Surgery for gallbladder cancer

Surgery is sometimes used to treat gallbladder cancer. The type of surgery you have depends mainly on the size of the tumour and stage of the cancer. When planning surgery, your healthcare team will also consider other factors, such as your age, your overall heath and whether the tumour can be removed with surgery (is resectable).

You may have surgery to:

• completely remove the cancer
• reduce pain and relieve symptoms or blockages in advanced gallbladder cancer (called palliative surgery)

Only a small number of gallbladder tumours can be completely removed because the cancer is usually found at an advanced stage. It may have spread to any of the following:

• both sides of the liver
• the lining of the abdomen (peritoneum)
• major blood vessels
• organs far from the gallbladder

The following types of surgery are used to treat gallbladder cancer. You may also have other treatments before or after surgery.

Surgery to remove the gallbladder is called a cholecystectomy. In a simple cholecystectomy, only the gallbladder is removed. It is done for early stage gallbladder cancer when the tumour is only in the gallbladder. A simple cholecystectomy may be done using a laparoscopic method or an open method.

In gallbladder cancer, an open cholecystectomy is preferred. A laparoscopic cholecystectomy is not done if gallbladder cancer is suspected because there is a chance that cancer cells can spread into the abdomen or along the cuts used for the surgery. In non-cancerous (benign) conditions, a cholecystectomy may be done using an open or a laparoscopic method.

In the open method, the gallbladder is removed through a wide cut in the upper-right part of the abdomen. Sometimes tubes are placed into the wound to drain excess fluid (bile) after the gallbladder has been removed.

When cancer is suspected before a cholecystectomy is done, the open method is used.

Laparoscopic surgery uses a laparoscope (a long, flexible tube with a light and camera at one end) passed into the abdomen through small cuts. A laparoscopic cholecystectomy is done to remove the gallbladder for non-cancerous conditions, such as gallstones or long-term inflammation of the gallbladder (chronic cholecystitis).

If cancer is found during laparoscopic surgery, the surgeon will change the operation to an open cholecystectomy to reduce the chance that any cancer will be left behind or will spread. If cancer is only found after the gallbladder has been removed with laparoscopic surgery, additional surgery may be needed to remove other nearby tissue where cancer may have spread.

Gallbladder cancer is often found by chance after the gallbladder is removed for a non-cancerous disease. If the cancer is diagnosed after a cholecystectomy and has not spread beyond the gallbladder, more surgery is not usually needed. If tests show that cancer has spread near the gallbladder, additional surgery may be needed to remove more tissue.

An extended cholecystectomy is a more complicated surgery. It is done when cancer has spread throughout the gallbladder. An extended cholecystectomy removes:

• the gallbladder
• a small section of liver tissue next to the gallbladder
• all the lymph nodes around the gallbladder (regional lymph nodes)
• tissue surrounding the site of previous laparoscopic surgery to the gallbladder

If the cancer has spread outside the gallbladder, but doctors believe that the cancer can be completely removed, they may do a radical resection. A radical resection removes even more of the surrounding tissue than an extended cholecystectomy. A radical resection removes:

• the gallbladder
• a small section of the liver near the gallbladder
• the cystic or common bile duct
• part of the ligament (band of tissue) between the liver and the intestines
• lymph nodes from around nearby organs, such as the pancreas and nearby blood vessels

To remove as much of the cancer as possible, doctors may also use more surgery to take out other organs around the gallbladder:

• In a Whipple procedure (pancreaticoduodenectomy), part of the bile duct, part of the pancreas, the first part of the small intestine (duodenum) and part of the stomach are removed. Then the surgeon attaches the remaining end of the stomach to the small intestine (gastrojejunostomy). The bile duct and the remainder of the pancreas are attached to the small intestine.
• In a liver (hepatic) resection, part of the liver may be removed if the cancer has spread to the liver. This is done if the cancer is small, does not affect any major blood vessels and can be completely removed with surgery. Doctors may need to remove a complete lobe of the liver (hepatic lobectomy).
• A hepatopancreatoduodenectomy (HPD) removes some liver tissue along with the organs and structures removed during a Whipple procedure. Doctors may consider this surgery in some cases of advanced gallbladder cancer.

