JOURNAL OF LAPAROENDOSCOP1C SURGERY Volume 1, Number 6. 1991 Mary Ann Liebert, Inc., Publishers
Brief Clinical
Report
Carcinoma of the Gallbladder Found During Laparoscopic Cholecystectomy: A Case Report and Review of the Literature ARON L.
DAVID AVERBACH, M.D., MARK R. SCHWARTZ, M.D.
GORNISH, M.D.,
F.A.C.S.,
and
ABSTRACT
Laparoscopic cholecystectomy has become an accepted appropriate method for removal of the diseased gallbladder. With cancer of the gallbladder to be expected in 1-2% of all biliary tract operations, it is likely that surgeons may be confronted with the unsuspected finding of gallbladder carcinoma during the course of laparoscopic cholecystectomy. We present here a case of gallbladder carcinoma found at laparoscopic cholecystectomy, and discuss the interesting clinical findings associated with this entity, including the preoperative suggestion of Trousseau's syndrome. A review of the pertinent literature is included.
INTRODUCTION rare malignancy, despite being the fifth most the United States, it will be discovered in approximately 2.5 per persons.1"3 It is expected that gallbladder cancer will be found in about 1% of all biliary tract The disease most often manifests itself in the seventh and eighth decades of life, and in general operations. occurs three times more commonly in women than in men.4 Sons and Borchard in a review of 46,593 autopsies found the incidence of carcinoma of the gallbladder to be approximately 0.62%.5 Despite the association of gallstones in 74-92%, as well as chronic inflammation in the patients with gallbladder cancer, the cause and effect remains relatively ambiguous.1-3 In a review of 315 patients with gallbladder cancer, Shuklaet al.3 found that pain in the right upper quadrant, icterus, and loss of appetite were some of the most common presenting symptoms. However, radiologie and laboratory findings were generally of little help in making the diagnosis.1-3 In fact, Koo et al.6 noted an accurate preoperative diagnosis in less
Adenocarci ngastrointestinal oma (GI) 100,000
of the gallbladder
common
is
a
relatively
tract cancer. In
Department of Surgery, Section of Laparoscopic Surgery,
Monmouth Medical Center,
361
Long Branch,
NJ.
GORNISH ET AL. reviewed. Nevertheless, many patients remain asymptomatic. Conversely, those with carcinoma of the gallbladder have been found to present with symptoms similar to patients diagnosed those of benign biliary tract diseases.7 Therefore, a high index of suspicion becomes a crucial factor. The prognosis of gallbladder cancer is universally grim, with an overall 1-year survival of 11.8% and a 5-year survival of 4.1%.2 The 5-year survival for incidentally found disease is 14.9%.8 In a retrospective review of 30 cases of gallbladder carcinoma, Bair and Wright found their longest survival to be 13 months despite stage or extent of treatment.9 In contrast, Ouche et al. have demonstrated clear improvement in 5-year survival in those patients with 'low DNA scores,' with tumor limited to mucosa (85% 5-year) or muscularis (57% 5-year).'"There remains controversy, however, regarding the correlation of histologie grade, stage, and type of "curative resection" with improved survival. For example, 5-year survival after cholecystectomy with stages I and II has been reported as high as 70-80%.' This is in contrast to a study by Kopelson and Gundersen" who showed a cure rate for "early" gallbladder carcinoma found coincidental to simple cholecystectomy to be less than 50%. And if the degree of extension was transmural, there were no 10-year survivors." This same review showed a high incidence of regional recurrence regardless of grade, lymph node status, or perineural invasion. Since April 1990, the majority of patients at our institution requiring cholecystectomy have had their gallbladder removed laparoscopically. The development of this procedure, and the technique have been described elsewhere.1213 In a personal series of over 200 consecutive laparoscopic cholecystectomies, we have encountered two cases of adenocarcinoma of the gallbladder. The first case occurred in a 41-year-old male medical lab director, and involved quite extensive disease that was not suspected until laparoscopy. He required Iaparotomy to remove the gallbladder and to confirm the diagnosis of malignancy. This patient expired 3 months after surgery of widespread métastases. The second patient in our series found to have carcinoma of the gallbladder is the subject of this presentation. than 10% of the
