Gallbladder polyps are outgrowths of the gallbladder mucosal wall. They are usually found incidentally on ultrasonography or after cholecystectomy. The majority of these lesions are not neoplastic but are hyperplastic or represent lipid deposits (cholesterolosis). A minority of polyps could be adenomas or inflammatory polyps.

Discuss the clinical features of GB polyps?

Gallbladder polyps can be associated with biliary pain.

Discuss the treatment of GB polyps?

• Patients who have gallbladder polyps and concomitant gallstones should undergo cholecystectomy regardless of the polyp size or symptoms since gallstones are a risk factor for gallbladder cancer in patients with gallbladder polyps.
• Cholecystectomy should also be recommended for patients who have biliary colic.
• Polyps 10 to 20 mm in diameter should be regarded as possibly malignant. Cancer of this size is usually an early stage cancer and laparoscopic cholecystectomy with full thickness dissection is recommended. Polyps less than 10 mm can be followed up by regular USS.
• Lesions larger than 18 to 20 mm are usually malignant and should be resected. Because these lesions may represent advanced cancer, patients should undergo preoperative staging with a CT scan and EUS.

The majority are adenocarcinomas. The majority are found incidentally in patients undergoing exploration for cholelithiasis. Women are affected two to six times more often than men.

What are the risk factors for GBC?

• Gallstone disease — is one of the strongest risk factors for the development of GBC.
• Porcelain gallbladder — is an uncommon manifestation of chronic cholecystitis that is characterized by intramural calcification of the gallbladder wall. It is associated with cholelithiasis in more than 95 percent of cases.
• Gallbladder polyps.

What are the clinical features of GBC?

• Patients with early invasive GBC are most often asymptomatic or have nonspecific symptoms.
• The most common symptoms caused by GBC are jaundice, pain, and fever.
• Patients with GBC may also present with obstructive jaundice by invasion of tumor into the porta hepatis.
• For GBC- loco regional growth predominates. Haematogenous metastases is unusual

Discuss TNM staging of GBC?

T1 Tumour invades the lamina propria (T1a) or muscle layer (T1b)

T2 Tumor invades perimuscular connective tissue; no extension beyond serosa or into liver

T3 Tumor perforates the serosa (visceral peritoneum) or directly invades one adjacent organ or both (extension 2 cm or less into the liver)

T4 Tumor extends more than 2 cm into the liver, and/or into two or more adjacent organs (stomach, duodenum, colon, pancreas, omentum, extrahepatic bile ducts, any involvement of the liver)

N0 No regional lymph node metastasis N1 Regional lymph node metastasis

M0 No distant metastasis M1 Distant metastases

Discuss the treatment of GBC?

Surgery is the only potentially curative therapy. Only T1 or T2 and N1 lesions are resectable.
A logical surgical approach to potentially resectable GBC consists of total removal of the gallbladder, a portion of the underlying liver (generally segments IVb and V), and dissection of the draining regional lymphatics. Simple cholecystectomy may be sufficient for T1 lesions.

What are the contraindications to surgery?

Among the absolute contraindications to surgery are liver or peritoneal metastases, ascites, extensive involvement of the hepatoduodenal ligament, and encasement or occlusion of major vessels.

Discuss the approach to incidental GBC discovered at cholecystectomy?

Current consensus is that patients would undergo a second curative procedure if an unexpected gallbladder cancer is diagnosed postoperatively after cholecystectomy, except for those who are found to have T1 disease. Implantation of the carcinoma at all port sites after laparoscopic removal of an unsuspected cancer is a problem. Even for stage I cancers, the port sites must be excised completely.

What is the role of adjuvant therapy?

No clear evidence that adjuvant therapy provides survival benefit

What are the treatment options for unresectable disease?

Patients with locally advanced unresectable disease are candidates for chemoradiotherapy. The relative merits of systemic chemotherapy versus basic supportive care for patients with locally advanced or metastatic disease remain to be established in controlled trials.

What is the prognosis?

Patients with cancers confined to the mucosa have 5-year survival rates of nearly 100%. Patients with muscular invasion or beyond have a survival of less than 15%.

Cholangiocarcinomas arise from the epithelial cells of the bile ducts. The majority of cholangiocarcinomas (>90 percent) are adenocarcinomas, with squamous cell carcinoma being responsible for most of the remaining cases. Distant metastases are distinctly uncommon in cholangiocarcinoma.

Cholangiocarcinoma may arise in the intrahepatic (least common), perihilar, or distal
(extrahepatic) biliary tree. Bile duct tumors that involve the common hepatic duct bifurcation are referred to as Klatskin tumors regardless of whether they arise from the intrahepatic or extrahepatic portion of the biliary tree.

