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Society for Surgery of the Alimentary Tract

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Elizabeth Olecki*, Kelly A. Stahl, Rolfy Perez-Holguin, June S. Peng, Matthew Dixon, Chan Shen, Niraj Gusani
General Surgery, Penn State Hershey Medical Center, Hershey, PA

Background: Gallbladder cancer (GBC) is the 5th most common cause of gastrointestinal malignancy. Given the aggressive nature of GBC, early detection and appropriate oncologic treatment is imperative for improved outcomes and survival. Risk factors of GBC are not well-defined resulting in greater than 60% of GBCs being diagnosed incidentally after a cholecystectomy is performed for presumed benign indications. As most localized GBC require a more extensive oncologic surgery beyond a cholecystectomy, this study aims to examine factors associated with incidentally found GBC in order improve preoperative and intraoperative diagnosis.

Methods: The American College of Surgeons National Surgical Quality Improvement Program Database from 2007-2017 was used to identify cholecystectomies performed with and without a final diagnosis of GBC. Cholecystectomies performed with concurrent liver procedures and lymphadenectomy were excluded in order to omit preoperatively known/suspected GBC. Chi-square test and multivariable logistic regression were used to compare demographic, intraoperative, and postoperative characteristics among those with and without a final diagnosis of GBC.

The incidence of incidentally found GBC was observed to be 0.109% (441/403,443). Preoperative factors found to be associated with increased risk of GBC included age >60 (OR 6.51, p<.001), female sex (OR 1.75, p<.001), history of recent weight loss (2.58, p<.001), and elevated preoperative alkaline phosphatase level (OR 1.67, p=.001). Open approach was associated with a 7 times increased risk of GBC compared to laparoscopic approach (OR 7.33, p<.001). In addition to preoperative and surgical planning characteristics, longer mean operative times (127 minutes vs 70.7 minutes, p<.001) were significantly associated with increased risk of GBC compared to benign final pathology.

This study demonstrates that those with incidentally discovered GBC at cholecystectomy are unique from those undergoing cholecystectomy for benign indications. By identifying independent predictors of a final diagnosis of GBC, high risk individuals can be identified pre-operatively and undergo further oncologic evaluation prior to surgical resection.
Additionally, by identifying intraoperative risk factors, we can selectively employ intraoperative frozen pathology and plan appropriate surgical treatment with extended cholecystectomy and lymph node dissection when indicated.

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