search
for
 About Bioline  All Journals  Testimonials  Membership  News  Donations


Indian Journal of Surgery
Medknow Publications on behalf of Association of Surgeons of India
ISSN: 0972-2068
Vol. 68, Num. 1, 2006, pp. 23-26

Indian Journal of Surgery, Vol. 68, No. 1, January-February, 2006, pp. 23-26

Original Article

Missed malignancies at laparoscopic cholecystecomy: A new emerging problem

Department of Surgical Oncology, Institute of Medical Sciences, Banaras Hindu University, Varanasi
Correspondence Address:Hari S. Shukla, 7, SKG Colony, Lanka, Varanasi - 221005, India. E-mail: harishukla@usa.net

Code Number: is06004

Abstract

Objective: With increase in laparoscopic cholecystectomy (LC) rates the chances of missing a concomitant cancer is high, if the laparoscopic surgeon is focused on gall bladder and does not look around. The aim of the present article therefore is to analyze the unsuspected concomitant cancer, for patients with atypical upper abdominal symptoms and diagnostic delay due to LC.
Materials and Methods:
This retrospective study evaluates the clinico- pathological data, diagnostic delay and outcome of patients who presented with intra-abdominal malignancy to our unit within 2-8 months of LC for gallstone disease elsewhere, between June 2003 and June 2005.
Results:
Six such patients were identified (age range 38-62 years). Two patients had carcinoma of the stomach, one each had carcinoma of the caecum, ascending colon and left ovary respectively, while one patient presented with malignant ascitis of unknown origin. Five of these 6 patients underwent a subsequent radical oncological procedure at our unit. Mean diagnostic delay was 4 months. The cTNM of tumor at diagnosis was Stage III/ IV in 5 of these 6 patients.
Conclusion:
The importance of a good clinical work-up, diagnostic imaging studies and exploration at the time of surgery is re-emphasized. Missing a concomitant lesion is high, if the surgeon focuses only on one organ during an LC.

Keywords: Missed malignacies, laparoscopic cholecystectomy, emerging problem

The safety and efficacy of laparoscopic cholecystectomy (LC) is now widely accepted for benign gall bladder diseases and has resulted in increasing number of cholecystectomies being performed. [1],[2],[3],[4] The benefits of LC are obvious in relation to reduced post operative pain, more rapid convalescence and better cosmetic results.[5],[6] A serious, albeit less frequently reported hazard of LC is a missed underlying pathology [Table - 1]. [6],[7],[8],[9],[10],[11],[12],[13],[14],[15],[16],[17],[18],[19],[20],[21],[22],[23],[24]

This article reports the case histories, diagnostic delay and the resultant impact on the patient′s prognosis due to an intra-abdominal malignancy missed in 6 such patients during LC outside our unit. The available reports on missed diagnosis after LC from indexed medical literature are also reviewed and discussed.

Materials and Methods

The data of all patients who had undergone LC elsewhere for suspected gall stone disease and then were either referred or presented themselves for various reasons to the Department of Surgical Oncology between June 2003 and June 2005, were reviewed from our own department′s patient′s follow up record books. Of these, patients diagnosed as having an intrabdominal malignancy within 2-8 months of LC were sorted out.

The age, sex and clinical symptoms at presentation to our unit, that prior to LC and the delay in diagnosis of a malignancy missed at LC elsewhere, were recorded as mentioned in the records. A thorough staging evaluation of each of these patients was carried out followed by a standard oncological procedure and adjuvant/ palliative therapy at our unit. The outcome of the patients was also retrospectively analyzed.

Results

In all, six patients with an intra-abdominal malignancy within 2-8 months of LC elsewhere, were identified from 46 patients who were admitted for various reasons following LC outside our unit, between June 2003 and June 2005. The age of the 6 patients selected, ranged from 38 to 62 years, with mean age of 51± 9.16 years. Among the 6 patients, 4 were female and 2 male.

Five of these 6 patients required re-exploration for malignant tumor missed at LC, while one was managed non-surgically. All six patients had complained of atypical upper abdominal pain before LC elsewhere. An abdominal ultrasonography and histology (done outside our unit), had revealed chronic cholecystitis in all these 6 patients.

The diagnostic delay ranged from 2-8 months (mean 4 months). The site of the malignant tumor, diagnostic delay and outcome is summarized in [Table - 2 ]. Five patients underwent curative resection, while one patient was diagnosed to have advanced cancer and was managed with palliative chemotherapy and supportive care.

