Mark A. Talamini

Objectives: We assess how laparoscopy has altered the presentation of patients with gallbladder cancer and determine whether radical resection in patients with gallbladder cancer is beneficial. Summary Background Data: The widespread adoption of laparoscopic cholecystectomy has led to an increased frequency of incidentally discovered gallbladder carcinoma. Little data exist to guide surgeons in the optimum management of patients with gallbladder cancer, particularly with respect to the potential advantages of radical resection. Methods: Records of 107 patients with gallbladder cancer admitted to a tertiary academic medical center between 1995 and 2004 were reviewed. Gallbladder cancer was found incidentally in 53 patients (50%). Fifty-two of these patients underwent a routine laparoscopic cholecystectomy and were found to have gallbladder cancer intraoperatively or following the operation by subsequent pathologic evaluation of the specimen. Gallbladder cancer had been diagnosed preoperatively by radiology in the other 54 patients (50%). These patients did not undergo laparoscopic cholecystectomy and were explored electively. Results: The median age at presentation was 67 years and 66% were female. Patients who were found to have gallbladder carcinoma incidentally at laparoscopic cholecystectomy had a significant increase in survival when compared with those who were admitted electively with a known diagnosis (P < 0.001). All patients who presented with a known diagnosis had stage II or greater disease, and 36% of these were stage IV carcinomas. However, 82% of those patients who were found incidentally were stage I or II. The overall 5-year survival for all patients was 15%; those discovered incidentally at laparoscopic cholecystectomy had a 5-year survival of 33%. This difference was significant among patients with stage II carcinomas. In the laparoscopic group, there was no difference in survival between the patients who were immediately converted to an open resection when identified to have gallbladder cancer intraoperatively (n = 6) and those who had a completed laparoscopic cholecystectomy and were re-explored at a later point when found to have gallbladder cancer by subsequent pathology (n = 33). There was a significant improvement in survival in 50 patients (47%) who underwent some form of radical resection (P < 0.001). Stage for stage comparison showed that this was significant in stage II disease. Patients who underwent hepatic resection along with lymphadenectomy and extra hepatic biliary resection had similar survival compared with those who had hepatic resection and lymphadenectomy alone. Conclusions: Laparoscopic cholecystectomy appears to have resulted in the earlier discovery of gallbladder cancer in some patients, resulting in increased probability of survival. Patients discovered with gallbladder carcinoma during a laparoscopic cholecystectomy do not have to be converted immediately to an open resection and should be referred to a tertiary care center for further exploration. Adjunctive radical surgical resection, either at the time of cholecystectomy or subsequently, increases survival significantly in early stage disease.

Carbon dioxide (CO₂) pneumoperitoneum alters the inflammatory response in animal models of sepsis. The spleen is a key organ in inflammation and its removal was predicted to modify this effect. The acute phase inflammatory response to lipopolysaccharide (LPS) challenge in male rats was examined for the effects of splenectomy (spx) and the technique of removal (open or laparpscopic). A series of experiments compared LPS-only controls with LPS injection 2 or 9 days following open spx, lap CO₂ spx, open sham, or lap CO₂ sham. The method of splenectomy was studied by randomization to control, open spx, lap CO₂ spx, lap helium (He) spx, or lap air spx with LPS challenge on postoperative day 2. Serum levels of tumor necrosis factor-α (TNF-α), interferon-γ (INF-γ) and, interleutin (IL) 10 were collected at multiple time points, assayed by commercial enzyme-linked immunosorbent assay, analyzed by analysis of variance. Levels of TNF-α at 1.5 were significantly lower following open sham than following lap sham (p < 0.05). Splenectomy drastically reduced INF-γ and TNF-α levels compared to controls (p < 0.05) on postoperative day 2. No method of spx preserved TNF-α or INF-γ responses. Recovery of TNF-α response on day 9 was delayed in the spx groups. Splenectomy dramatically reduces TNF-α and INF-γ responses to LPS challenge, although by different mechanisms. Pneumoperitoneum-mediated modulation of the septic inflammatory response is partially dependent on the spleen.