Retrospective Study
Copyright ©The Author(s) 2020.
World J Hepatol. Sep 27, 2020; 12(9): 641-660
Published online Sep 27, 2020. doi: 10.4254/wjh.v12.i9.641
Table 1 Preoperative evaluation, chemotherapy and/or radiation, and the final stage
CaseSymptomatic (Yes or No)Preoperative biliary drainage (Yes or No)PBM (Yes or No)Preoperative diagnosis (GBC or benign)Preoperative stage1Neoadjuvant chemotherapy (Yes or No)Preoperative radiation (Yes or No)Conversion to surgery (Yes or No)The final stage1Adjuvant chemotherapy (Yes or No)Chemotherapy for metastases/recurrences (Yes or No)
1NoNoNoBenign-NoNoNoIANoNo
2NoNoYesBenign-NoNoNoIBNoNo
3NoNoNoGBCIIIBNoNoNoIIANoNo
4NoNoNoBenign-NoNoNoIIANoNo
5NoNoNoGBCIIANoNoNoIIANoNo
6YesNoNoBenignIIBNoNoNoIIBNoNo
7YesNoNoBenignIIBNoNoNoIIBNoYes
8NoNoNoBenignIIIANoNoNoIIIANoNo
9YesNoNoGBCIVBNoNoNoIIIANoNo
10YesNoNoGBCIVANoNoYesIIIANoYes
11NoNoNoGBCIIANoNoNoIIIAYesNo
12YesNoNoGBCIIIANoNoNoIIIANoNo
13NoNoNoGBCIVANoNoNoIIIBNoNo
14YesYesNoGBCIVBNoNoNoIIIBNoNo
15NoNoNoGBCIIANoNoNoIIIBNoNo
16NoNoYesGBCIVBNoNoNoIIIBNoNo
17YesYesNoGBCIVBNoNoNoIVANoNo
18YesNoNoGBCIIIBNoNoNoIVBNoNo
19NoNoNoGBCIVBNoNoNoIVBNoYes
Table 2 Operative factors
CaseSurgical approach (Primary or two-stage)Surgical procedures
Caudate Lobectomy (Yes or No)Graphic/Surgical R03(Curative resection) (Yes or No)Postoperative complications
Resected area1Intentional LN dissection2 (Yes or No)EHBD resection (Yes or No)
PODGrade4
1PrimaryLCNoNoNoYes--
2PrimaryLCNoNoNoYes--
3PrimaryExtended cholecystectomyYesYesNoYesIntraperitoneal abscess (8)3a
4PrimaryLCNoNoNoYes--
5PrimaryExtended cholecystectomyNoNoNoYes--
6Two-stageWedge resectionYesNoNoYes--
7Two-stageWedge resectionYesYesNoYes--
8Two-stageWedge resectionYesNoNoYesIntraperitoneal abscess (8)2
9PrimaryExtended cholecystectomyNoNoNoNoIntraperitoneal abscess (20)3a
10PrimaryExtended cholecystectomyNoNoNoNo--
11PrimaryExtended cholecystectomyYesYesNoNo--
12PrimaryExtended cholecystectomyNoNoNoYes--
13PrimaryExtended cholecystectomy + SSpPDYesYesNoYesIntraperitoneal abscess (14)2
14PrimaryExtended cholecystectomy + SSpPD + partial resection of the portal veinYesYesNoYes--
15PrimaryLCNoNoNoYes--
16PrimaryExtended cholecystectomy + SSpPDYesYesNoYesPancreatitis (21)2
17PrimaryRight hepatectomy + SSpPDYesYesYesNoPancreatic fistula (14)3b
18PrimaryExtended cholecystectomy+partial hepatectomyYesNoNoYes--
19PrimaryExtended cholecystectomy + SSpPDYesYesNoYes--
Table 3 Pathological findings
CaseTumor occupation1
Depth2 (invaded organ)Invasions into the neck and/or cystic duct (Yes or No)Invasions
Positive margin at the cut end (Yes or No)Metastatic LNs (Positive LNs/total LNs)Metastatic LN #12c3 (The LN around the cystic duct) (Positive LNs/sampling LNs)
Lymphoid duct (Yes or No)Vessels (Yes or No)Nerve plexus (Yes or No)
Ventral or liver side
1GbVentral sidemNoNoNoNoNo--
2GfVentral sidempNoNoNoNoNo0 / 10 / 1
3GfVentral sidessNoNoNoNoNo0 / 13-
4GfVentral sidessNoNoNoNoNo--
5GfVentral sidessNoNoYesNoNo--
6GfbnLiver sidessYesNoNoNoNo0 / 20-
7GfbnLiver sidessYesNoNoNoNo0 / 190 / 1
8GfbLiver sidessNoNoYesNoNo0 / 16-
9GfbnLiver sidesi (liver)YesNoYesNoYes--
10GfbLiver sidessNoNoNoNoNo--
11GfbnVentral sidesi (liver)YesYesYesYesYes0 / 6-
12GfbnLiver sidesi (liver, EHBD)YesYesNoNoYes--
