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Rationally view the controversy of laparoscopic surgery in the treatment of gallbladder cancer.
Written by | Wang Hang, Huang Siyu
At a time when minimally invasive concepts are highly regarded by surgery, the surgical treatment of gallbladder cancer was once considered a forbidden area for laparoscopic surgery.
Recently, the first "Expert Consensus on Laparoscopic Radical Resection of Gallbladder Cancer" was released in mainland China, which mentioned that although laparoscopic radical cholecystectomy has become more and more mature, there is still some controversy in laparoscopic treatment of gallbladder cancer.
As one of the consensus makers, Chen Yajin, chairman of the Hepatobiliary and Pancreatic ERAS (Rapid Recovery) Professional Committee of the China Branch of the International Hepatobiliary and Pancreatic Association, and director of the Department of Hepatobiliary Surgery at Sun Yat-sen Memorial Hospital of Sun Yat-sen University, told the "medical community" that laparoscopic treatment of gallbladder cancer is indeed controversial due to concerns about surgical safety and oncology.
He reminded that medical institutions must be cautious before carrying out laparoscopic surgery for biliary tract tumors, and should not rush to the top, especially to be vigilant against the subjective behavior of "only endoscopy first". At the same time, with the introduction of the consensus, it will provide an important reference for clinical work, strengthen the standardized operation of laparoscopic surgery in gallbladder cancer, and promote and promote biliary tract tumors into the era of minimally invasive surgery.
What's the dispute?
Gallbladder cancer is a highly aggressive malignant tumor, with about 50,000 new cases and 40,000 deaths in mainland China every year, and an overall 5-year survival rate of about 10%. Due to the insidious and rapid progression, many patients are found to be in the middle and advanced stages, with a poor prognosis, and are worthy of the name "king of cancer".
Radical open gallbladder cancer surgery is the mainstay of surgery. In recent years, with the development of minimally invasive technology, laparoscopic surgery has been widely used in the surgical treatment of abdominal tumors such as liver cancer, pancreatic cancer, and gastric cancer.
Can laparoscopy be used to treat gallbladder cancer? The question has been controversial in the field of biliary surgery. In 2019, Liu Zhengcai and others from the First Affiliated Hospital of the Air Force Medical University published an article in the Journal of Laparoscopic Surgery, sorting out the controversy and consensus on laparoscopic radical cholecystectomy.
The article mentions that laparoscopic surgery should be a contraindication to the treatment of gallbladder cancer because the pneumoperitoneum of laparoscopic surgery may lead to problems such as metastasis of the abdominal wall puncture hole and abdominal spread of tumor cells. However, the article also pointed out that many scholars at home and abroad have tried to apply laparoscopic surgery to the treatment of gallbladder cancer, and have achieved good results.
This is where the controversy over laparoscopic treatment of gallbladder cancer lies. On the one hand, laparoscopy has the advantages of minimally invasive techniques such as magnified surgical field of view and multi-view operation dimension, and if the operation is standardized, the field of view will become wider in terms of surgical resection and lymphatic dissection, and with the support of rich minimally invasive surgical techniques, the recovery speed of patients after minimally invasive surgery will be faster.
On the other hand, laparoscopic operation and radical surgery for gallbladder cancer are complex, technically difficult, and tumors are prone to peritoneal implant dissemination, and it remains to be seen whether patients with gallbladder cancer can benefit from laparoscopic techniques, especially in terms of short-term efficacy and long-term prognosis, and it is necessary to continue to evaluate whether minimally invasive techniques can achieve the same effect as traditional laparotomy.
Also in 2019, Professor Cai Xiujun, President of Sir Run Run Shaw Hospital, Zhejiang University School of Medicine, published an article entitled "Application Status and Thoughts of Laparoscopic Technique in the Diagnosis and Treatment of Gallbladder Cancer" in the Chinese Journal of Surgery. Cai Xiujun believes that purely from a technical level, the current laparoscopic technology can meet the requirements of early gallbladder cancer treatment.
However, he emphasized that the pursuit of minimally invasive treatment is not the fundamental purpose of malignant tumor treatment, and the improvement of long-term prognosis should be the ultimate goal of surgery. "At present, the feasibility of laparoscopic technology for the treatment of gallbladder cancer has not been fully verified, and the majority of surgeons still need to maintain a cautious attitude towards the development of laparoscopic radical cholecystectomy. ”
In the past two years, from the papers published in the Chinese Journal of Practical Surgery, laparoscopy has made some progress in the development of radical cholecystectomy, although the controversy has not been completely eliminated, but it shows that this operation has a good development prospect.
In 2023, Li Fuyu et al., Department of Biliary Surgery, West China Hospital, Sichuan University, sorted out the application status of laparoscopy in radical gallbladder cancer surgery, and reviewed the controversial issues in laparoscopic application of radical gallbladder cancer surgery, as well as whether laparoscopic radical cholecystectomy can achieve the same or even better surgical effect compared with laparotomy.
The results showed that laparoscopic radical cholecystectomy was theoretically and technically feasible at this stage, and had good development prospects.
