Surgical Procedures: Surgery and Staging for Gallbladder Cancer
Cancerous cells of the gallbladder is called gallbladder cancer. The gallbladder sits under the liver in the right upper quadrant of the abdomen. It is pear-shaped and responsible for bile storage. Bile, a digestive fluid that digests fat, is made by the liver and stored in the gallbladder until it is ready to be released through the common bile duct of the gallbladder. The common bile duct is what connects the gallbladder and liver to the first part of the small intestine.
Gallbladder cancer is uncommon but some people are at higher risk for developing the disease. Risk factors include:
- Being female.
- Being of Native American descent.
- Older age.
- Being overweight.
- A personal history of gallstones, porcelain gallbladder, choledochal cyst and chronic gallbladder infection
Most commonly, gallbladder cancers start in the inner lining of the gallbladder or mucosa, within the glandular cells. These cancers are classified as adenocarcinoma.
What is staging and how is it performed?
Staging is a way to find out how far the cancer has spread in your body. Your provider will have you get a few tests to figure out the stage of your cancer. These tests may include:
Physical Exam: This is a general exam to look at your body and to talk about your past health issues.
Imaging: Radiology tests can look inside your body to look at the cancer and determine if it has spread. These tests can include:
- Chest X-ray.
- CT scan.
Laboratory Tests: Blood tests such as liver function tests, blood chemistry studies and evaluation of carcinoembryonic antigen (CEA) assay and CA 19-9 assay may be recommended.
Procedures: These may include:
- Percutaneous Transhepatic Cholangiography (PTC): Dye is injected into the liver or bile ducts through a needle inserted through the abdomen below the ribs. After the dye is injected, an X-ray is taken to look for blockages, which may require stent placement to allow for bile drainage from the liver. At times, it may be necessary to drain the bile into an external collection bag.
- Endoscopic Retrograde Cholangiopancreatography (ERCP): An adendoscope is passed through the upper parts of the digestive tract, the mouth, esophagus and stomach, and it is placed into the first portion of the small intestine where a smaller tube is passed through the bile ducts. An X-ray is obtained after dye is injected to look for any blockages, in which a stent may be placed to keep the duct patent or open.
- Magnetic Resonance Cholangiopancreatography (MRCP): During an MRCP, evaluation of the liver, gallbladder, bile ducts, pancreas and pancreatic duct are looked at using specialized magnetic resonance technology.
- Biopsy: Removal of tissue to be looked at under a microscope to check for cancerous cells.
- Laparoscopy: Small incisions are made into the abdomen and the surgeon will insert surgical tools into the abdomen to look for abnormalities and obtain biopsies and/or remove organs as needed. This procedure allows the surgeon to see if the gallbladder cancer is contained or has metastasized to other areas.
Gallbladder cancer spreads to other parts of the body through the tissue, lymph and blood systems. Cancer stage determines how extensive the cancer is, how far it has spread and what treatment course will be recommended. Gallbladder cancer is staged as stages 0 (Carcinoma in-situ) through stage IV. Stage I disease is localized to the gallbladder wall, whereas stages II-IV disease is described as unresectable, recurrent or metastatic. These staging descriptions will determine how the cancer can be treated.
In some cases surgery is used to treat gallbladder cancer.
Surgical Procedures for Gallbladder Cancer
There are different surgeries used to treat gallbladder cancer, depending on your particular stage and situation and include curative and palliative surgeries. These surgical procedures include:
- Staging Laparoscopy: This is done prior to other surgeries to evaluate for disease metastasis and to see what surgical options exist. During a staging laparoscopy, small incisions made within the abdomen, allow for the placement of a laparoscope (lighted tube), which gives the surgeon better visualization of the abdomen. At times, if the cancer is deemed resectable, or operable, then the cancerous areas can be removed during this procedure.
Simple Cholecystectomy: During this procedure, the gallbladder and some of the surrounding tissue is removed, however, this is reserved to early stage cancers or non-cancerous diagnoses. Often times, gallbladder cancer is found during a procedure for a benign (non-cancerous) condition. The procedure can be done open or laparoscopically:
- Open Cholecystectomy: Removal of the gallbladder through a large abdominal incision. This is not the preferred method when cancer is known or suspected. Most patients will undergo an extended cholecystectomy in these cases.
