Georgios V Georgakis, MD, PhD, David L Bartlett, MD, Amer H Zureikat, MD, Herbert J Zeh, MD, Melissa E Hogg, MD, MS. University of Pittsburgh Medical Center, Division of Surgical Oncology
Introduction: Minimally invasive surgery (MIS) continues to grow within surgical oncology. With the robotic platform, complex surgeries can be done safely and effectively through small incisions. Gallbladder cancer is very rare and liver resection with portal lymphadenectomy is the only curative therapy. The introduction of MIS in the treatment of the gallbladder cancer has not been studied. We aim to evaluate outcomes of patients with gallbladder cancer undergoing MIS compared to open central hepatectomy.
Methods and Procedures: Using the institutional cancer registry and surginet databases, we retrospectively reviewed patients who underwent a central hepatectomy with portal lymphadenectomy for gallbladder cancer from 2011-2014. Gallbladder cancer patients with metastatic disease, undergoing chemoperfusion, or without definitive surgery were excluded. Surgeries were analyzed by MIS, robotic (14) and laparoscopic (3), compared to open (17) surgery.
Results: There was no difference in BMI, but MIS patients were younger than open patients (64 versus 76 years respectively; p=0.0043). No difference in mean operative time was seen in MIS versus open cohorts: 185.1 and 241.7 minutes respectively (p=0.23). The mean EBL was less in MIS versus open cohorts: 144.2 ml and 350.3 ml respectively (p=0.006). Increased operative time was correlated with increased blood loss in the both cohorts (MIS: p=0.01; Open: p=0.0009). Peri-hepatic drains were placed less frequently in MIS (29.4%) compared to open cohorts (76.5%; p=0.01). R0 resection rate was 88.3% in both cohorts (p=1.0). ICU admission postop for the MIS and open cohorts was 29.4% for both groups (p=1.0). No difference in diet initiation was noted with a median postoperative day 3 for both (p=0.24). MIS cohort were converted to oral pain medications quicker (median 2 versus 3 days respectively; p=0.022) and discharged home earlier (median 4 days versus 6 days; p=0.018), than the open cohort. There was no postoperative 30-day mortality and complication rates were 52.9% in both cohorts (p=1.0). Clavien 1 and 2 complications were seen in 52.9% (MIS) and 47.1% (open). In the open cohort there was one bile leak and one re-operation for a fascial dehiscence (Clavien 3). There was a trend, but no statistically significant difference in median overall survival between the two groups (MIS: not reached versus open: 20 months; p=0.092).
Conclusion: Our data suggest that the minimally invasive, especially the robotic, approach to liver surgery is a safe and equally effective technique for the management of the gallbladder cancer with improvement in blood loss and length of stay.