Revision Surgery for Incidental Gallbladder Cancer-Challenging the Dogma: Ideal Timing and Real-World Applicability

Background. There is a lack of consensus on the ideal time interval and therapeutic value of revision surgery in patients with incidental gallbladder cancer (iGBC) in the context of multimodality management. Patients and Methods. Retrospective analysis of an institutional database of patients with iGBC who underwent surgery from January 2010 to December 2019 was performed. Patients who underwent upfront surgery were divided into four time interval groups: A, B, C, and D (< 6 weeks, 6-10 weeks, 10-14 weeks, and > 14 weeks, respectively). Results. A cohort of 517 patients planned for revision surgery was analyzed. Overall, 382 (73.9%) patients underwent upfront surgery while 135 (26.1%) were given neoadjuvant treatment. With median follow-up of 18 months, 2-year overall survival (OS) was 66% and disease-free survival (DFS) was 52.6%, with inferior survival outcomes observed with advancing stage and presence of residual disease on final histopathology. Propensity score-matched analysis after matching for pT stage of cholecystectomy specimen suggested a survival benefit for patients operated between 10 and 14 weeks in terms of OS (p = 0.049) and DFS (p = 0.006). Patients with locally advanced iGBC at presentation had superior OS when operated after neoadjuvant therapy [3-year estimated OS of 59.9% vs 32.3%, respectively (p = 0.001)]. Conclusions. Revision surgery is at best the most accurate staging procedure guiding timely initiation of systemic therapy. Patients with iGBC operated between 10 and 14 weeks after initial cholecystectomy tend to have favorable survival outcomes, although this depends on final disease stage. Revision surgery should also be offered to all patients presenting at any later point of time, if deemed operable.