13GfbLiver sidesi (liver)NoYesYesYesNo2 / 35-
14GnbLiver sidesi (liver, EHBD)YesNoYesYesNo3 / 13-
15GfVentral sidessNoNoNoNoNo1 / 11 / 1
16GfbnVentral sidessYesYesYesNoNo2 / 61 / 1
17GfbnVentral sidesi (EHBD)YesYesYesYesYes0 / 4-
18GfbnLiver sidesi (liver)YesNoYesNoNo0 / 4-
19Gfbn (b)Liver sidesi (liver)NoYesYesYesNo18 / 29-
Table 4 Metastases, recurrences and outcome
CaseMetastasis and/or recurrence (Yes or No)The target sites of metastases/recurrences1Postoperative liver metastases (Right and/or left side)Disease-free survival (yr)Overallsurvival(yr)Follow-up term (yr)Prognosis (Dead or alive)
1No--2.42.42.4Alive
2No--2.35.05.0Alive
3No--3.63.63.6Alive
4No--3.63.63.6Alive
5YesLiverRight side0.40.80.8Alive
6No--8.08.08.0Alive
7YesPeritoneal cavity-2.02.82.8Dead
8YesLiverRight side1.42.02.0Dead
9YesPeritoneal cavity-0.10.20.2Dead
10YesLocal site, hepatic hilum-1.22.62.6Dead
11YesPerineal cavity-0.81.01.0Dead
12YesLocal site, liverLeft side0.10.20.2Dead
13YesPeritoneal cavity, paraaortic LN-0.41.71.7Dead
14YesLocal site-0.93.43.4Dead
15YesParaaortic LN-4.05.45.4Alive
16YesBone, paraaortic LN-2.07.57.5Alive
17YesLiver remnantLeft side0.60.70.7Dead
18YesLiverRight and left sides0.20.30.3Dead
19YesLiver, local site, paraaortic LNLeft side0.61.01.0Dead
Table 5 Important literature and guidelines
Ref.CountryYearRemarksComments in each guideline
[43]Germany2013Prognosis of incidental GBC was not influenced by the primary access technique.Conventional open surgery is recommended for suspicious GBCs.
[44]Japan2003Preoperative information indicated strategies for surgical treatment of GBCs.Conventional open surgery is recommended for suspicious GBCs.
[45]Japan1996Outcome of radical surgery for GBCs was evaluated according to the TNM classification.Intentional LN dissection and prophylactic EHBD resection are considered for potential pathological invasions.
[46]Japan2004Strong consideration should be given to intentional LN dissection and EHBD resection.Intentional LN dissection and prophylactic EHBD resection are considered for potential pathological invasions.
[47]Japan2013Hepatectomy of segments 4a and 5 was not superior to extended cholecystectomy in patients with pathological T2.The EHBD resection does not improve the prognosis in patients with T2N0.
[48]Korea2013Radical resection (R0 surgery) including EHBD resection should be considered in patients with T2 and T3 (A single-centre retrospective study).The EHBD resection does not improve the prognosis in patients with T2N0.
[49]Japan2014Surgery might not be indicated for patients with advanced invasion to the EHBD and visible paraaortic LN metastasis (A single-centre retrospective study).The EHBD resection does not improve the prognosis in patients with T2N0.
[50]Korea2015Two-stage surgery was highly recommended for patients with pathological T2 (A single-centre retrospective study).The EHBD resection does not improve the prognosis in patients with T2N0.
[51]Japan2015Combined treatment of intentional LN dissection and prophylactic EHBD resection had no survival impact for patients without the EHBD invasion (A single-centre retrospective study).The EHBD resection does not improve the prognosis in patients with T2N0.
