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EVALUATING THE PRACTICE OF CHOLECYCSTECTOMY DURING CYTOREDUCTIVE SURGERY WITH HIPEC
Moustafa Moussally
*, Oscar Hernandez Dominguez, Scott Steele, David Liska, Emre Gorgun, Daniel Joyce, Michael Valente
Cleveland Clinic, Cleveland, OH
Background
Cytoreductive surgery (CRS) with hyperthermic intraperitoneal chemotherapy (HIPEC) was shown to increase survival in patients with peritoneal metastasis. One point of contention is whether a cholecystectomy should be performed during the index CRS/HIPEC as this may avoid the risk of missing difficult-to-assess gallbladder (GB) tumor involvement and the potential for a future higher-risk cholecystectomy. We aim to evaluate the practice of cholecystectomy during CRS/HIPEC and analyze the benefit of concurrent cholecystectomy.
Methods:
Adult patients who underwent CRS with HIPEC across our health care system were retrospectively reviewed for GB pathology pre- or post-CRS/HIPEC or GB intervention at index or post-CRS/HIPEC. Patients with prior cholecystectomy were excluded. Pre-operative variables collected included patient demographics, cancer diagnosis, and surgical history. Operative reports were reviewed for intraoperative GB evaluation, GB interventions, peritoneal cancer index (PCI), and surgeon specialty. Post-CRS/HIPEC GB disease, GB intervention, and associated complications, and mortality were collected. Pathology reports were reviewed for GB disease and malignant involvement.
Results:
Between 2009 and 2023, a total of 83 patients underwent CRS with HIPEC and met our inclusion criteria (Table 1). 64 patients underwent cholecystectomy at index CRS/HIPEC, with one Clavien-Dindo (CD) grade-I complication. Among those 64, 28 patients had evidence of malignant gallbladder involvement. Most cholecystectomies were performed by HPB/Surgical oncology (82.8%), colorectal (12.5%) , or general surgeons (4.7%) assisting gynecologists.Only 12 out of 20 patients with preoperative evidence of gall bladder disease underwent cholecystectomy at time of CRS/HIPEC. Cholelithiasis was the most common preoperative gall bladder pathology. The percentage of cholecystectomies performed at index CRS/HIPEC was 94 % for appendiceal malignancies, 83% for peritoneal malignancy, and 80% for colorectal cancers. The concordance between intra-operative surgeon perspective of GB disease and final pathology was 41%. Patients who underwent cholecystectomy had a lower PCI compared to those who didn’t (p-value 0.014). Post-CRS/HIPEC GB intervention was required for 11 patients which included 8 open cholecystectomies, 1 cholecystostomy tubes, and 1 medical-management with 1 CD-IV complication during cholecystectomy. Two of the patients who required open cholecystectomy had preoperative evidence of cholelithiasis.
Conclusion:
In our study, cholecystectomy performed during CRS/HIPEC may be safe and feasible. Furthermore, cholecystectomy at time of CRS/HIPEC may ensure more comprehensive tumor removal. Cholecystectomy at the time of CRS/HIPEC may decrease the need for further interventions in this complex patient population.
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