Defining the Role of Staging Laparoscopy in the Management of the Gallbladder Cancers: A Single Institution Experience

ABSTRACT Introduction Despite advances in imaging and extensive staging work‐up, occult metastases may still be encountered at laparotomy in patients with apparently resectable gallbladder cancer (GBC), resulting in nontherapeutic surgery. This study evaluates the incremental yield of staging laparoscopy (SL) in detecting radiologically occult metastases in resectable GBC and its role in routine staging. Methods A prospectively maintained database of patients operated for GBC at a high volume institution was analyzed to calculate the diagnostic yield of SL and the percentage of missed metastases by modern imaging analysis but subsequently diagnosed on SL. In the univariate and multivariate logistic regression, the following binary variables were evaluated to identify predictors of metastasis on SL: (i) NACT (neoadjuvant chemotherapy) receipt: yes versus no; (ii) serum carbohydrate antigen 19–9 (CA19‐9) level: > 1000 u/mL versus ≤ 1000 U/mL; (iii) 18 fluorodeoxyglucose positron emission tomography/computed tomography ( 18 FDG PET/CT) scan result: equivocal versus negative (positive results were excluded from this analysis as they would not have proceeded to SL without additional workup); (iv) clinical stage: locally advanced versus early; (v) incidental GBC: yes versus no; (vi) tumor grade: moderate/poorly differentiated versus well differentiated. Results The SL was incorporated into the diagnostic and management pathway of 330 GBC patients. SL was performed (i) as a staging prior to a planned radical cholecystectomy ( n = 210, 63.6%) and (ii) prior to initiating systemic therapy ( n = 120, 36.4%). The diagnostic yield of SL for detection of metastases over cross‐sectional imaging was 11.5% ( n = 38). Reasons for inoperability on laparotomy were metastatic 16b1 lymph node (LN) ( n = 19, 50%), locally unresectable disease ( n = 15, 39.5%), peritoneal metastasis ( n = 2, 5.3%), and liver metastasis ( n = 2, 5.3%). The reason for locally unresectable disease was right hepatic artery encasement at the porta hepatis. Regression analysis showed that the significant predictors for metastatic disease on SL were equivocal uptake on 18 FDG PET/CT scan ( p = < 0.001) and prior NACT ( p = 0.026). Conclusion SL provides an incremental detection of radiologically occult metastasis in up to 11.5% patients. The study underscores the benefit of SL and suggests that it should be incorporated in the management of all GBC patients.