cases
CASE STUDY A pleasant 53-year-old female presented with a 4-month history of right upper quadrant pain. The pain had been relatively constant over the 4-month period. Almost all foods made the pain worse, including but not limited to fatty foods. She denied fever, chills, or jaundice. She reported occasional nausea, and one episode of vomiting. She denied any prior abdominal surgery, and had no significant medical problems. She did report another interesting set of symptoms, the significance of which did not become clear until later. For several months she reported a history of intermittent local swelling of both lower and upper extremities. The affected area would become swollen, erythematous, and tender, and would resolve within a few days, only to recur elsewhere. This was present for several months prior to her development of abdominal symptoms. Evaluation by her family physician failed to elucidate the etiology of these unusual complaints. She underwent upperGI series, which was normal. Sonography of the abdomen revealed cholelithiasis, and the gallbladder was specifically noted to be of normal size, shape, and configuration. There was no thickening of the gallbladder wall noted, and the liver was reported to be acoustically normal. No abnormality was noted in the pancreas. Bloodwork was completely normal, including liver function studies. Options were discussed with the patient, and it was decided that laparoscopic cholecystectomy would be an appropriate procedure for her. She was scheduled for elective laparoscopic cholecystectomy. Laparoscopy failed to reveal any visual evidence of significant abnormalities, except for a small area of puckering noted at the fundus of the gallbladder, near its junction with the liver edge. The procedure was uneventful, until the final stages of dissecting the gallbladder from the undersurface of the liver with the electrocautery. The tissue at the dome of the gallbladder was noted to be thickened and whitish and quite adherent to the liver over an area of only 1-2 cm. When the final attachments were divided, the gallbladder was withdrawn through the umbilical port, as is usual for laparoscopic cholecystectomy. No bile was spilled intra-abdominally. The gallbladder wall did come in contact with the subcutaneous tissue of the umbilicus. After the neck of the gallbladder was delivered through the abdominal wall, the organ was opened to allow aspiration of bile to facilitate its removal. A small amount of bile spillage onto the abdominal wall and into the umbilical incision occurred at this time. The gallbladder was sent for frozen section analysis. This is not standard procedure, but
362
CARCINOMA OF THE GALLBLADDER there was a suspicion about the thickening at the dome of the gallbladder (Fig. 1 ). The pathologic diagnosis on frozen section was probable adenocarcinoma. The final pathology report returned with a diagnosis of well-differentiated adenocarcinoma of the gallbladder, involving the serosal surface, and approaching the adjacent hepatic parenchyma. The lesion itself was a firm, tan-white nodule, 1.0 cm in diameter, located at the fundus of the gallbladder (Fig. 2). The cystic duct region appeared to be microscopically free of malignancy. CT scan of the abdomen performed on the first postoperative day showed no evidence of metastatic disease. She was referred to Memorial Sloan-Kettering Hospital and underwent surgical exploration 3 weeks after her cholecystectomy. At laparotomy, she was found to have matted fixed portal adenopathy and retroduodenal soft tissue métastases that were histologically confirmed to be metastatic adenocarcinoma consistent with the gallbladder primary. No liver resection was performed. After her discharge, she was begun on a chemotherapy regimen of weekly 5-fluorouracil as well as radiation therapy. Twelve weeks after her laparotomy, her radiation oncologist noticed that she had developed a firm soft tissue mass at the umbilicus. Biopsy of this mass, as well as a second mass located at the lateral aspect of the laparotomy incision, showed metastatic carcinoma. The radiation ports were widened to include the two areas of subcutaneous recurrence. The patient subsequently developed a malignant pleural effusion and had a progressively downhill course. She expired 6 months after her cholecystectomy.