[52]Japan2012Hepatectomy procedures (e.g., systematic, segmental and partial resections) did not significantly affect surgical outcomesRadical resection (R0 surgery) is the most important prognostic factor
[53]United States2008GBC was commonly diagnosed incidentally, and two-stage surgery revealed a high incidence of residual disease.Overall prognosis is poor.
[54]United States2004Surgeries were not routinely indicated for advanced GBCs with jaundice.Jaundice is common in patients with advanced GBC.
[55]France2011EHBD resection increased postoperative morbidity but did not improve survival.Partial hepatectomy without EHBD resection indicates incidental GBC.
[56]Korea2011Extended cholecystectomy was not advantageous over simple cholecystectomy for patients with T1b.Simple cholecystectomy is adequate therapy for patients with T1a.
[57]United States2007Radical resection for patients with T2 and T3 resulted in a significant survival advantage compared with simple cholecystectomy.Advantages of radical resection including extended hepatectomy for incidental GBC and patients with T1b are controversial.
[58]Canada2008Intentional LN dissection and EHBD resection may have stage-specific effects on survival.Radical resection improves survivals in patients with T1b and T2 (not in patients with T3).
[59]Korea2008Cholecystectomy with intentional LN dissection without EHBD resection was recommended for patients with T1b.Advantages of radical resection including extended hepatectomy for incidental GBC and patients with T3b are controversial.
[60]United States2009Radical resection had survival advantage for patients with T1b and T2.Radical resection improves survival in patients with T1b and T2 (not in patients with T3).
[61]United States2011Extended surgery including intentional LN dissection improved survival for incidental GBCAggressive surgeries including hepatectomy, LN dissection and EHBD resection are indicated for patients with T3, localized hepatic invasion and regional LN metastases.
[62]Japan2012Extended cholecystectomy was adequate for patients with T2, and more aggressive surgeries were indicated for patients with T3, localized hepatic invasion and regional LN metastases.Aggressive surgeries including hepatectomy, LN dissection and EHBD resection are indicated for patients with T3, localized hepatic invasion and regional LN metastases.
[63]United States2009Major hepatectomy and EHBD resection were significantly associated with perioperative morbidity, and were not mandatory in all cases.Independent prognostic factors associated with survival are T factor, N factor, pathological poor differentiation and EHBD involvement.
[64]United States2007EHBD resection did not yield a greater count of LNs. Over one-third had residual disease in the EHBD at two-stage surgery.During two-stage surgery, EHBD resection is indicated for negative cystic duct margins.
[65]United States2000Radical resection can provide long-term survival, even for large tumors with extensive liver invasion.Aggressive surgeries including hepatectomy, LN dissection and EHBD resection are indicated for patients with T3, localized hepatic invasion and regional LN metastases.
[66]United States2007Incidental GBCs during laparoscopic cholecystectomy did not indicate immediate conversion to open surgery, and these patients should be referred to a tertiary care center for further surgery.There was no difference in surgical deficit between immediate resection at the initial hospital and delayed resection at tertiary care center.
[67]France2011Jaundice was a poor prognostic factor, but radical resection had survival benefit especially in highly selected patients with N0.Radical resection improves survival in patients with N0.
[20]Japan2011Patients with advanced GBCs were candidates for EHBD resection, if radical resection (R0) was achievable.Radical resection improves survival in patients with EHBD invasion.
[68]India2016Chemoradiotherapy in unresectable GBCs resulted in the resectability, and subsequent radical surgery (R0) had survival benefit. LN regression could serve as a predictor of response to radiochemotherapy.Chemoradiotherapy in unresectable GBCs may result in the resectability, and conversion surgery (R0) has survival benefit.
[69]United States2017Radical surgeries after favorable responses to neoadjuvant chemotherapies were associated with long-term survival in selected patients.Chemoradiotherapy in unresectable GBCs may result in the resectability, and conversion surgery (R0) has survival benefit.
[70]United States2011Pathological assessment of at least 6 LNs was important.Patients with incidental GBC and T2 associated with residual tumor, and should undergo surgery to reflect the adverse outcome.
[71]Canada2012Adjuvant radiochemotherapy had the greatest benefit in patients with positive LNs and R1 disease.Adjuvant radiochemotherapy is beneficial.