The prognostic importance of jaundice in surgical resection with curative intent for gallbladder cancer

BMC Cancer

Xin-wei Yang³  Jian-mao Yuan²  Jun-yi Chen¹  Jue Yang³  Quan-gen Gao²  Xing-zhou Yan³  Bao-hua Zhang³  Shen Feng³  Meng-chao Wu³ 

[1] Department of General Surgery, Branch of the first People’s Hospital of Shanghai, North Sichuang Road 1878, Shanghai 200081, China

[2] Department of General Surgery, The First People’s Hospital of Wujiang affliated Wujiang Hospital of Nantong University, Suzhou, China

[3] Eastern Hepatobiliary Surgery Hospital, Second Military Medical University, Changhai Road 225, Shanghai 200438, China

关键词: Prognosis;    Preoperative biliary drainage;    Curative resection;    Jaundice;    Gallbladder cancer;   

Others  :  1121111
DOI  :  10.1186/1471-2407-14-652

 received in 2014-05-01, accepted in 2014-08-30,  发布年份 2014

【 摘 要 】

Background

Preoperative jaundice is frequent in gallbladder cancer (GBC) and indicates advanced disease. Resection is rarely recommended to treat advanced GBC. An aggressive surgical approach for advanced GBC remains lacking because of the association of this disease with serious postoperative complications and poor prognosis. This study aims to re-assess the prognostic value of jaundice for the morbidity, mortality, and survival of GBC patients who underwent surgical resection with curative intent.

Methods

GBC patients who underwent surgical resection with curative intent at a single institution between January 2003 and December 2012 were identified from a prospectively maintained database.

Results

A total of 192 patients underwent surgical resection with curative intent, of whom 47 had preoperative jaundice and 145 had none. Compared with the non-jaundiced patients, the jaundiced patients had significantly longer operative time (p < 0.001) and more intra-operative bleeding (p = 0.001), frequent combined resections of adjacent organs (23.4% vs. 2.8%, p = 0.001), and postoperative complications (12.4% vs. 34%, p = 0.001). Multivariate analysis showed that preoperative jaundice was the only independent predictor of postoperative complications. The jaundiced patients had lower survival rates than the non-jaundiced patients (p < 0.001). However, lymph node metastasis and gallbladder neck tumors were the only significant risk factors of poor prognosis. Non-curative resection was the only independent predictor of poor prognosis among the jaundiced patients. The survival rates of the jaundiced patients with preoperative biliary drainage (PBD) were similar to those of the jaundiced patients without PBD (p = 0.968). No significant differences in the rate of postoperative intra-abdominal abscesses were found between the jaundiced patients with and without PBD (n = 4, 21.1% vs. n = 5, 17.9%, p = 0.787).

Conclusions

Preoperative jaundice indicates poor prognosis and high postoperative morbidity but is not a surgical contraindication. Gallbladder neck tumors significantly increase the surgical difficulty and reduce the opportunities for radical resection. Gallbladder neck tumors can independently predict poor outcome. PBD correlates with neither a low rate of postoperative intra-abdominal abscesses nor a high survival rate.

【 授权许可】

   
2014 yang et al.; licensee BioMed Central Ltd.

【 图 表 】

Figure 1.

Figure 2.

Figure 3.

Figure 4.

Figure 5.