DISCUSSION
Laparoscopic cholecystectomy, although still in its infancy, has become accepted as appropriate treatment for most patients requiring cholecystectomy. Malignancy of the gallbladder, although a relatively rare lesion, must be sought in the patient with an atypical presentation of cholecystitis. The finding of a migratory thrombophlebitis in our presented case, it seems, should have raised suspicion and prompted further investigation. CT scan done immediately postoperatively was negative for any signs of malignancy, so the predictive value of this test, had it been done preoperatively, is questionable.
FIG. 1. indicates
Intraoperative photograph of the gallbladder just before division of the final attachments to the area
of tumor.
363
liver. Arrow
GORNISH ET AL.
n at
i:
\*
y
-..
rIf***.
*
':^^-«
'
Í :.... 'siib
FIG. 2.
Histologie section of the tumor (X 10).
r
«
•
I
m
w
3 I
'lia
i
\ %
I
,
ß
»
/
¥
i FIG. 3.
1
Histologie section of the tumor ( X40). 364
•4
CARCINOMA OF THE GALLBLADDER
••; }
Pf '-
FIG. 4.
'\
*
1
*
"V;
Histologie section of the metastatic lesion from the periumbilical soft tissue ( x4).
V
% \
..0,
"»-f
wtk
"jißfe
.
>
#» fa
m
.
FIG. 5.
Histologie section of the metastatic lesion from periumbilical soft tissues ( x40). 365
"-
GORNISH ET AL. Trousseau's syndrome, described in 1865, associated migratory thrombophlebitis with various visceral malignancies. Whether, in fact, this represents a type of coagulopathy has yet to be clearly elucidated.14 Whether in this case the preoperative findings actually represented a migratory thrombophlebitis is not certain, because the details of the symptoms and the extent of the work up are sketchy. However, in an extensive review of the literature Sack et al. reported on 373 accumulated cases of coagulation disorders, including migratory thrombophlebitis, associated with visceral malignancies; only 8 cases (2.1%) were associated with cancer of the gallbladder.I4 Of particular interest is the association between gallbladder cancer and low femoral vein thrombosis in as high as 22.6% of 287 patients.5 If the incidence of gallbladder malignancy truly is 1-2% of all biliary tract operations, a busy surgical practice may expect to encounter cases of gallbladder cancer periodically. There are often no clinical clues to the diagnosis of cancer of the gallbladder, in that one of the most common presentations of this type of of chronic cholecystitis.3 Also, the association of gallstones with cancer malignancy is almost identical to that ' is well known. the of Thus, it is not surprising that the diagnosis of gallbladder cancer is often gallbladder made at the time of surgery. Using the laparoscopic method, it appears that it is possible to implant tumor cells at the trocar sites, especially the umbilical site where the gallbladder often comes in direct contact with the subcutaneous tissues. Although not proven by this anecdotal report, one might assume that the patient's prognosis, however dismal, was probably worsened by the early local recurrence/metastases that may have been related to the operative method. This may be the fourth case reported in the surgical literature of implantation or métastases to a laparoscopic trocar site. The first three cases involved ovarian and gastric carcinoma,l516 but this may represent the first such case related to gallbladder cancer. This is not meant asan indictment of laparoscopic cholecystectomy by any means. It would suggest, however, that should the diagnosis of cancer of the gallbladder be entertained, this may represent a relative contraindication to laparoscopic cholecystectomy.
REFERENCES 1.
Nagorney DM, McPherson
GA: Carcinoma of the
gallbladder
and
extrahepatic
bile ducts. Sem Oncol 1988;
15(2): 106.
Primary carcinoma of the gallbladder. Surg Gynecol Obstet 1978;147:929. Shukla VK, etal: Primary carcinoma of the gallbladder: a review of a 16 year period at the university hospital. J Surg
2. Piehler J, Crihlow R: 3.
Oncol 1985;28:32-35. 4.
KlamerTW, Max MH: Carcinoma of the gallbladder. Surg Gynecol Obstet 1983; 156:641.