Professor Chen Yajin also pointed out in the article "The Application Value of Laparoscopic Surgery in the Treatment of Gallbladder Cancer in the Era of Comprehensive Treatment" that the role of laparoscopic surgery in gallbladder cancer is worthy of further exploration and evaluation in the era of comprehensive treatment.
The development of laparoscopic techniques in gallbladder cancer surgery
With the promulgation of the "Expert Consensus on Radical Resection of Laparoscopic Gallbladder Cancer", how should we objectively and rationally look at the development status and future of laparoscopic technology in the treatment of gallbladder cancer? Chen Yajin expressed his views to the "medical community".
Director Chen Yajin interpreting the case source: Sun Yat-sen Memorial Hospital of Sun Yat-sen University
Professor Chen Yajin was one of the first experts to carry out laparoscopic surgery in the 90s of the 20th century in mainland China, and one of the first famous experts to explore complex laparoscopic hepatobiliary and pancreatic surgery in China, and was elected as a "Fellow of the Royal College of Surgeons of the United Kingdom" in 2022.
For some of the controversy, he told the "medical community" that gallbladder cancer surgery is complicated, and most patients often only have one chance of radical surgery in their lifetime, "due to the special highly aggressive biological behavior of gallbladder cancer, coupled with the uneven development of laparoscopic technology in hospitals at all levels, medical institutions must be cautious in carrying out laparoscopic gallbladder cancer surgery, and preoperative evaluation needs to be done carefully." ”
According to Chen Yajin, this is related to a variety of factors. First of all, gallbladder cancer requires a variety of imaging and pathology to assess the stage, and laparoscopic surgery is generally not recommended for advanced gallbladder cancer. Secondly, it is necessary to evaluate whether the laparoscopic technical ability and equipment support of the surgeon team can meet the same or better quality standards as traditional open surgery, otherwise it will bring adverse consequences in terms of minimally invasive and radical tumor curability.
"The development level of laparoscopic technology in the world and even in the mainland is unbalanced, although the level of laparoscopic technology in some regions and hospitals in the mainland has been at the advanced level, and even reached the world's leading level, but we still have a lot of space to break through and develop. ”
In addition, Chen Yajin said that due to the problem of iatrogenic spread of tumors, the oncological efficacy of laparoscopic gallbladder cancer surgery has been controversial so far. "Problems such as intraoperative bile spillage contamination, improper use of laparoscopic instruments on the gallbladder, and the 'chimney' effect caused by pneumoperitoneum may lead to the spread and implantation of gallbladder cancer. ”
Chen Yajin pointed out that the biological characteristics of tumors determine that once a patient's gallbladder rupture occurs during surgery, the prognosis will be extremely poor. At the same time, laparoscopic anatomical operations fail to achieve the tumor-free principle required for laparotomy, which will also lead to the spread of small tumor cells in the pneumoperitoneum environment.
Based on this problem, gallbladder cancer was once considered a contraindication to laparoscopic therapy and was avoided in patients with a confirmed or suspected diagnosis before surgery.
Another major reason for the controversy comes from the bottlenecks of laparoscopic techniques in the early years: the precision of liver resection, the thoroughness of lymph node dissection, and the high-quality reconstruction of the digestive tract.
"The mastery of these techniques requires a strong teamwork, as well as rich case practice and standardized technical standards, and these challenges have also made laparoscopic cholecystectomy questionable: can gallbladder cancer achieve the goal of R0, and can it be inferior to laparotomy in terms of tumor prognosis and postoperative complications?"
Not only in China, Chen Yajin introduced to the "medical community" that this operation is currently controversial around the world. Laparoscopic surgery is not recommended for patients with gallbladder cancer in Japan, laparoscopic surgery is only recommended for gallbladder cancer staging in the United States, and laparoscopic surgery for T1b and T2 gallbladder cancer is only recommended in a hepatobiliary and pancreatic surgery center with rich laparoscopic experience.
Regarding the mainland's guidelines, Chen Yajin explained that some primary medical institutions with insufficient experience and technology should refer patients with gallbladder cancer or suspected gallbladder cancer to regional medical centers and experienced large hepatobiliary centers for diagnosis and treatment, rather than carrying out surgery on the spot.
"If the stage of the tumor, the degree of malignancy and the relevant technology are not clarified, the laparoscopic treatment of gallbladder cancer is rushed, which will eventually affect the prognosis of patients. ”
Combined with the "Expert Consensus on Radical Resection of Laparoscopic Gallbladder Cancer", Chen Yajin said that it is based on the breakthrough of laparoscopic hepatobiliary and pancreatic technology bottlenecks and the accumulation of experience in recent years, aiming to formulate technical specifications and quality control standards for radical surgery for abdominal gallbladder cancer, minimize the spread of iatrogenic tumors, and then achieve the same quality standards as open surgery.
