving of R‘0’ resection
• In advanced GBC with adjacent organ removal including
hepatopancreaticoduodenectomy (HPD).
• Reasons –
• First is the direct invasion of pancreas or duodenum
• Second to facilitate excision of densely adherent
peripancreatic lymph nodes.
• Former indication is usually considered worth HPD as survival
is likely to be more after R‘0’ resection is achieved.
70. • The second indication (lymphadenectomy) is not well accepted
as lymph nodes in itself is a poor prognostic feature and high
postoperative morbidity and mortality.
• Sakamoto Y,Nara S, Kishi Y,et al. Surgery 2013
• Lim CS, Jang JY, Lee SE, et al. Reappraisal of hepatopancreatoduodenectomy as a treatment
modality for bile duct and gallbladder cancer. J Gastrointest Surg 2012;
• Araida T,Yoshikawa T,Azuma T, et al.. J Hepatobiliary Pancreat Surg 2004
71. Laparosocpic radical
surgery
• Traditionally, laparoscopic surgery has not been routinely
recommended in the non incidental setting.
• Recent studies suggesting equivalent outcomes between
laparoscopic and open approaches.
• Robotic-assisted procedures have also been described and are
carried out.
72.
73.
74. Adjuvant therapy
• Despite conflicting data, limited level I data.
• Currently, gemcitabine-based regimens, often combined with a
platinum agent, have become the most common choice for
treating gallbladder cancer
• Gemcitabine shown to improve median overall survival (9.5
months).
• Sharma A, Dwary AD, Mohanti BK, et al. Best supportive care compared with chemotherapy for
unresectable gall bladder cancer: a randomized controlled study. J Clin Oncol 2010;28:4581–6.
75. • Japanese multi-institutional trial, randomized resection
followed by adjuvant mitomycin and 5-FU vs resection
alone.
• The study showed 5-year survivals of 20.3% vs 11.6% in
favor of adjuvant therapy in patients with gallbladder cancer.
• Takada T,Amano H, Yasuda H, et al. Is postoperative adjuvant chemotherapy useful for
gallbladder carcinoma? A phase III multicenter prospective randomized controlled trial in
patients with resected pancreaticobiliary carcinoma. Cancer 2002;95:1685–95
76. • Most recently, a phase II trial combining gemcitabine,
capecitabine, and radiation therapy in patients with
extrahepatic biliary tract and gallbladder cancers showed
promising results.
• Ben-Josef E, Guthrie KA, El-Khoueiry AB, et al. SWOG S0809: a phase II intergroup trial of
adjuvant capecitabine and gemcitabine followed by radiotherapy and concurrent capecitabine in
extrahepatic cholangiocarcinoma
77. Neoadjuvant therapy
• Neoadjuvant chemotherapy is thought to provide an
opportunity to be determine, biologically aggressive tumors
who, arguably, may not benefit from extensive operations.
• Small case series suggested gemcitabine-platinum based
combinations have some role.
• Sirohi B, Rastogi S, Singh A, et al. Use of gemcitabine-platinum in Indian patients
with advanced gall bladder cancer. Future Oncol 2015
• Kato A, Shimizu et al. Surgical resection after downsizing
chemotherapy for initially unresectable locally advanced biliary tract
cancer: a retrospective single-center study. Ann Surg Oncol 2013.
78. • In a recent study from the MD Anderson Cancer Center, a
retrospective review of their gallbladder cancers resected
with wide 1-cm negative margins and received either
neoadjuvant or adjuvant therapy. 5 year survival was 50.6%.
• Adjuvant therapy showed no improvement in survival, and
neoadjuvant treatment had only served to significantly delay
time to operation in their study.
• Glazer ES, Liu P,Abdalla EK, et al. Neither neoadjuvant nor adjuvant therapy
increases survival after biliary tract cancer resection with wide negative margins. J
Gastrointest Surg 2012;16:1666–71.
79. Palliative procedures
Pallation for jaundice, upper abdominal pain, and symptoms of biliary
obstruction
Methods
• Simple cholecystectomy.
• Endoscopic or percutaneous biliary drainage
• Endoscopic stenting or intestinal bypass
• Biliary bypass –in patients who can tolerate surgery is biliary bypass, but
many patients fail these procedures with recurrent obstruction.
In one study, intrahepatic segment III cholangiojejunostomy and staying
away from the hepatoduodenal ligament, the most common site of disease
progression, successfully palliated the majority of patients.
Kapoor VK, Pradeep R, Haribhakti SP, et al. Intrahepatic segment III cholangiojejunostomy in advanced carcinoma of the
gallbladder. Br J Surg 1996
80. Summary
• Surgery is the only curative option.
• High index of clinical suspicion should be kept in mind.
• 0.2% to 3% of all lap cholecystectomy specimen shows GB
cancer.
• Pre op imaging – CT dual phase angio- assessment of hepatic
reserve.
• All patients should undergo staging laparoscopy, aorto caval
lymph node sampling and cystic duct margin frozen.
81. • Jaundice indicates advanced disease but not precluding
resection.
• Radical cholecystectomy – liver bed excision with
lymphdenectomy with or without bile duct excision is the
treatment of choice.
• N1 group of lymph node removal, N2 to stage the disease
unresectable.
• AJCC 3, MSKCC 6 lymph node removal.
• Bile duct excision frozen positive/ ischemia/ trauma
82. • T1a tumor bile spillage or cystic duct margin?
• T1b and further completion cholecystectomy
• No clear cut role of neoadjuvant therapy.
• Adjuvant therapy advised in node positive, T2 tumors, R1
margin, poor differentiation.