5. Sons HU, Borchard F, Joel BS: Carcinoma of the literature. J Surg Oncol 1985;28:1999.
gallbladder: autopsy findings
in 287
cases
and review of the
Wong J, Cheng FCY, Ong GBP: Carcinoma of the gallbladder. Br J Surg 1981;68:161. Hamrick R Jr: Primary carcinoma of the gallbladder. Ann Surg 1983; 195:270. Jones RS: Carcinoma of the gallbladder. Surg Clin North Am 1990;70(6):1419.
6. Koo J, 7. 8.
Wright FH: Carcinoma of the gallbladder. Am Surg 1990;50:275. Ouche K, Owada Y, Matsuno S, Sata T: Prognostic factors in the surgical treatment of gallbladder cancer. Surgery
9. Bair LH, 10.
1989;101:731. 11.
Kopelson G, Gunderson LL: Primary and adjuvant radiation therapy in gallbladder and extrabiliary tract carcinoma. J Clin Gastroenterol 1983;5:43. Saye WB: Laparoscopic cholecystectomy. J MAG 1990:79:157. Reddick EJ, Olsen DO: Reddick laparoscopic cholecystectomy. KTP/532 Clin Update 1990;31. Sack GH Jr, Levin J, Bell W: Trousseau's syndrome and other manifestations of chronic diseminated coagulopathy in patients with neoplasms: clinical, pathophysiologic and therapeutic features. Medicine 1977;561:1-37.
12. McKennan JB, 13.
14.
366
CARCINOMA OF THE GALLBLADDER 15. Miralies RM, Petit J, Baraguere L: Metastatic carcinoma spread at the laparoscopic puncture site. a patient with carcinoma of the ovary. Case report. Eur J Gynecol Oncol 1989;10(6):442.
16. Cava A, Roman J, Gonzalez QA, Martin F, Arambure P: Subcutaneous métastases carcinoma. Eur J Gynecol Oncol 1989:106:442.
Report of a case in
following laparoscopy in gastric
Address reprint requests to: Aron L. Gornish, M.D.
Department of Surgery Section of Laparoscopic Surgery Monmouth Medical Center Long Branch, NJ 07740
367
Brief Clinical
Report
Carcinoma of the Gallbladder Found During Laparoscopic Cholecystectomy: A Case Report and Review of the Literature ARON L.
DAVID AVERBACH, M.D., MARK R. SCHWARTZ, M.D.
GORNISH, M.D.,
F.A.C.S.,
and
ABSTRACT
Laparoscopic cholecystectomy has become an accepted appropriate method for removal of the diseased gallbladder. With cancer of the gallbladder to be expected in 1-2% of all biliary tract operations, it is likely that surgeons may be confronted with the unsuspected finding of gallbladder carcinoma during the course of laparoscopic cholecystectomy. We present here a case of gallbladder carcinoma found at laparoscopic cholecystectomy, and discuss the interesting clinical findings associated with this entity, including the preoperative suggestion of Trousseau's syndrome. A review of the pertinent literature is included.
INTRODUCTION rare malignancy, despite being the fifth most the United States, it will be discovered in approximately 2.5 per persons.1"3 It is expected that gallbladder cancer will be found in about 1% of all biliary tract The disease most often manifests itself in the seventh and eighth decades of life, and in general operations. occurs three times more commonly in women than in men.4 Sons and Borchard in a review of 46,593 autopsies found the incidence of carcinoma of the gallbladder to be approximately 0.62%.5 Despite the association of gallstones in 74-92%, as well as chronic inflammation in the patients with gallbladder cancer, the cause and effect remains relatively ambiguous.1-3 In a review of 315 patients with gallbladder cancer, Shuklaet al.3 found that pain in the right upper quadrant, icterus, and loss of appetite were some of the most common presenting symptoms. However, radiologie and laboratory findings were generally of little help in making the diagnosis.1-3 In fact, Koo et al.6 noted an accurate preoperative diagnosis in less
Adenocarci ngastrointestinal oma (GI) 100,000
of the gallbladder
common
is
a
relatively
tract cancer. In
Department of Surgery, Section of Laparoscopic Surgery,
Monmouth Medical Center,
361
Long Branch,
NJ.
