title: A prospective analysis of the preoperative assessment of duodenal involvement in gallbladder cancer.
abstract: BACKGROUND
  Duodenal involvement occurs frequently in gallbladder cancer (GBC) as a result of the proximity of the duodenum to the gallbladder.
  
  
  METHODS
  The study group included 74 GBC patients assessed between August 2009 and March 2011 in whom computed tomography (CT) of the abdomen indicated suspicion for duodenal involvement.
  
  
  RESULTS
  Of 172 patients with resectable GBC, 74 (43.0%) had suspected duodenal involvement on imaging. Of these, 51 (68.9%) had suspected duodenal involvement on upper gastrointestinal endoscopy (UGIE). Symptoms of gastric outlet obstruction (GOO) were present in only 14 (18.9%) patients. Thirteen (17.6%) patients underwent staging laparoscopy alone. Of the 61 patients who underwent laparotomy, 31 (50.8%) were found to have actual duodenal involvement. The positive predictive value (PPV) of CT of the abdomen for duodenal involvement was 50.8% (31 of 61 patients). The addition of UGIE increased the PPV to 65.9% (27 of 41 patients). In the subgroup with evidence of duodenal mural thickening or mucosal irregularity on CT of the abdomen (n= 9) or duodenal mucosal infiltration on UGIE (n= 14), the PPV increased to 100%. A total of 33 (44.6%) patients underwent curative resection. The resectability rate was significantly lower in patients with symptoms of GOO [two of 14 (14.3%) vs. 31 of 60 (51.7%); P= 0.010], CT findings of duodenal mural thickening or mucosal irregularity compared with only loss of the fat plane [two of 12 (16.7%) vs. 31 of 62 (50.0%); P= 0.032], and UGIE evidence of duodenal infiltration compared with extrinsic compression or normal endoscopic findings [three of 16 (18.8%) vs. 18 of 35 (51.4%) and 12 of 23 (52.2%), respectively; P= 0.027 and P= 0.036, respectively].
  
  
  CONCLUSIONS
  Overall, CT of the abdomen demonstrated a PPV of 50.8% in detecting duodenal involvement, which increased to 65.9% with the addition of UGIE. The combined presence of GOO symptoms, CT findings of duodenal mural thickening and mucosal irregularity, and UGIE findings of infiltration of the duodenal mucosa significantly decreases resectability but does not preclude resection.
authors.affiliation: Departments of Gastrointestinal Surgery, Govind Ballabh Pant Hospital and Maulana Azad Medical College, Delhi University, New Delhi, India.
authors.forename: Raja
authors.initials: R
authors.lastname: Kalayarasan
authors.forename: Amit
authors.initials: A
authors.lastname: Javed
authors.forename: Amarender S
authors.initials: AS
authors.lastname: Puri
authors.forename: Sunil K
authors.initials: SK
authors.lastname: Puri
authors.forename: Puja
authors.initials: P
authors.lastname: Sakhuja
authors.forename: Anil K
authors.initials: AK
authors.lastname: Agarwal
mesh_terms: D004386:Duodenum / Q000000981:diagnostic imaging / Q000473:pathology* / Q000601:surgery; D016099:Endoscopy, Gastrointestinal; D005260:Female; D005706:Gallbladder Neoplasms / Q000000981:diagnostic imaging / Q000473:pathology* / Q000601:surgery; D006801:Humans; D007413:Intestinal Mucosa / Q000000981:diagnostic imaging / Q000473:pathology* / Q000601:surgery; D008297:Male; D008875:Middle Aged; D009361:Neoplasm Invasiveness; D009367:Neoplasm Staging; D011237:Predictive Value of Tests; D011300:Preoperative Care; D011379:Prognosis; D011446:Prospective Studies; D013270:Stomach / Q000473:pathology; D014057:Tomography, X-Ray Computed