Palliative surgery or other procedures are done for gallbladder cancer that is widespread and cannot be removed with surgery. These procedures relieve symptoms, such as jaundice and pain. Jaundice can occur if the tumour causes a blockage (obstruction) in the bile duct or gallbladder.

A stent is a small metal or plastic tube placed into the bile duct. Most stents are made of a wire mesh that expands. The stent helps keep the bile duct open and allows bile to flow into the small intestine.

• The most common way to insert a stent to relieve a blockage of the bile duct is with an endoscopy. The stent is put into place during an ERCP (endoscopic retrograde cholangiopancreatography). Stents may also be inserted with surgery, but that is not as common.
• Another way to place a stent is through the abdomen using an x-ray to guide the doctor during a PTC (percutaneous transhepatic cholangiography). A needle is inserted through the skin into the gallbladder and dye is injected into the bile ducts through the needle. The dye helps show blockages in the biliary tract so the doctor knows where to place the stent. The doctor then uses a guide wire to insert the stent. Once the stent is in place, the needle and guide wire are removed.

Side effects can happen with any type of treatment for gallbladder cancer, but everyone’s experience is different. Some people have many side effects. Other people have few or none at all.

If you develop side effects, they can happen any time during, immediately after or a few days or weeks after surgery. Sometimes late side effects develop months or years after surgery. Most side effects will go away on their own or can be treated, but some may last a long time or become permanent.

Side effects of surgery will depend mainly on the type of surgery and your overall health.

The gallbladder is not a vital organ, so the body can function without it. If doctors need to remove it because of disease, there are few long-term effects. Many of the side effects of gallbladder cancer surgery happen when other organs are also removed.

You may have some of the general side effects of surgery, such as pain, nausea, vomiting or infection. Surgery for gallbladder cancer may also cause these other side effects:

• Diarrhea or more frequent bowel movements happen in up to 20% of people who have their gallbladder removed. After the gallbladder is removed, bile flows directly into the small intestine because the gallbladder is no longer there to store it. Stools also tend to stay in the bowel for less time. Diarrhea may start immediately after gallbladder surgery. It usually improves with time, but in some cases diarrhea can last for many years. There are ways to help control diarrhea after a cholecystectomy. The doctor may recommend antidiarrheal drugs to slow down the bowel. Some changes in diet may help too.
• Post-cholecystectomy syndrome (PCS) can sometimes happen after the gallbladder is removed because it alters the flow of bile. Symptoms include heartburn, indigestion, persistent pain in the upper-right or lower abdomen, diarrhea, bloating or gas, fever or jaundice. PCS can occur right after a cholecystectomy or much later. The healthcare team will recommend medicines to control symptoms. Sometimes surgery is needed to correct the problem.
• A bile leak or bile duct injury is a problem that can sometimes happen after gallbladder surgery. It occurs more often after a laparoscopic cholecystectomy than an open cholecystectomy. Bile leaks or a bile duct injury can cause abdominal pain. An ERCP may be done to determine the source of the leak and place a stent to help drain the bile. Surgery is sometimes needed to repair the leak or injury to the bile duct.
• Digestion problems can happen after a radical resection that includes a Whipple procedure. The pancreas makes digestive enzymes, and removing part of the pancreas can cause a decrease of enzymes. About 1 in 3 people who have a Whipple procedure need to take enzymes to help them digest food. After gallbladder surgery, you may not feel like eating (anorexia) or may feel bloated or full faster. It may be easier to eat small meals throughout the day rather than having 3 large meals. Snacking between meals can also help the body absorb food and lessen bloating or feeling too full.
• Problems with blood sugar levels may develop after radical resection surgery. If part of the pancreas was removed, you may develop diabetes. The chance of developing diabetes is greater if you had blood sugar problems before surgery. The healthcare team will monitor blood sugar levels. Changes in diet and medicines may be needed to control high levels.

Tell your healthcare team if you have these side effects or others you think might be from surgery. The sooner you tell them of any problems, the sooner they can suggest ways to help you deal with them.

Find out more about surgery and side effects of surgery. To make the decisions that are right for you, ask your healthcare team questions about surgery.