GORNISH ET AL. reviewed. Nevertheless, many patients remain asymptomatic. Conversely, those with carcinoma of the gallbladder have been found to present with symptoms similar to patients diagnosed those of benign biliary tract diseases.7 Therefore, a high index of suspicion becomes a crucial factor. The prognosis of gallbladder cancer is universally grim, with an overall 1-year survival of 11.8% and a 5-year survival of 4.1%.2 The 5-year survival for incidentally found disease is 14.9%.8 In a retrospective review of 30 cases of gallbladder carcinoma, Bair and Wright found their longest survival to be 13 months despite stage or extent of treatment.9 In contrast, Ouche et al. have demonstrated clear improvement in 5-year survival in those patients with 'low DNA scores,' with tumor limited to mucosa (85% 5-year) or muscularis (57% 5-year).'"There remains controversy, however, regarding the correlation of histologie grade, stage, and type of "curative resection" with improved survival. For example, 5-year survival after cholecystectomy with stages I and II has been reported as high as 70-80%.' This is in contrast to a study by Kopelson and Gundersen" who showed a cure rate for "early" gallbladder carcinoma found coincidental to simple cholecystectomy to be less than 50%. And if the degree of extension was transmural, there were no 10-year survivors." This same review showed a high incidence of regional recurrence regardless of grade, lymph node status, or perineural invasion. Since April 1990, the majority of patients at our institution requiring cholecystectomy have had their gallbladder removed laparoscopically. The development of this procedure, and the technique have been described elsewhere.1213 In a personal series of over 200 consecutive laparoscopic cholecystectomies, we have encountered two cases of adenocarcinoma of the gallbladder. The first case occurred in a 41-year-old male medical lab director, and involved quite extensive disease that was not suspected until laparoscopy. He required Iaparotomy to remove the gallbladder and to confirm the diagnosis of malignancy. This patient expired 3 months after surgery of widespread métastases. The second patient in our series found to have carcinoma of the gallbladder is the subject of this presentation. than 10% of the
cases
CASE STUDY A pleasant 53-year-old female presented with a 4-month history of right upper quadrant pain. The pain had been relatively constant over the 4-month period. Almost all foods made the pain worse, including but not limited to fatty foods. She denied fever, chills, or jaundice. She reported occasional nausea, and one episode of vomiting. She denied any prior abdominal surgery, and had no significant medical problems. She did report another interesting set of symptoms, the significance of which did not become clear until later. For several months she reported a history of intermittent local swelling of both lower and upper extremities. The affected area would become swollen, erythematous, and tender, and would resolve within a few days, only to recur elsewhere. This was present for several months prior to her development of abdominal symptoms. Evaluation by her family physician failed to elucidate the etiology of these unusual complaints. She underwent upperGI series, which was normal. Sonography of the abdomen revealed cholelithiasis, and the gallbladder was specifically noted to be of normal size, shape, and configuration. There was no thickening of the gallbladder wall noted, and the liver was reported to be acoustically normal. No abnormality was noted in the pancreas. Bloodwork was completely normal, including liver function studies. Options were discussed with the patient, and it was decided that laparoscopic cholecystectomy would be an appropriate procedure for her. She was scheduled for elective laparoscopic cholecystectomy. Laparoscopy failed to reveal any visual