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Incidental Gallbladder Cancer at Cholecystectomy: When Should the Surgeon Be Suspicious?

Pitt, Susan C. MD*; Jin, Linda X. BS*; Hall, Bruce L. MD, PhD, MBA*,†,‡,§; Strasberg, Steven M. MD*; Pitt, Henry A. MD

doi: 10.1097/SLA.0000000000000485
Original Articles

Background: Preoperative predictors of incidental gallbladder cancer (iGBC) have been poorly defined despite the frequency with which cholecystectomy is performed. The objective of this study was to define the incidence of and consider risk factors for iGBC at cholecystectomy.

Methods: The American College of Surgeons-National Surgical Quality Improvement Program (ACS-NSQIP) database (2005–2009) was used to identify all patients who underwent cholecystectomy (N = 91,260). Patients with an International Classification of Diseases, Ninth Revision, diagnosis of gallbladder malignancy who underwent a laparoscopic cholecystectomy (LC; n = 80,924) or open cholecystectomy (OC; n = 10,336) alone were included.

Results: The incidence of iGBC was 0.19% (n = 170) for all cholecystectomy cases, but 0.05% at LC, 0.60% at LC converted to OC (P < 0.001 vs LC), and 1.13% at OC (P < 0.001 vs others). Patients undergoing OC were 17.3 times more likely to have iGBC than LC patients. Age 65 years or older, Asian or African American race, ASA (American Society of Anesthesiologists) class 3 or more, diabetes mellitus, hypertension, weight loss more than 10%, alkaline phosphatase levels 120 units/L or more, and albumin levels 3.6 g/dL or less were associated with iGBC. Multiple logistic regression identified having an OC, age 65 years or older, Asian or African American race, an elevated alkaline phosphatase level, and female sex as independent risk factors. Patients with 1, 2, 3, and 4 of these factors had a 6.3-, 16.7-, 30.0-, and 47.4-fold risk of iGBC, respectively, from a zero-risk factor baseline of 0.03%.

Conclusions: Surgeons' suspicion for GBC should be heightened when they are performing or converting from LC to OC and when patients are older, Asian or African American, female, and have an elevated alkaline phosphatase level.

The American College of Surgeons-National Surgical Quality Improvement Program database was used to determine the incidence of (0.19%), and risk factors for, and 30-day outcomes of patients with incidental gallbladder cancer at cholecystectomy. Type of procedure, age, race, laboratory values, and sex all had associations with the risk of incidental gallbladder cancer.

*Department of Surgery, Washington University School of Medicine in St Louis, St Louis, MO

Washington University Olin Business School, and Center for Health Policy, St Louis, MO

St Louis VA Medical Center, St Louis, MO

§BJC Healthcare, St Louis, MO

Temple University School of Medicine, Philadelphia, PA.

Reprints: Susan C. Pitt, MD, Washington University School of Medicine, 660 South Euclid Ave, Campus Box 8109, St Louis, MO 63110. E-mail:

Data were presented at the American College of Surgeons Surgical Forum on October 2, 2012.

Disclosure: The authors did not receive any funding for this study. Dr Hall is a paid consultant for the American College of Surgeons. No other conflicts of interest exist.

© 2014 by Lippincott Williams & Wilkins.