1. Speaker Dr. Mohammed Abu Khair IMO, SU-3 Chairman Dr. Md. Ashraf Uddin Associate professor, SU-3

2. Incidental gallbladder cancer diagnosed during or after laparoscopic cholecystectomy with gallstone disease

3. Source: Turk J Gastroenterol. Author: Volkan GENC, Elvan ONUR KIRIMKER, Cihangir AKYOL, Akin Firat KOCAAY, Ayea KARABORK, Acer TUZUNAR, Esra ERDEN, Kaan KARAYALCIN. Published on: 2011; 22 (5): 513-516.

4. Background: Gallbladder cancer is a rare neoplasm that is diagnosed incidentally during or after laparoscopic cholecystectomy performed for gallstone disease.

5. Introduction: Gallbladder cancer is the fifth most common cancer of gastrointestinal tract. About 15-30 % of patients show no pre and post-operative evidence of gallbladder cancer. Laparoscopic cholecystectomy (LC) is the goldstandard treatment for gallstone disease and the incidence of gallbladder cancer following LC is 0.2- 2.85 %.

6. Risk factors: 1.Gallstone disease. 2.Porcelain gallbladder. 3.Sclerosing cholangitis. 4.Advanced age.

7. Risk factors (continue): Ultrasound examination. Single large gallstone casting an ‘acoustic shadow’

8. Risk factors(continue): Plain radiograph showing radio-opaque stones in the gall bladder.

9. Risk factors (continue): Porcelain gallbladder

10. Risk factors (continue): Sclerosing cholangitis in a patient with ulcerative colitis

11. Materials and Methods: An observational (retrospective) study was conducted on 5164 patients who underwent laparoscopic cholecystectomy in the surgery department of Ankara University Medical Faculty from may 1999 to 2010. Pre-operatively all patients were assessed by liver function test (LFT), abdominal ultrasonography of hepatobiliary system.

12. Materials and Methods: Inclusion criteria: Patients with gallstone disease undergoing laparoscopic cholecystectomy. Exclusion criteria: Suspicion of malignancy and or gallbladder polyp detected on pre-operative ultrasonography.

13. Materials and Methods: Operative procedure: All the operations were conducted by senior surgeons and trainees under supervision using four-port, two-hand technique. Intraoperative cholangiogram and drains were used where applicable.

14. Materials and Methods: Operative procedure of laparoscopic Cholecystectomy

15. Materials and Methods: Operative procedure (continue): During surgical intervention gallbladder was assessed, abnormal gallbladder was found in 98 patients, in remaining patients morphology of gallbladder was normal.

16. Materials and Methods: Operative procedure (continue): Irregularity and nodularity of the gallbladder wall was the suspicion of cancer. No bag was used to extract the gallbladder and there was no evidence of port site metastasis.

17. Materials and Methods: All the relevant information of the patients regarding demography, operative procedure, peri-operative outcome, histopathology, follow-up was recorded in a pre-designed data collection sheet. In the post-operative period they were followed up with clinical examination; serum CEA, CA 19-9 level; ultrasound and CT scan.

18. Results: Out of 5382 patients 5164 patients were included in this study. Patients with polyps (n=202) and suspecion of malignancy (n=16) before surgery were excluded from this study.

19. Results (continue): Mean age of the patients was 49.3 ± 11.1 years (from 16-89 years) and 3594 (69.6 %) patients were female. Male to female ratio was 1:2.3

20. Results (continue): Out of 5164 patients adenocarcinoma was diagnosed in only 5 (4 female and 1 male ) patients (0.09%). Mean age of this group was 66.2±14.2 years and was significantly higher in comparison to the remaining population (p<0.001). 80% of the malignant patients were > 60 years of age.

21. Results (continue): Age and sex distribution of Malignant patients: Patient No.Age (years)SexDiagnosis 1.76FPost-operatively 2.75FPost-operatively 3.42MIntra-operatively 4.65FIntra-operatively 5.73FIntra-operatively

22. Results (continue): All the patients with adenocarcinoma presented with cholecystitis without jaundice. Three patients were converted to open surgery as frozen section biopsy reveled carcinoma.