The "medical community" combed and found that the consensus put forward suggestions from many aspects, such as safety, preoperative evaluation, indications, surgical team, patient position layout, intraoperative frozen pathology, lymph node dissection, liver resection method, bile duct resection, etc., and provided guiding opinions for the standardized development of laparoscopic radical cholecystectomy.
How to rationally look at minimally invasive technology?
Although minimally invasive technology is booming in the field of surgery, Chen Yajin believes that minimally invasive technology must adhere to the principle of overall minimally invasive and long-term benefits, because it is easy to make minimally invasive technology a "heavy injury" if you are not careful, and "especially be vigilant against the subjective behavior of 'only endoscopy first', so as not to bring harm to patients." ”
He revealed that he has been doing laparoscopic hepatobiliary and pancreatic surgery for many years, and he has also carried out the exploration of laparoscopic radical resection of gallbladder cancer at an early stage.
"Laparoscopic technique is a landmark technique in modern surgery, which has brought about a revolutionary change in modern surgery, especially in benign diseases, gastrointestinal tumors and liver tumors, and has been proven to be safe, feasible and effective. However, for biliary tract tumors, whether the minimally invasive technique represented by laparoscopy is more advantageous than open surgery still needs more clinical evidence to support. ”
At the same time, he believes that whether it is laparoscopic or traditional surgery, the ultimate goal is the patient's benefit. At present, minimally invasive surgery is no longer limited to the concept of simple micro-incisions, but focuses more on the field of precision surgery with precise anatomy, fine operation and functional protection, and ultimately is oriented to the benefit of patients.
"What we pursue is overall minimally invasive, patients not only need small incisions, less trauma in the abdominal cavity, less bleeding, and fast recovery, but the real minimally invasive should be the overall minimally invasive of the whole process, including the benefits of minimally invasive surgery and oncology. ”
Professor Chen Yajin (first from right) led a team to perform laparoscopic liver resection
Chen Yajin emphasized that when carrying out minimally invasive surgery, it is necessary to pay attention to the quality control standards of the process and results, including the incidence of complications, length of hospitalization, mortality rate of low-risk surgical patients, 30-day unplanned reoperation rate, 90-day rehospitalization rate and other indicators, and the medium and long-term survival rate of malignant tumors should be evaluated for timely summary, feedback and improvement.
"Minimally invasive surgical techniques should be explored and researched under reasonable norms and supervision, and more and higher-level evidence-based medical evidence should be obtained under the premise of ethical principles to ensure the maximum benefit of patients, so as to ultimately promote the overall progress of the field. ”
In Chen Yajin's view, in the future, minimally invasive surgery represented by laparoscopy will still be the basic trend of surgical development, "This trend will not change, but the current exploration of minimally invasive technology in some tumor fields is relatively lagging behind, and it is very advanced in some aspects, which also reminds us that for high-risk laparoscopic surgery, we need to adhere to the principle of step-by-step, solid evidence, and steady progress." ”
"The mainland consensus does not prohibit laparoscopic gallbladder cancer surgery, but advocates that experienced medical institutions carry out exploratory standard implementation, which also means that laparoscopic gallbladder cancer surgery cannot be beaten to death with a stick. Chen Yajin told the "medical community" that with the development of technology, tumors will tend to a comprehensive treatment mode, including but not limited to systemic treatment, interventional therapy, radiation therapy, surgical treatment, etc.
"In the context of the era of comprehensive treatment, the rapid development of Internet video teaching and laparoscopic training system has significantly shortened the learning curve of complex hepatobiliary laparoscopic surgery, preoperative neoadjuvant therapy can downgrade and reduce tumor activity and reduce tumor activity, and postoperative adjuvant therapy may eliminate potential micrometastases and reduce the chance of abdominal dissemination. ”
From these aspects, Chen Yajin believes that the role of laparoscopic surgery in gallbladder cancer in the future is still worthy of further exploration and evaluation.
Expert Profile
Prof. Yajin Chen
- Director of the Department of Hepatobiliary Surgery and Director of the Department of General Surgery, Sun Yat-sen Memorial Hospital, Sun Yat-sen University
- Chairman of the Hepatobiliary and Pancreatic ERAS Professional Committee of the China Branch of the International Hepatobiliary and Pancreatic Association
- Member of the Standing Committee of the Surgical Branch of the Chinese Medical Doctor Association
- Chairman of the Hepatobiliary Surgeon Branch of Guangdong Medical Doctor Association
- Member of the Biliary Surgery Group of the Surgery Branch of the Chinese Medical Association
- He is a member of the Standing Committee of the Biliary Surgeon Professional Committee of the Surgeon Branch of the Chinese Medical Doctor Association
- Vice Chairman of the Biliary Tract Professional Committee of the Capacity Building and Continuing Education Surgery Committee of the National Health Commission
- He is a Fellow of the Royal College of Surgeons of the United Kingdom (FRCS), and a member of the Standing Committee of the International Association for Laparoscopic Liver Surgery (ILLS).
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Source of this article: Medical Editor-in-Charge: Xiang Yu
*The Medical Community strives to be professional and reliable in its published content, but does not make any commitment to the accuracy of the content.
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