Case 1
A 45 year old woman with a history of episodic right upper abdominal pain, but no complaints of altered bowel habits or bleeding per rectum, underwent LC at a private nursing home. The histopathology reported chronic cholecystitis.

The patient was referred to Department of Surgical Oncology, 3 months following LC, with complaints of weight loss and blood mixed stools. Abdominal computed tomography and colonoscopy at our department showed a circumferential tumor in caecum. The Carcinoembryonic Antigen (CEA) level was within the normal range. After the colonoscopic biopsy confirming an adenocarcinoma, a radical right hemicolectomy was performed. The histology revealed it to be a well differentiated adenocarcinoma of the caecum with metastasis to 4 of 12 regional lymph nodes (Dukes C). She also received standard 6 courses of adjuvant chemotherapy (5-Fluorouracil 425 mg/m2 D1-5, given after Folinic acid 20 mg/m2 D1-5 x q 4 weeks).

Case 2
A 62 year old man with a history of pain in the right upper abdomen was diagnosed as having a gall stone disease by abdominal ultrasonography and underwent LC. He presented 8 months later with pain upper abdomen, loss of weight and appetite. Upper GI endoscopy and barium meal showed an ulceroproliferative growth at pyloric antrum, in the stomach. After staging evaluation and endoscopic biopsy confirming adenocarcinoma, the patient underwent a radical D2 distal gastrectomy. The histology revealed a moderately differentiated adenocarcinoma with subserosal invasion and lymph node metastasis in 7 of 20 lymph nodes dissected. The patient was given 6 cycles of adjuvant FAMTX regimen (5-Fluorouracil 1,500 mg/m2 i.v. D1 ; Doxorubin 30 mg/m2 i.v. D15 ; Folinic acid 15 mg/m2 p.o, every 6 hours for total 12 doses, starting 24 hours after methotrexate dose; Methotexate 1,000 mg/m2 i.v. D1 x q 4 weeks)

Case 3
A 60 year old preterminal woman presented with deep icterus and gross ascitis following LC for suspected gall stone disease. Cytology of ascitic fluid revealed malignant (adenocarcinoma) cells. The primary site could not be ascertained and this patient was given palliative chemotherapy (Cisplatin 75 mg/m2 i.v. D1 and 5-Fluorouracil 500 mg/m2 i.v. D1-5 x q 4 weeks) and supportive care.

Case 4
A 38 year old woman presented with a lump in the lower abdomen, 2 months after LC. Abdominal computed tomography was suggestive of a malignant left ovarian mass. Total abdominal hysterectomy and bilateral salpingo oophrectomy was done and histology revealed serous cyst adenocarcinoma (grade III). The patient received 6 cycles of adjuvant chemotherapy (Carboplatin AUC=7.5 i.v. D1 and Paclitaxel 175 mg/m2 i.v. 3 hours infusion D1 q 3 weeks).

Case 5
A 48 year old woman with a history of intermittent upper abdominal pain underwent LC for cholelithiasis. She was referred to our unit 3 months later, with complaints of generalized weakness, weight loss and altered bowel habits. A colonoscopy showed ulceroproliferative growth in the ascending colon. The biopsy confirmed an adenocarcinoma. Her CEA was 4.26 ng/ml. The patient was salvaged by a standard radical right hemicolectomy. Histology of the resected specimen revealed well differentiated adenocarcinoma, with serosal invasion. Eleven of 16 lymph nodes dissected were positive for malignancy. She was given adjuvant chemotherapy (5-Fluorouracil and Folinic acid).

Case 6
A 53 year old man with history of pain in upper abdomen, was diagnosed of having a gall stone disease by abdominal ultrasonography. The patient underwent LC at a nursing home. He presented 2 months later with similar complaints, to our department. An upper GI endoscopy showed an ulcerative growth in the stomach. The patient underwent D2 radical gastrectomy and histology revealed well differentiated adenocarcinoma, with serosal invasion and metastasis in 11 of 20 lymph nodes dissected. He was also given adjuvant chemotherapy (FAMTX).

Discussion

Since its first description in 1985, the technique of LC has undergone great technical refinements, as well as general acceptance for uncomplicated and complicated cholelithiasis. A potential disadvantage of LC is its lost ability to palpate abdominal organs, which the formal laparotomy of open cholecystectomy previously allowed.