- Laparoscopic Cholecystectomy: Small incisions are made within the abdomen, allowing for the placement of a laparoscope (lighted tube) which gives the surgeon better visualization of the abdomen. This method is not used when gallbladder cancer is known or suspected.
- Extended (Radical) Cholecystectomy: Often this is recommended for patients with gallbladder cancer to minimize the risk of disease recurrence. This procedure involves removing the gallbladder, a portion of the surrounding liver tissue, and several surrounding lymph nodes. In some cases, a more extensive operation may be needed to remove a larger portion of the liver (wedge resection) or removal of an entire liver lobe (hepatic lobectomy), the common bile duct, certain ligaments, additional lymph nodes, the pancreas, the duodenum and any other areas where disease is found.
Palliative (pain and symptom relieving) procedures include:
- Surgical Biliary Bypass: The gallbladder or bile duct will be severed and attached to the small intestine to allow bile flow, blocked by a tumor, to flow more freely.
- Endoscopic Stent: A stent may be placed in the bile duct to allow bile drainage. This is done when there is a tumor blocking the duct and not allowing the bile to flow freely. Depending on the situation, the bile may drain into the small intestine or externally, outside of the body, into a collection bag.
- Percutaneous transhepatic biliary drainage: This procedure is typically performed in the presence of pre-operative jaundice. During this procedure, a liver and bile duct X-ray locates the presence of a blockage. An ultrasound guided stent placement is then completed to relieve the bile blockage into the small intestine or an external collection bag.
What are the risks associated with gallbladder surgery?
As with any surgery, there are risks and possible side effects. These can be:
- Reaction to anesthesia. (Anesthesia is the medication you are given to help you sleep through the surgery, not remember it and manage pain. Reactions can include wheezing, rash, swelling and low blood pressure.)
- Blood clots.
- Bile leakage into the abdomen.
- Injury to the bile duct and/or liver.
- Liver failure.
- Scarring and/or incisional numbness.
- Incisional hernia.
- Post-operative digestive problems, such as issues with eating.
What is recovery like?
Recovery from gallbladder cancer surgery will depend on the extent of the procedure you have had. You may have a tube in your nose that rests in the stomach to remove swallowed air. Additionally, you may also have drains placed in your surgical wounds.
You will be told how to care for your surgical incision before leaving the hospital.
Your medical team will discuss with you the medications you will be taking, such as those for pain, blood clot prevention and/or other conditions.
Your healthcare provider will discuss your particular activity restrictions depending on the surgery you have had.
Contact your healthcare team if you experience:
- Fever or chills.
- Abdominal bloating/swelling/cramping/pain.
- Pain unrelieved with medication.
- Nausea or vomiting.
- Incisional drainage, swelling, bleeding and/or redness.
- Difficulty eating or drinking.
- Jaundice (yellowing of the skin and/or whites of your eyes).
- 3 days of not passing gas or having a bowel movement.
- Pain located behind the breast bone, shortness of breath and/or a persistent cough.
- Gray stool.
- Any other concerning symptoms.
How can I care for myself?
You may need a family member or friend to help you with your daily tasks until you are feeling better. It may take some time before your team tells you that it is ok to go back to your normal activity.
Be sure to take your prescribed medications as directed to prevent pain, infection and/or constipation. Call your team with any new or worsening symptoms.
There are ways to manage constipation after your surgery. You can change your diet, drink more fluids, and take over-the-counter medications. Talk with your care team before taking any medications for constipation.
Taking deep breaths and resting can help manage pain, keep your lungs healthy after anesthesia, and promote good drainage of lymphatic fluid. Try to do deep breathing and relaxation exercises a few times a day in the first week, or when you notice you are extra tense.
- Example of a relaxation exercise: While sitting, close your eyes and take 5-10 slow deep breaths. Relax your muscles. Slowly roll your head and shoulders.
This article contains general information. Please be sure to talk to your care team about your specific plan and recovery.