Gallbladder carcinoma during laparoscopic cholecystectomy: is it associated with bad prognosis?

Laparoscopic cholecystectomy is the treatment of choice for gallstone disease. The ultrasonogram has failed for the early detection of gallbladder cancer, especially if inflammation (chronic or acute) is present. Incidental gallbladder could be an important cancer finding during laparoscopic cholecystectomy, due to the potential cancer cell dissemination during the procedure. In our Department, 6500 laparoscopic cholecystectomies have been performed in the last 5 years and in 15 cases (0.23%) gallbladder cancer was found during surgery or after histological examination of the resected gallbladder. In none of these 15 patients was pre-operative diagnosis of gallbladder carcinoma postulated. When re-evaluation of the pre-operative ultrasonograms was done, it was possible to observe signs suggesting the presence of neoplastic infiltration in 4 of them (28.6%). During videoscopic exploration, also in 4 patients, the suspicion of gallbladder cancer was noted. Laparoscopic cholecystectomy was completed in 9 patients. In 2 of them, in situ or mucosal invasion was demonstrated with a long survival. One patient presented recurrence at the biliary hilum 2,5 years after surgery. Six patients were re-operated and in 4 of them peritoneal or port site metastasis was found; all died early (4.5 month median survival). The other 2 patients were submitted to liver bed resection and lymph node dissection. These patients are free of cancer recurrence after 15 months of follow-up. Six patients were converted to open surgery, performing palliative procedures and died before the 12 month follow-up. The suspicion of pre-operative gallbladder cancer is generally unlikely to be confirmed based on ultrasonographic signs; but, in some cases with high suspicion, further investigation (TAC, tumor markers, etc.) must be indicated in order to avoid poor results. Laparoscopic cholecystectomy could be associated with bad prognosis, and then, when gallbladder cancer is suspected during the laparoscopic procedure, conversion to open surgery could be the best choice.