Incidental gallbladder cancer: feasibility and implementation of a selective histopathologic policy

This dissertation explores the feasibility and implementation of selective histopathological (Sel-HP) examination of the gallbladder after a cholecystectomy. The hypothesis is that Sel-HP is safe due to the low incidence of abnormalities in gallbladder pathology and the fact that a previous cholecystectomy is often sufficient, even in cases where abnormalities may have been missed. This controversial topic has faced resistance due to concerns about missing malignancies, potential consequences for the patient, and legal liability. The findings in this dissertation, based on both retrospective and prospective studies, demonstrate that a selective approach is oncologically safe. Moreover, surgeons can adequately identify abnormal gallbladders through macroscopic inspection. To support less experienced surgeons, a standardized macroscopic assessment method and a clinical prediction model have been developed.
Socially, this approach is relevant because gallstone problems are common, and cholecystectomy is one of the most frequently performed surgeries. Although gallbladder cancer is rare, it has serious consequences, requiring careful management. Economically, Sel-HP offers significant savings by avoiding unnecessary histopathological examinations. This reduces costs and provides pathologists with more room for other investigations. Especially in countries with limited resources, this policy can be valuable. While selective approaches may result in higher costs per examined specimen, the net effect is positive. The results of this study can contribute to policy changes in hospitals, both in the Netherlands and internationally. The dissertation emphasizes the importance of implementation by training young surgeons and widely sharing conclusions at conferences. This promotes a shift from routine to selective approaches, which are both cost-saving and clinically safe. In the Netherlands, it is expected that more hospitals will transition to Sel-HP, supported by the robust evidence in this research.