D. Berger-Richardson1, T. Chesney1, M. Englesakis3, S. Cleary1,3, A. Govindarajan1,2, C. Swallow1,2 1University Of Toronto,Division Of General Surgery,Toronto, ONTARIO, Canada 2Mount Sinai Hospital,Toronto, ONTARIO, Canada 3University Health Network,Toronto, Ontario, Canada
Introduction: Laparoscopic cholecystectomy for the treatment of symptomatic cholelithiasis was rapidly adopted in the early 1990’s. However, there were early reports of port-site metastasis (PSM) when incidental gallbladder adenocarcinoma (GBCA) was discovered in the specimen after surgery. In a review of cases up until 1999, the estimated incidence of PSM in incidental GBCA was reported to be 14%. Recognition of this phenomenon may have prompted changes in surgical technique, and we questioned whether the incidence of port-site metastasis has changed since then. Furthermore, direct contact between the specimen and wound edges during extraction is one of the possible mechanisms of PSM. Determining the incidence of both extraction and non-extraction port PSMs may provide insight into this hypothesis. Hypothesis: 1) The risk of PSM following resection of GBCA has decreased over the past fifteen years. 2) Extraction ports are more likely to harbour recurrence than non-extraction ports.
Methods: A systematic review of articles related to wound recurrence of GBCA was conducted by two independent reviewers. Inclusion criteria for our first objective of determining the modern incidence of PSM were English language papers reporting the presence or absence of PSM following a minimum of 5 cholecystectomies harbouring GBCA published from 2000 – 2014, the 15 year period following the previous review. Inclusion criteria for our second objective of determining the location of the port site involved include English language papers reporting the presence of PSM following laparoscopic cholecystectomy in the setting of GBCA, without limiting this search temporally or by study size.
Results:5448 abstracts were screened. 23 published case series met criteria for estimating the modern incidence of PSM in GBCA. PSM were found in 73 of 728 patients (incidence=10%). Results from the two largest studies using prospectively collected databases (n= 114 and n= 96) had PSM incidences of 14% and 15% respectively. With respect to the pattern of PSM, data was extracted from 98 papers meeting inclusion criteria. More than 305 individual port sites have been reported to harbour recurrence in 236 patients with GBCA (number of PSM/ person = 1-4). Of those with decipherable location (extraction vs non-extraction) (n=190) based on description within the paper, 53% occurred at extraction ports compared to 47% at non-extraction ports (p=0.526).
Conclusion:Despite the implementation of techniques for risk reduction, the incidence of PSM following gallbladder cancer resection is stable at 10-15%. Recurrence at non-extraction ports may indicate mechanism(s) other than direct contact with the wound during extraction. Studies into mechanisms of PSM are warranted. Preoperative imaging studies should be carefully reviewed to minimize inappropriate laparoscopic resection of gallbladder cancer.