It appears that the enthusiasm with which LC is now performed, has led to labelling of anyone who presents with right upper abdominal pain and a positive ultrasound, as having symptomatic cholelithiasis. Asymptomatic gallstone or those discovered incidentally, generally require no further treatment, but with the advent of LC, its application has increased inadvertently.

The six patients that we are reporting, highlight the emerging problem of missed malignancies during LC. In our study, the delay in diagnosing malignancy was between two to eight months, post LC. Fortunately, a curative radical resection was still possible in 5 patients. The stage at presentation was advanced in the majority, with a relatively short delay in diagnosis. It can be emphasized further, that as a cancer grows rapidly, even a small delay can be detrimental.

There have been reports of missed malignancies at the time of LC, in the world literature but the incidence has infrequently been quantified. According to related articles describing cancer missed during LC [Table - 1], the delay in diagnosis ranged from 2 weeks to 24 months and majority of tumors were advanced at presentation and the mean incidence of missed intra abdominal pathologies is 0.65%.

Patients with atypical symptoms or unusual findings warrant a more detailed preoperative assessment of alternative etiologies, as the resultant delay in the diagnosis of cancer obviously upstage the tumor at the time of presentation and decrease its potential curability, hence overall survival benefit. Should patients under going LC be investigated more thoroughly preoperatively, more intense investigation would probably be of benefit in a small number of patients and thus would not be cost effective. Rickman concluded that the risk is small and that abdominal exploration at the time of treatment of cholelithiasis is unnecessary.[26] The National Institute of Health Consensus Conference on Gall-stone, emphasized that patient of cholelithiasis with atypical pain or dyspepsia needs further investigation to determine the cause of their symptoms.[27]

Open mini-cholecystectomy allows minimal access to other organs and perhaps offers a greater disadvantage than a formal Kocher′s incision, or even a LC. Its use may not be advisable in all patients, especially when diagnosis is doubtful.

Conclusion

This study emphasizes that the success of a treatment should not be compromised to merely utilize the minimally invasive approach. A careful evaluation of each patient, especially the elderly and those with atypical symptoms, along with good visualization of the neighboring organs may aid in preventing such iatrogenic complications in future.

