Introduction Gallbladder cancer is an uncommon primary intra-abdominal malignancy, with around 800 new cases diagnosed in the UK each year.1Nevertheless, routine histopathological analysis of cholecystectomy specimens is current practice within many trusts. In our unit, a tertiary centre for hepatobiliary surgery, we perform approximately 1000 cholecystectomies per annum. Histological testing requires in the range of 15–60 min per gallbladder analysed, at a fixed cost of £64.95.
We aim to determine the cost-benefit value of routine histopathological testing in light of current demographics and ever-increasing financial constraints.
Method Retrospective analysis of all cholecystectomy cases performed over 1 year (October 2013–14). Histopathology reports were reviewed and case notes analysed in those identifying malignancy. All new diagnoses of gallbladder malignancy within the trust during the same time period were also analysed for patient demographics, clinical presentation and imaging findings.
Results 983 cholecystectomies were performed, with 70 cases excluded due to known intra-abdominal malignancy or incorrect coding. Median age was 51 years (range 16–90 years) with female:male ratio 2.5:1. 90.7% of cases were elective, 45.0% day-case, with 91.5% performed laparoscopically (conversion rate = 5.5%). Gallbladders were sent for histological testing in 92.9%. Most were reported as chronic cholecystitis (85.0%). Malignancy was identified in 2 cases (0.22%) and dysplasia in a further 5 cases (0.55%), however no patients in this subgroup underwent further surgery or curative oncological treatment.
During the same period, a total of 8 cases of gallbladder carcinoma were diagnosed within the trust. Median age was 68.5 years. 37.5% of patients had previous history of non-biliary malignancy and all patients had at least 1 feature of locally advanced disease on imaging performed at first presentation.
Conclusion Our results show that cost and time implications for routine histopathological testing cannot be justified in the majority of cases of routine cholecystectomy for gallstone disease. Certainly in patients under 60 years of age with no risk factors, the probability of incidental diagnosis of gallbladder cancer is negligible.
In our trust, this cohort comprises 592 cases per year, 65% of our total activity. Selective testing in these cases, based on risk factors, imaging and macroscopic examination of specimens, could give a saving of up to £38,450 per year.
We combine our findings with concurrent analysis of gallbladder carcinoma patients to deduce guidelines for selective histopathological testing of cholecystectomy specimens.
Disclosure of interest None Declared.
Cancer Research UK. Risks and causes of gallbladder cancer, 2014
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