title: Anticipatory extended cholecystectomy: the 'Lucknow' approach for thick walled gall bladder with low suspicion of cancer.
abstract: BACKGROUND
  Gall stones (GS) cause inflammation of the gall bladder (GB) i.e., chronic cholecystitis (CC) and xantho-granulomatous cholecystitis (XGC) which can result in a thick walled GB (TWGB). Gall bladder cancer (GBC) may also present as TWGB. While CC and XGC can be treated with simple cholecystectomy (SC), GBC merits extended cholecystectomy (EC). We propose a new surgical approach, anticipatory extended cholecystectomy (AEC), for doubtful TWGB in the belief that AEC would not violate the sacrosanct cholecysto-hepatic plane in doubtful cases and thereby not ruin the chances of cure for a patient whose GB demonstrates malignancy on frozen section histopathology. The addition of lymphadenectomy in cases which turn out to be malignant completes the procedure for GB cancer, but spares all problems related to lymphadenectomy in an undeserving patient.
  
  
  METHODS
  AEC involves removal of GB with a 2-cm wedge of liver, which is then subjected to frozen section histological examination. Lymphadenectomy is performed if GBC is confirmed. AEC was performed in 13 patients between January 2011 and June 2014. During the same period, 1,673 SC for CC/XGC and 116 EC for GBC were performed.
  
  
  RESULTS
  All patients were symptomatic for GS (3 with acute cholecystitis). Ultrasonography (US) raised suspicion of GBC in 11 patients. CT raised suspicion of GBC in 9 patients. Preoperative FNAC was done in 2 patients; in 1 it was negative and in 1 it was suspicious for malignancy. Preoperative diagnosis was GBC in 8, TWGB in 2, XGC, porcelain GB and GB perforation in 1 each. AEC and frozen section was done in all 13 patients. It was reported as GBC in 2 patients and as suspicious of GBC in 1 patient; lymphadenectomy was performed in these 3 patients. Final histopathology revealed XGC in 9, CC in 2 and GBC in 2 patients.
  
  
  CONCLUSIONS
  In patients with TWGB on US/ CT with low suspicion of cancer, AEC serves as a triage-if frozen section biopsy turns out to be positive for GBC, AEC can be completed to EC by performing lymphadenectomy. We wish to name this approach as the 'Lucknow' approach for TWGB.
authors.affiliation: Sanjay Gandhi Post-graduate Institute of Medical Sciences (SGPGIMS), Lucknow, India. vkkapoor.india@gmail.com.
authors.forename: Vinay K
authors.initials: VK
authors.lastname: Kapoor
authors.affiliation: Department of Surgical Gastroenterology, Sanjay Gandhi Post-graduate Institute of Medical Sciences (SGPGIMS), Lucknow, India.
authors.forename: Rakesh
authors.initials: R
authors.lastname: Singh
authors.affiliation: Department of Surgical Gastroenterology, Sanjay Gandhi Post-graduate Institute of Medical Sciences (SGPGIMS), Lucknow, India.
authors.forename: Anu
authors.initials: A
authors.lastname: Behari
authors.affiliation: Department of Surgical Gastroenterology, Sanjay Gandhi Post-graduate Institute of Medical Sciences (SGPGIMS), Lucknow, India.
authors.forename: Supriya
authors.initials: S
authors.lastname: Sharma
authors.affiliation: Department of Surgical Gastroenterology, Sanjay Gandhi Post-graduate Institute of Medical Sciences (SGPGIMS), Lucknow, India.
authors.forename: Ashok
authors.initials: A
authors.lastname: Kumar
authors.affiliation: Department of Surgical Gastroenterology, Sanjay Gandhi Post-graduate Institute of Medical Sciences (SGPGIMS), Lucknow, India.
authors.forename: Anand
authors.initials: A
authors.lastname: Prakash
authors.affiliation: Department of Surgical Gastroenterology, Sanjay Gandhi Post-graduate Institute of Medical Sciences (SGPGIMS), Lucknow, India.
authors.forename: Rajneesh Kumar
authors.initials: RK
authors.lastname: Singh
authors.affiliation: Department of Surgical Gastroenterology, Sanjay Gandhi Post-graduate Institute of Medical Sciences (SGPGIMS), Lucknow, India.
authors.forename: Ashok
authors.initials: A
authors.lastname: Kumar
authors.affiliation: Department of Surgical Gastroenterology, Sanjay Gandhi Post-graduate Institute of Medical Sciences (SGPGIMS), Lucknow, India.
authors.forename: Rajan
authors.initials: R
authors.lastname: Saxena
mesh_terms: D000328:Adult; D000368:Aged; D002763:Cholecystectomy / Q000379:methods*; D002764:Cholecystitis / Q000000981:diagnostic imaging / Q000473:pathology / Q000601:surgery*; D005260:Female; D005500:Follow-Up Studies; D005706:Gallbladder Neoplasms / Q000000981:diagnostic imaging / Q000473:pathology / Q000601:surgery*; D006801:Humans; D008197:Lymph Node Excision / Q000379:methods; D008297:Male; D008875:Middle Aged; D009367:Neoplasm Staging; D011379:Prognosis; D011446:Prospective Studies; D012189:Retrospective Studies; D014463:Ultrasonography; D055815:Young Adult
keywords: Chronic cholecystitis (CC); extended cholecystectomy (EC); gall bladder cancer (GBC); thick walled gall bladder (TWGB); xantho-granulomatous cholecystitis (XGC)