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Reassessing the Need for Prophylactic Surgery in Patients with Porcelain Gallbladder Case Series and Systematic Review of the Literature

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Reassessing the Need for Prophylactic Surgery in Patients with Porcelain Gallbladder Case Series and Systematic Review of the Literature ORIGINAL ARTICLE Reassessing the Need for Prophylactic Surgery in Patients With Porcelain Gallbladder Case Series and Systematic Review of the Literature Zarrish S. Khan, MD; Edward H. Livingston, MD; Sergio Huerta, MD Objective: To evaluate the risk of gallbladder cancer had concomitant gallstones (n=9). None of the patients (GBC) in patients with a porcelain gallbladder (PGB). with a PGB had evidence of carcinoma. We also re- viewed the histologic analysis results of 35 cases of GBC Design: Retrospective analysis of our institutional ex- operated on between 1997 and 2009; none of these had perience and a systematic review of the literature. gallbladder wall calcifications. Most patients under- went a laparoscopic cholecystectomy without any post- Setting: Academic teaching facility, Parkland Memo- operative complications. We reviewed 7 published se- rial Hospital, and the Dallas Veterans Affairs Medical Cen- ries that included 60 665 cholecystectomies. The overall ter (all in Dallas, Texas). incidence of PGB was 0.2%, and GBC occurred in 15% of the PGB cases. Most cases of GBC occurring in PGB Patients: Medical records of 1200 cholecystectomies per- were found in the older literature; in the contemporary formed between 2008 and 2009 at Parkland Memorial Hospital, The University of Texas Southwestern Medi- series, there were few reports of GBC associated with a cal Center, and the Dallas Veterans Affairs Medical Cen- PGB. ter were reviewed. Patients with radiologic or histologic evidence of PGB or GBC were included. Conclusions: Porcelain gallbladder is only weakly as- sociated with GBC. Prophylactic cholecystectomy is not Main Outcome Measures: The risk of GBC in indicated for PGB alone and should be performed only patients with a PGB was assessed by contingency table in patients with conventional indications for cholecys- analysis. tectomy. A laparoscopic approach is appropriate for most patients with a PGB. Results: We identified 13 patients with a PGB among 1200 cholecystectomies (1.1%). Most of these patients Arch Surg. 2011;146(10):1143-1147 ORCELAIN GALLBLADDER tion of gallbladder calcification than did (PGB) is relatively uncom- plain film radiography. This has resulted in mon,1-3 but it is a clinically im- a distortion of the evidence base, since what portant entity because of its is called porcelain gallbladder in the mod- association with gallbladder ern era is different from what it was many Pcancer (GBC).2,4,5 As a result of this histori- decades ago. More recent series2,3,6 have sug- cal association, once the diagnosis of PGB gested that the relationship between gall- bladder calcification and cancer is not as clear as is commonly thought. Conse- See Invited Critique quently, we reviewed our own experience at end of article with PGB and performed a systematic re- view of the literature to update treatment has been made, an open cholecystectomy recommendations for this entity. is generally recommended. The relation- ship between PGB and GBC was estab- METHODS Author Affiliations: lished 50 years ago with reports5 describ- Departments of Surgery, The ing an incidence of cancer in PGB exceeding University of Texas INSTITUTIONAL EXPERIENCE 60%. Since these early descriptions, the abil- Southwestern Medical Center (Drs Khan, Livingston, and ity to detect gallbladder calcification has Hospital medical records and radiology and pa- Huerta), and Veterans Affairs changed with newer and more sophisti- thology reports from Parkland Memorial Hos- North Texas Health Care cated diagnostic imaging modalities that pital, The University of Texas Southwestern System (Dr Huerta), Dallas. have far greater sensitivity for the detec- Medical Center, and the Dallas Veterans Af- ARCH SURG/ VOL 146 (NO. 10), OCT 2011 WWW.ARCHSURG.COM 1143 ©2011 American Medical Association. All rights reserved. Downloaded From: https://jamanetwork.com/ on 10/03/2021 145 Citations screened for eligibility 103 Case reports 12 Consecutive case series 16 Review articles (no original 14 Miscellaneous 35 Non-English; reviewed experience to evaluate) 4 Communications to the editor translations and abstracts 7 Studies reported incidence of 2 Images only 68 Cases reviewed (heterogeneous both PGB and GBC; in addition, 8 Opinions regarding diagnostic group with limited ability to draw these confirmed diagnoses by modalities and management general conclusions) histologic examination after of PGB cholecystectomy UT Southwestern experience added 8 Studies included in final analysis Figure 1. CONSORT (Consolidated Standards of Reporting Trials) diagram showing literature review results for