23. Results (continue): In two patients there was no suspicion of malignancy intra-operatively but routine histopathology report reveled malignancy and they underwent only LC due to low stage (pTis, pT1b).

24. Results (continue): Tumor staging was performed on American Joint Committee on Cancer (AJCC), 7 th edition. Only one patient had pTis, one had pT1b, pT2 in one and pT3 in two patients. No patient had pT4 disease or metastasis. Median survival rate was 32 months (8.1- 68 months).

25. Results (continue): Stage, operation and outcome of malignant patients : StageOperationOutcome pT1bLC (no additional surgery)No evidence of disease, 7m pTisLC (no additional surgery)No evidence of disease, 22m pT3Converted from LC to OC + LBx + LND No evidence of disease, 52m pT2Converted from LC to OC + LBx + LND No evidence of disease, 32m pT3Converted from LC to OC + LBx + LND Died of MI, 15m

26. Results (continue): One of the five patients died with acute myocardial infarction, 15 months after operation without recurrence. Remaining four patients were alive without any complication.

27. Discussion: Gallbladder carcinoma is not an uncommon health problem with poor prognosis. Incidence is highest in Woman from India, Chile, and Pakistan. Incidence of incidentally diagnosed gallbladder cancer is up to 2.85% but recently the incidence has raised. In this study this value was 0.09%.

28. Discussion (continue): This was the lowest rate in the published English literature, possible cause may be due to diagnosis at advanced stage due to avoidance of elective cholecystectomy. Advanced age and female persons are more susceptible to this type of deadly disease.

29. Discussion (continue): In this study ratio of incidentally diagnosed cancer in male and female is 1:4 and the mean age of this group was significantly higher in comparison to the remaining patients. Median survival for this group was 32 months (8.1- 68 months).

30. Discussion (continue): Surgical resection of gallbladder carcinoma depends upon the stage of the disease. One patient with pTis and one patient with pT1b underwent simple cholecystectomy. Many authors advocated only cholecystectomy is sufficient for pT1a tumor but necessity of further surgery for pT1b is controversial.

31. Discussion (continue): Staging (AJCC): Primary tumor (T): TX Primary tumor can not be assessed. T0No evidence of primary tumor. TisCarcinoma in situ. T1Tumor invades lamina propria or muscle layer. T1aTumor invades lamina propria. T1bTumor invades muscle layer. T2Tumor invades peri-muscular connective tissue, no extension beyond serosa or liver involvement. T3Tumor perforates the serosa and invades the liver or other organs like stomach, duodenum, colon, pancreas, omentum, extra hepatic bile duct. T4Tumor invades portal vein, hepatic artery or at least two extra hepatic organs.

32. Discussion (continue): Staging (AJJCC): Regional lymph node (N): NXRegional lymph node can not be assessed. N0No regional lymph node metastasis. N1Metastasis to lymph nodes to cystic duct, common bile duct, hepatic artery and/ or portal vein. N2Metastasis to peri-aortic, peri-caval, superior mesenteric artery and/ or celiac artery lymph node.

33. Discussion (continue): Staging (AJJCC): Distant metastasis (M): M0 No distant metastasis. M1 Distant metastasis.

34. Anatomic stage: StageTNM 0TisN0M0 IT1N0M0 IIT2N0M0 IIIAT3N0M0 IIIBT1-3N1M0 IVAT4N0-1M0 IVBAny TN2M0 Any TAny NM1

35. Discussion (continue): For pT2 tumor liver resection and lymph node dissection was mandatory and for pT3 was also managed by same procedure but long time survival rate was only 5%. In this study only one patient with pT2 and two patient with pT3 patient received same type of surgical intervention.

36. Conclusion: The incidence of incidentally diagnosed carcinoma gallbladder vary from center to center, up to 2.85%. Study conducted in the department of surgery Ankara University Medical Faculty the incidence rate was 0.09%. Female persons and aged persons are more susceptible to this type of gravely disease. But if diagnosed early prognosis is better.