【 参考文献 】

• [1]Nishio H, Kamiya J, Nagino M, Uesaka K, Sano T, Nimura Y: Biliobiliary fistula associated with gallbladder carcinoma. Br J Surg 2000, 87:1656-1657.
• [2]Misra S, Chaturvedi A, Misra NC, Sharma ID: Carcinoma of the gallbladder. Lancet Oncol 2003, 4:167-176.
• [3]Fong Y, Jarnagin W, Blumgart LH: Gallbladder cancer: comparison of patients presenting initially for definitive operation with those presenting after prior noncurative intervention. Ann Surg 2000, 232:557-569.
• [4]D’Angelica M, Dalal KM, DeMatteo RP, Fong Y, Blumgart LH, Jarnagin WR: Analysis of the extent of resection for adenocarcinoma of the gallbladder. Ann Surg Oncol 2009, 16:806-816.
• [5]Dixon E, Vollmer CM Jr, Sahajpal A, Cattral M, Grant D, Doig C, Hemming A, Taylor B, Langer B, Greig P, Gallinger S: An aggressive surgical approach leads to improved survival in patients with gallbladder cancer: a 12-year study at a North American Center. Ann Surg 2005, 241:385-394.
• [6]Pilgrim C, Usatoff V, Evans PM: A review of the surgical strategies for the management of gallbladder carcinoma based on T stage and growth type of the tumour. Eur J Surg Oncol 2009, 35:903-907.
• [7]Shih SP, Schulick RD, Cameron JL, Lillemoe KD, Pitt HA, Choti MA, Campbell KA, Yeo CJ, Talamini MA: Gallbladder cancer: the role of laparoscopy and radical resection. Ann Surg 2007, 245:893-901.
• [8]Regimbeau JM, Fuks D, Bachellier P, Le Treut YP, Pruvot FR, Navarro F, Chiche L, Farges O: Prognostic value of jaundice in patients with gallbladder cancer by the AFC-GBC-2009 study group. Eur J Surg Oncol 2011, 37:505-512.
• [9]Nishio H, Ebata T, Yokoyama Y, Igami T, Sugawara G, Nagino M: Gallbladder cancer involving the extrahepatic bile duct is worthy of resection. Ann Surg 2011, 253:953-960.
• [10]International Union Against Cancer: TNM Classification of Malignant Tumors. 7th edition. New York: Wiley; 2009.
• [11]Clavien PA, Barkun J, de Oliveira ML, Vauthey JN, Dindo D, Schulick RD, de Santibañes E, Pekolj J, Slankamenac K, Bassi C, Graf R, Vonlanthen R, Padbury R, Cameron JL, Makuuchi M: The Clavien-Dindo classification of surgical complications: five-year experience. Ann Surg 2009, 250:187-196.
• [12]Liu F, Li Y, Wei Y, Li B: Preoperative biliary drainage before resection for hilar cholangiocarcinoma: whether or not? A systematic review. Dig Dis Sci 2011, 56:663-672.
• [13]Cherqui D, Benoist S, Malassagne B, Humeres R, Rodriguez V, Fagniez PL: Major liver resection for carcinoma in jaundiced patients without preoperative biliary drainage. Arch Surg 2000, 135:302-308.
• [14]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. Ann Surg Oncol 2007, 14:2831-2837.
• [15]Lai EC, Chu KM, Lo CY, Mok FP, Fan ST, Lo CM, Wong J: Surgery for malignant obstructive jaundice: analysis of mortality. Surgery 1992, 112:891-896.
• [16]McPherson GA, Benjamin IS, Hodgson HJ, Bowley NB, Allison DJ, Blumgart LH: Pre-operative percutaneous transhepatic biliary drainage: the results of a controlled trial. Br J Surg 1984, 71:371-375.
• [17]Pitt HA, Gomes AS, Lois JF, Mann LL, Deutsch LS, Longmire WP Jr: Does preoperative percutaneous biliary drainage reduce operative risk or increase hospital cost? Ann Surg 1985, 201:545-553.
• [18]Su CH, P’eng FK, Lui WY: Factors affecting morbidity and mortality in biliary tract surgery. World J Surg 1992, 16:536-540.
• [19]Bhalala M, Rude K, Wang A, Sauer B, White GE, Kahaleh M, Shami VM: Analysis of complications after EUS-FNA in patients with obstructive jaundice and drained with plastic biliary stents or self-expandable metal stent (SEMS): do complications differ between the type of stent? J Interv Gastroenterol 2013, 3:128-132.
• [20]Saiki S, Chijiiwa K, Komura M, Yamaguchi K, Kuroki S, Tanaka M: Preoperative internal biliary drainage is superior to external biliary drainage in liver regeneration and function after hepatectomy in obstructive jaundiced rats. Ann Surg 1999, 230:655-662.
• [21]Vauthey JN, Blumgart LH: Recent advances in the management of cholangiocarcinomas. Semin Liver Dis 1994, 14:109-114.
• [22]Clements WD, Diamond T, McCrory DC, Rowlands BJ: Biliary drainage in obstructive jaundice: experimental and clinical aspects. Br J Surg 1993, 80:834-842.
• [23]Sewnath ME, Karsten TM, Prins MH, Rauws EJ, Obertop H, Gouma DJ: A meta-analysis on the efficacy of preoperative biliary drainage for tumors causing obstructive jaundice. Ann Surg 2002, 236:17-27.
• [24]Yang XW, Yang J, Li L, Man XB, Zhang BH, Shen F, Wu MC: Analysis of the relationships between clinicopathologic factors and survival in gallbladder cancer following surgical resection with curative intent. PLoS One 2012, 7:e51513.
• [25]Pilgrim CH, Usatoff V, Evans P: Consideration of anatomical structures relevant to the surgical strategy for managing gallbladder carcinoma. Eur J Surg Oncol 2009, 35:1131-1136.
• [26]Kondo S, Hirano S, Tanaka E, Tsuchikawa T, Kato K, Matsumoto J, Nasu Y, Shichinohe T: Two types of extended liver resection for advanced gallbladder cancer: how to do it. Dig Surg 2011, 28:148-153.
• [27]Shimada K, Nara S, Esaki M, Sakamoto Y, Kosuge T, Hiraoka N: Extended right hemi- hepatectomy for gallbladder carcinoma involving the hepatic hilum. Br J Surg 2011, 98:117-123.
• [28]Shimizu Y, Ohtsuka M, Ito H, Kimura F, Shimizu H, Togawa A, Yoshidome H, Kato A, Miyazaki M: Should the extrahepatic bile duct be resected for locally advanced gallbladder cancer? Surgery 2004, 136:1012-1017.
• [29]Foster JM, Hoshi H, Gibbs JF, Iyer R, Javle M, Chu Q, Kuvshinoff B: Gallbladder cancer: defining the indications for primary radical resection and radical re-resection. Ann Surg Oncol 2007, 14:833-840.
• [30]Wakai T, Shirai Y, Tsuchiya Y, Nomura T, Akazawa K, Hatakeyama K: Combined major hepatectomy and pancreaticoduodenectomy for locally advanced biliary carcinoma: long-term results. World J Surg 2008, 32:1067-1074.
• [31]Araida T, Yoshikawa T, Azuma T, Ota T, Takasaki K, Hanyu F: Indications for pancreatoduodenectomy in patients undergoing lymphadenectomy for advanced gallbladder carcinoma. J Hepatobiliary Pancreat Surg 2004, 11:45-49.
• [32]Kondo S, Nimura Y, Kamiya J, Nagino M, Kanai M, Uesaka K, Yuasa N, Sano T, Hayakawa N: Factors influencing postoperative hospital mortality and long-term survival after radical resection for stage IV gallbladder carcinoma. World J Surg 2003, 27:272-277.