What is the epidemiology of cholangiocarcinoma?

Cholangiocarcinoma generally presents between 50 and 70 years of age. However, patients with primary sclerosing cholangitis (PSC) and those with choledochal cysts present nearly two decades earlier. The incidence of cholangiocarcinoma is slightly higher in men. This probably reflects the higher incidence of PSC in men.

What are the risk factors for cholangiocarcinoma?

• PSC is the commonest known predisposing factor for cholangiocarcinoma in the UK. It is interesting to note that the risk of developing cholangiocarcinoma is not associated with the duration of PSC.
• Chronic intraductal gall stones.
• Bile duct adenoma and biliary papillomatosis.
• Caroli’s disease (cystic dilatation of ducts)
• Choledochal cysts
• Thorotrast (a radiological agent no longer licensed for use)
• Smoking (increased risk in association with PSC).
• In SE Asia, where the tumour is quite common, the associated risk factors are liver flukes (Opisthorchis viverrini and Clonorchis sinensis) and chronic typhoid carriers.

What are the clinical features of cholangiocarcinoma?

i. Painless obstructive jaundice, abdominal pain and weight loss.
ii. Cholangiocarcinoma is often associated with intermittent rather than steadily progressive jaundice.

Discuss the diagnosis of cholangiocarcinoma?

• USS- Diagnosis should be suspected when ducts are dilated.
• CT- abdominal lymphadenopathy is common in PSC & does not necessarily indicate malignant change.
• Tumour markers- The value of CA 19-9 in patients with suspected cholangiocarcinoma is unclear. CEA and Ca 125 are also raised in cholangiocarcinoma.
• Tissue diagnosis of cholangiocarcinoma is difficult because it is highly desmoplastic tumour composed of a few malignant cholangiocytes within excessive fibrous tissue. Thus cytology is positive in only 1/3rd of cases.
• Positron emission tomography — PET scan permits visualization of cholangiocarcinomas because of the high glucose uptake of bile duct epithelium. Another role for PET is in screening patients with PSC for the presence of cholangiocarcinoma.
• Staging laparoscopy —laparoscopy will identify 25-30% of patients as unresectable who were thought to be operable before laparoscopy. Therefore laparoscopy should be standard before operation.

Discuss the management of cholangiocarcinoma?

Surgery is the only curative treatment for patients with cholangiocarcinoma.

• Distal cholangiocarcinomas are managed by pancreatoduodenectomy as with pancreatic head cancers.
• Intrahepatic cholangiocarcinoma is treated by resection of the involved segments or lobe of the liver.
• Hilar tumours- en bloc resection of the extrahepatic bile ducts and gall bladder, regional lymphadenectomy, and Roux-en-Y hepaticojejunostomy with or without right or left hepatectomy

Criteria for resectability — the traditional guidelines for resectability in US include:

• Absence of nodal metastases or distant liver metastases.
• Absence of invasion of the portal vein or main hepatic artery
• Absence of extrahepatic adjacent organ invasion
• Absence of disseminated disease

However, as a general rule, true resectability is ultimately determined at surgery, particularly with perihilar tumors.

What is the role of preoperative biliary decompression?

This is controversial. Many surgeons proceed directly to laparotomy without preoperative biliary drainage. On the other hand, there is often uncertainty as to resectability as well as the timetable of surgical evaluation and operative management in patients presenting with jaundice. As a practical issue, stents are often placed to alleviate jaundice while these issues are being settled.

What is the role of chemoradiotherapy?

Neoadjuvant or adjuvant chemotherapy or radiotherapy therapy is not shown to be beneficial in patients with cholangiocarcinoma.

What are the palliative treatment options?

• Photodynamic therapy is emerging as an important palliative option for patients with unresectable cholangiocarcinoma.
• Biliary stenting to relieve symptoms. Palliative radiation therapy after biliary bypass or intubation may be beneficial for some patients.
• Patients with unresectable disease can be considered candidates for phase I and II studies of chemotherapeutic agents or biologics.

What is the prognosis?
Surgery for cholangiocarcinoma is usually extensive and have a high operative mortality (5%-10%) and low curability. There is a 9–18% five year survival for proximal bile duct lesions and 20–30% for distal lesions.
Median survival for patients with intrahepatic cholangiocarcinoma without hilar involvement is 18–30 months and 12–24 months with perihilar involvement.

Ref

1. British Society of Gastroenterology Guidelines for the diagnosis and treatment of cholangiocarcinoma: consensus document