evidence of significant abnormalities, except for a small area of puckering noted at the fundus of the gallbladder, near its junction with the liver edge. The procedure was uneventful, until the final stages of dissecting the gallbladder from the undersurface of the liver with the electrocautery. The tissue at the dome of the gallbladder was noted to be thickened and whitish and quite adherent to the liver over an area of only 1-2 cm. When the final attachments were divided, the gallbladder was withdrawn through the umbilical port, as is usual for laparoscopic cholecystectomy. No bile was spilled intra-abdominally. The gallbladder wall did come in contact with the subcutaneous tissue of the umbilicus. After the neck of the gallbladder was delivered through the abdominal wall, the organ was opened to allow aspiration of bile to facilitate its removal. A small amount of bile spillage onto the abdominal wall and into the umbilical incision occurred at this time. The gallbladder was sent for frozen section analysis. This is not standard procedure, but
362
CARCINOMA OF THE GALLBLADDER there was a suspicion about the thickening at the dome of the gallbladder (Fig. 1 ). The pathologic diagnosis on frozen section was probable adenocarcinoma. The final pathology report returned with a diagnosis of well-differentiated adenocarcinoma of the gallbladder, involving the serosal surface, and approaching the adjacent hepatic parenchyma. The lesion itself was a firm, tan-white nodule, 1.0 cm in diameter, located at the fundus of the gallbladder (Fig. 2). The cystic duct region appeared to be microscopically free of malignancy. CT scan of the abdomen performed on the first postoperative day showed no evidence of metastatic disease. She was referred to Memorial Sloan-Kettering Hospital and underwent surgical exploration 3 weeks after her cholecystectomy. At laparotomy, she was found to have matted fixed portal adenopathy and retroduodenal soft tissue métastases that were histologically confirmed to be metastatic adenocarcinoma consistent with the gallbladder primary. No liver resection was performed. After her discharge, she was begun on a chemotherapy regimen of weekly 5-fluorouracil as well as radiation therapy. Twelve weeks after her laparotomy, her radiation oncologist noticed that she had developed a firm soft tissue mass at the umbilicus. Biopsy of this mass, as well as a second mass located at the lateral aspect of the laparotomy incision, showed metastatic carcinoma. The radiation ports were widened to include the two areas of subcutaneous recurrence. The patient subsequently developed a malignant pleural effusion and had a progressively downhill course. She expired 6 months after her cholecystectomy.
DISCUSSION
Laparoscopic cholecystectomy, although still in its infancy, has become accepted as appropriate treatment for most patients requiring cholecystectomy. Malignancy of the gallbladder, although a relatively rare lesion, must be sought in the patient with an atypical presentation of cholecystitis. The finding of a migratory thrombophlebitis in our presented case, it seems, should have raised suspicion and prompted further investigation. CT scan done immediately postoperatively was negative for any signs of malignancy, so the predictive value of this test, had it been done preoperatively, is questionable.
FIG. 1. indicates
Intraoperative photograph of the gallbladder just before division of the final attachments to the area
of tumor.
363
liver. Arrow
GORNISH ET AL.
n at
i:
\*
y
-..
rIf***.
*
':^^-«
'
Í :.... 'siib
FIG. 2.
Histologie section of the tumor (X 10).
r
«
•
I
m
w
3 I
'lia
i
\ %
I
,
ß
»
/
¥
i FIG. 3.
1
Histologie section of the tumor ( X40). 364
•4
CARCINOMA OF THE GALLBLADDER
••; }
Pf '-
FIG. 4.
'\
*
1
*
"V;
Histologie section of the metastatic lesion from the periumbilical soft tissue ( x4).
V
% \
..0,
"»-f
wtk
"jißfe
.
>
#» fa
m
.
FIG. 5.
