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Original Investigation
October 26, 2016

Association of Optimal Time Interval to Re-resection for Incidental Gallbladder Cancer With Overall SurvivalA Multi-Institution Analysis From the US Extrahepatic Biliary Malignancy Consortium

Author Affiliations
  • 1Division of Surgical Oncology, Department of Surgery, Winship Cancer Institute, Emory University, Atlanta, Georgia
  • 2Division of Surgical Oncology, Department of Surgery, The Johns Hopkins Hospital, Baltimore, Maryland
  • 3Deputy Editor, JAMA Surgery
  • 4Department of Surgery, Stanford University Medical Center, Stanford, California
  • 5Division of Surgical Oncology, Department of Surgery, Vanderbilt University Medical Center, Nashville, Tennessee
  • 6Department of Surgery, Washington University School of Medicine, St Louis, Missouri
  • 7Department of Surgery, University of Wisconsin School of Medicine and Public Health, Madison
  • 8Division of Surgical Oncology, Department of Surgery, University of Louisville, Louisville, Kentucky
  • 9Department of Surgery, Wake Forest University, Winston-Salem, North Carolina
  • 10Division of Surgical Oncology, The Ohio State University Comprehensive Cancer Center, Columbus
  • 11Department of Surgery, New York University, New York
JAMA Surg. Published online October 26, 2016. doi:10.1001/jamasurg.2016.3642
Key Points

Question  Is there an association between time interval from the initial cholecystectomy to reoperation and overall survival?

Findings  In this multi-institutional cohort study of 207 patients who underwent reoperation for incidental gallbladder cancer, reoperation between 4 and 8 weeks after the initial cholecystectomy was associated with improved median overall survival (40.8 months) compared with reoperation less than 4 weeks (17.4 months) and greater than 8 weeks (22.4 months).

Meaning  Reoperation between 4 and 8 weeks after the initial cholecystectomy appears to be the optimal time interval for re-resection in incidental gallbladder cancer.

Abstract

Importance  The current recommendation is to perform re-resection for select patients with incidentally discovered gallbladder cancer. The optimal time interval for re-resection for both patient selection and long-term survival is not known.

Objective  To assess the association of time interval from the initial cholecystectomy to reoperation with overall survival.

Design, Setting, and Participants  This cohort study was conducted from January 1, 2000, to December 31, 2014 at 10 US academic institutions. A total of 207 patients with incidentally discovered gallbladder cancer who underwent reoperation and had available data on the date of their initial cholecystectomy were included.

Exposures  Time interval from the initial cholecystectomy to reoperation: group A: less than 4 weeks; group B: 4 to 8 weeks; and group C: greater than 8 weeks.

Main Outcomes and Measures  Primary outcome was overall survival.

Results  Of 449 patients with gallbladder cancer, 207 cases (46%) were discovered incidentally and underwent reoperation at 3 different time intervals from the date of the original cholecystectomy: group A: less than 4 weeks (25 patients, 12%); B: 4 to 8 weeks (91 patients, 44%); C: more than 8 weeks (91 patients, 44%). The mean (SD) ages of patients in groups A, B, and C were 65 (9), 64 (11), and 66 (12) years, respectively. All groups were similar for baseline demographics, extent of resection, presence of residual disease, T stage, resection margin status, lymph node involvement, and postoperative complications. Patients who underwent reoperation between 4 and 8 weeks had the longest median overall survival (group B: 40.4 months) compared with those who underwent early (group A: 17.4 months) or late (group C: 22.4 months) reoperation (log-rank P = .03). Group A and C time intervals (vs group B), presence of residual disease, an R2 resection, advanced T stage, and lymph node involvement were associated with decreased overall survival on univariable Cox regression. Only group A (hazard ratio, 2.63; 95% CI, 1.25-5.54) and group C (hazard ratio, 2.07; 95% CI, 1.17-3.66) time intervals (vs group B), R2 resection (hazard ratio, 2.69; 95% CI, 1.27-5.69), and advanced Tstage (hazard ratio, 1.85; 95% CI, 1.11-3.08) persisted on multivariable Cox regression analysis.

Conclusions and Relevance  The optimal time interval for re-resection for incidentally discovered gallbladder cancer appears to be between 4 and 8 weeks after the initial cholecystectomy.

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