References

1. Macintyre IM, Wilson RG. Laparoscopic cholecystectomy. Br J Surg 1993;80:552-9.  Back to cited text no. 1  [PUBMED]  
2. Wherry DC, Rob CG, Marohn MR, Rich NM. An external audit of laparoscopic cholecystectomy performed in medical treatment facilities of the department of defense. Ann Surg 1994;220:626-34.  Back to cited text no. 2  [PUBMED]  [FULLTEXT]
3. McMahon AJ, Russell IT, Baxter JN, Ross S, Anderson JR, Morran CG, et al. Laparoscopic versus minilaparotomy cholecystectomy: a randomised trial. Lancet 1994;343:135-8.  Back to cited text no. 3  [PUBMED]  
4. The Southern Surgeons Club. A prospective analysis of 1518 laparoscopic cholecystectomies. N Engl J Med 1991;324:1037-8.  Back to cited text no. 4    
5. Perissat J. Laparoscopic cholecystectomy: the European experience. Am J Surg 1993;165:444-9.  Back to cited text no. 5  [PUBMED]  
6. Icoz G, Makay O, Dayangac M, Zeytunlu M, Kilic M, Korkut M. Missed intra-abdominal malignancies after laparoscopic cholecystectomy. Ann Saudi Med 2005;25:172-3.  Back to cited text no. 6  [PUBMED]  
7. Iorgulescu R, Ilie R, Iorgulescu A, Borca V, Dragomirescu C. Intraabdominal malignant pathology missed at laparoscopic cholecystectomy. Chirurgia (Bucur) 2005;100:121-5.  Back to cited text no. 7  [PUBMED]  
8. Malouf AJ, Murray AW, MacGregor AB. Major intra-abdominal pathology missed at laparoscopic cholecystectomy. Br J Surg 2000;87:1434-5.  Back to cited text no. 8  [PUBMED]  [FULLTEXT]
9. Johnson AG. Gall Stone: the real issues. BMJ 1993;306:1114-5.  Back to cited text no. 9  [PUBMED]  
10. Ishida H, Ohsawa, T, Murata N, Fujioka M, Hashimoto D. Risk of missing colorectal cancer during laparoscopic cholecystectomy. Surg Today 2002;32:392-6.   Back to cited text no. 10    
11. Wysocki A, Lejman W, Bobrzynski A. Abdominal malignancies missed during laparoscopic cholecystectomy. Surg Endosc 2001;15:959-61.  Back to cited text no. 11  [PUBMED]  
12. Hamaloglu E, Yorganci K, Oner Z, Sayek I. Missed malignancies during laparoscopic cholecystectomy. Hepatogastroenterology 1999;46:126-9.  Back to cited text no. 12    
13. Gal I, Szivos J, Jaberansari MT, Szabo Z. Laparoscopic cholecystectomy. Risk of missed pathology of other organs. Surg Endosc 1998;12:825-7.   Back to cited text no. 13  [PUBMED]  [FULLTEXT]
14. Sinha SN, Hoffman TA. Laparoscopic cholecystectomy and missed malignancies. Aust N Z J Surg 1998;68:81-3.  Back to cited text no. 14  [PUBMED]  
15. Kalacinski J, Ziaja K, Fraczek J. Missed abdominal neoplasms during laparoscopic cholecystectomy and herniorrhaphy - analysis of material. Wiad Lek 1997;50:246-9.  Back to cited text no. 15  [PUBMED]  
16. Junger W, Junger WG, Hutter J, Miller K, Moritz E. Delayed diagnosis of malignant tumors missed at laparoscopic cholecystectomy, Surg Endosc 1997;11:1010-2.  Back to cited text no. 16  [PUBMED]  [FULLTEXT]
17. Hanney RM, Bond G, de Costa A. Laparoscopic cholecystectomy: the missed diagnosis. Aust NZJ Surg 1997;67:166-7.  Back to cited text no. 17  [PUBMED]  
18. Slim K, Pezet D, Clark E, Chiopponi J. Malignant tumors missed at laparoscopic cholecystectomy. Am J Surg 1996;171:364-5.  Back to cited text no. 18    
19. Kim JS, Lee YC, Chung BW, Chung KS, Lee YJ. Pitfalls in laparoscopic cholecystectomy: unrecognized carcinoma of another site. Surg Laparosc Endosc 1996;6:32-4.   Back to cited text no. 19    
20. Denning DA, Lipshy KA. Missed pathology following laparoscopic cholecystectomy: a cause for concern? Am Surg 1995;61:117-20.  Back to cited text no. 20  [PUBMED]  
21. O'Hanlon DM, Kerin MJ, O'Donoghue JM, Doyle JP, Flynn JR. Laparoscopic cholecystectomy: potential for missed pathology. Ann R Coll Surg Engl 1994;76:315-6.   Back to cited text no. 21    
22. Sharp EJ, Springall RG, Theodorou NA. Delayed diagnosis of malignant tumors missed at laparoscopic cholecystectomy. Br J Surg 1994;81:1650.  Back to cited text no. 22    
23. Morgan AR, Jackson S, Mason MC. Delayed diagnosis of malignant tumors missed at laparoscopic cholecystectomy. Br J Surg 1995;82:569.  Back to cited text no. 23    
24. Williams I, Lloyd-Davies E, Ganta S, Forster ME. Laparoscopic cholecystectomy: potential for missed pathology. Ann R Coll Surg Engl 1995;77:152-3.  Back to cited text no. 24    
25. Renton-Power W. Laparoscopic cholecystectomy: potential for missed pathology. Ann R Coll Surg Engl 1995;77:233.  Back to cited text no. 25    
26. Rickman A, Kistner RL, Schlinkert RT. Complete abdominal exploration is unnecessary during the treatment of cholelithiasis. J Laparosc Surg 1993;3:205-8.  Back to cited text no. 26    
27. NIH Consensus conference. Gallstones and laparoscopic cholecystectomy. JAMA 1993;269:1018-24.  Back to cited text no. 27    

Copyright 2006 - Indian Journal of Surgery


The following images related to this document are available:

Photo images

[is06004t1.jpg] [is06004t2.jpg]
Home Faq Resources Email Bioline
© Bioline International, 1989 - 2019, Site last up-dated on 15-Ago-2019.
Site created and maintained by the Reference Center on Environmental Information, CRIA, Brazil
System hosted by the Internet Data Center of Rede Nacional de Ensino e Pesquisa, RNP, Brazil