Histologie section of the metastatic lesion from periumbilical soft tissues ( x40). 365
"-
GORNISH ET AL. Trousseau's syndrome, described in 1865, associated migratory thrombophlebitis with various visceral malignancies. Whether, in fact, this represents a type of coagulopathy has yet to be clearly elucidated.14 Whether in this case the preoperative findings actually represented a migratory thrombophlebitis is not certain, because the details of the symptoms and the extent of the work up are sketchy. However, in an extensive review of the literature Sack et al. reported on 373 accumulated cases of coagulation disorders, including migratory thrombophlebitis, associated with visceral malignancies; only 8 cases (2.1%) were associated with cancer of the gallbladder.I4 Of particular interest is the association between gallbladder cancer and low femoral vein thrombosis in as high as 22.6% of 287 patients.5 If the incidence of gallbladder malignancy truly is 1-2% of all biliary tract operations, a busy surgical practice may expect to encounter cases of gallbladder cancer periodically. There are often no clinical clues to the diagnosis of cancer of the gallbladder, in that one of the most common presentations of this type of of chronic cholecystitis.3 Also, the association of gallstones with cancer malignancy is almost identical to that ' is well known. the of Thus, it is not surprising that the diagnosis of gallbladder cancer is often gallbladder made at the time of surgery. Using the laparoscopic method, it appears that it is possible to implant tumor cells at the trocar sites, especially the umbilical site where the gallbladder often comes in direct contact with the subcutaneous tissues. Although not proven by this anecdotal report, one might assume that the patient's prognosis, however dismal, was probably worsened by the early local recurrence/metastases that may have been related to the operative method. This may be the fourth case reported in the surgical literature of implantation or métastases to a laparoscopic trocar site. The first three cases involved ovarian and gastric carcinoma,l516 but this may represent the first such case related to gallbladder cancer. This is not meant asan indictment of laparoscopic cholecystectomy by any means. It would suggest, however, that should the diagnosis of cancer of the gallbladder be entertained, this may represent a relative contraindication to laparoscopic cholecystectomy.
REFERENCES 1.
Nagorney DM, McPherson
GA: Carcinoma of the
gallbladder
and
extrahepatic
bile ducts. Sem Oncol 1988;
15(2): 106.
Primary carcinoma of the gallbladder. Surg Gynecol Obstet 1978;147:929. Shukla VK, etal: Primary carcinoma of the gallbladder: a review of a 16 year period at the university hospital. J Surg
2. Piehler J, Crihlow R: 3.
Oncol 1985;28:32-35. 4.
KlamerTW, Max MH: Carcinoma of the gallbladder. Surg Gynecol Obstet 1983; 156:641.
5. Sons HU, Borchard F, Joel BS: Carcinoma of the literature. J Surg Oncol 1985;28:1999.
gallbladder: autopsy findings
in 287
cases
and review of the
Wong J, Cheng FCY, Ong GBP: Carcinoma of the gallbladder. Br J Surg 1981;68:161. Hamrick R Jr: Primary carcinoma of the gallbladder. Ann Surg 1983; 195:270. Jones RS: Carcinoma of the gallbladder. Surg Clin North Am 1990;70(6):1419.
6. Koo J, 7. 8.
Wright FH: Carcinoma of the gallbladder. Am Surg 1990;50:275. Ouche K, Owada Y, Matsuno S, Sata T: Prognostic factors in the surgical treatment of gallbladder cancer. Surgery
9. Bair LH, 10.
1989;101:731. 11.
Kopelson G, Gunderson LL: Primary and adjuvant radiation therapy in gallbladder and extrabiliary tract carcinoma. J Clin Gastroenterol 1983;5:43. Saye WB: Laparoscopic cholecystectomy. J MAG 1990:79:157. Reddick EJ, Olsen DO: Reddick laparoscopic cholecystectomy. KTP/532 Clin Update 1990;31. Sack GH Jr, Levin J, Bell W: Trousseau's syndrome and other manifestations of chronic diseminated coagulopathy in patients with neoplasms: clinical, pathophysiologic and therapeutic features. Medicine 1977;561:1-37.
12. McKennan JB, 13.
14.
366
CARCINOMA OF THE GALLBLADDER 15. Miralies RM, Petit J, Baraguere L: Metastatic carcinoma spread at the laparoscopic puncture site. a patient with carcinoma of the ovary. Case report. Eur J Gynecol Oncol 1989;10(6):442.
16. Cava A, Roman J, Gonzalez QA, Martin F, Arambure P: Subcutaneous métastases carcinoma. Eur J Gynecol Oncol 1989:106:442.
Report of a case in
following laparoscopy in gastric
Address reprint requests to: Aron L. Gornish, M.D.
Department of Surgery Section of Laparoscopic Surgery Monmouth Medical Center Long Branch, NJ 07740
367