porcelain gallbladder (PGB). GBC indicates gallbladder cancer; UT, The University of Texas. fairs Medical Center (all in Dallas, Texas) from 2008 to 2009 possible, the authors of some of the published studies were con- were reviewed for patients who had a diagnosis of PGB. All op- tacted for further information to include in our review.7 erations performed at our institution are entered into a central billing database for the entire department of surgery called SNIPS (Surgical Network Information Processing System). This da- STATISTICAL ANALYSIS tabase was queried for all patients who have undergone cho- lecystectomy during the study period using Current Proce- Descriptive statistics, proportions, and percentages were used dural Terminology codes 47564, 47600, 47605, 47618, 475262, to illustrate the data. The Fischer exact test was used to look 47563, and 47570. Histopathologic and diagnostic imaging was for any association between cancer and PGB. then reviewed for all patients undergoing cholecystectomy to establish the diagnosis of PGB. RESULTS We also reviewed the medical records of 35 patients with GBC who underwent a surgical procedure between 1997 and 2009 and who had pathologic examination results available for We identified 13 patients with PGB in 1200 consecutive review. cholecystectomies performed at Parkland Memorial Hos- The operative reports of patients with PGB were reviewed pital, The University of Texas Southwestern Medical Cen- to determine whether the cholecystectomy was performed lapa- ter, and the Dallas Veterans Affairs Medical Center dur- roscopically or by an open operation. We also reviewed the medi- ing the study period (Table 1). The incidence of PGB cal records for indication of any complications or technical dif- in our series was 1.1%. Most of these patients were women ficulties that occurred. (8 patients [62%]), with a wide age range (32-69 years). Most patients with a PGB had biliary symptoms (9 pa- SYSTEMATIC REVIEW tients [69%]) and concomitant gallstones (9 [69%]) (Table 1). Incidental diagnoses of PGB were made in 3 A systematic review of the literature was conducted. We did patients during radiographic examinations for urinary not perform a meta-analysis because of the extreme heteroge- symptoms, back pain, or trauma. neity of the diagnostic methods and clinical report designs used by studies in the available literature. In addition, there were Of the 13 patients with a PGB, 9 (69%) had complete no prospective, randomized clinical trials or any clinical trial transmural calcifications and 3 (23%) had mucosal cal- with a trial design amenable to statistical data aggregation. Con- cifications. One patient received a diagnosis of PGB af- sequently, this systematic review is reported as a narrative rather ter review of the sonogram and computed tomography than a meta-analysis. A literature review was undertaken using results and underwent surgery for “PGB.” However, post- the MEDLINE database with the following keywords: porce- operative histologic examination did not show wall cal- lain gallbladder, gallbladder calcification, calcified gallbladder, cifications; instead, gallstones were found exclusively, and gallstones, and gallbladder carcinoma. We also used Ovid syn- these may have given the appearance of wall calcifica- tax from 1949 to January 2010, the Cochrane Library, Google, tion on imaging. None of these patients had evidence of and Google Scholar. The clinical trial database Clinicaltrials carcinoma. .gov was also interrogated. The histologic review from the 35 patients with GBC did not demonstrate gallbladder wall calcifications in any PUBLICATION SELECTION specimen. Of 12 patients in whom laparoscopy was at- tempted for PGB, 9 procedures were completed, with 3 We screened 145 citations. There were 12 consecutive series, 103 case reports, 16 review articles, and 14 miscellaneous pub- requiring conversion to open cholecystectomy. In each lications (communications to the editor, reviews, and opinion case, conversion was the result of an inability to obtain articles) on this subject. We did not find any trials or prospec- an adequate critical view of the cystic duct and artery. tive series in the literature (Figure 1). Seven consecutive case There were no operative complications, and all patients series contained sufficient information for review. Wherever recovered uneventfully. ARCH SURG/ VOL 146 (NO. 10), OCT 2011 WWW.ARCHSURG.COM 1144 ©2011 American Medical Association. All rights reserved. Downloaded From: https://jamanetwork.com/ on 10/03/2021 Table 1. Characteristics of 13 Patients With PGB in Our Seriesa Patient No./ Sex/Age, y Symptoms Gallstones Calcification Pattern Surgical Procedure 1/F/57 Abdominal pain Yes Transmural Lap cholecystectomy 2/F/60 Biliary colic Yes Transmural Lap cholecystectomy 3/M/39 Biliary colic Yes Mucosal Lap cholecystectomy 4/F/32 Biliary colic Yes Transmural Lap converted to open cholecystectomy 5/F/59
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