Surgical treatment of gallbladder cancer

Gallbladder cancer is usually a fatal illness because early stages of this carcinoma cause no specific signs or symptoms. Although the best chance of cure for gallbladder cancer remains incidental discovery, radical resection of the gallbladder, with the adjacent liver, adherent structures, plus a regional lymphadenectomy, has been suggested to improve survival. We retrospectively analyzed all patients with gallbladder cancer who were treated surgically at Mayo Clinic (Rochester) between 1984 and 2000. There were 131 patients for whom complete survival information was available. Patients who underwent a radical cholecystectomy had a significantly longer median survival (24 months) than patients who had a simple cholecystectomy (6 months) or noncurative treatment (4 months) (P < 0.0001). The radical cholecystectomy group had significantly longer survival than the simple cholecystectomy group for all American Joint Committee on Cancer (AJCC) stages except stage I. Of the different variables tested in a univariate analysis (sex, surgical treatment modality, AJCC stage, tumor grade, jaundice, hyperbilirubinemia, and adjuvant therapy), all variables except sex, tumor grade, and adjuvant therapy were statistically significant predictors for the survival of patients with gallbladder cancer. AJCC stage and surgical treatment modality were the only significant predictors in a multivariate analysis. Our results support radical surgical resection for the treatment of gallbladder cancer to improve patient survival. Presented at the Forty-Fourth Annual Meeting of The Society for Surgery of the Alimentary Tract, Orlando, Florida, May 18–21, 2003 (oral presentation).     

Surgical management of gallbladder cancer

Gallbladder cancer is a very common malignancy in the northern part of India. Surgery is the only potentially curative modality of treatment for this disease. Radical cholecystectomy is the optimal surgical standard for resectable gallbladder cancer. This includes cholecystectomy, liver resection (wedge, segments 4b and 5, or extended right hepatectomy), and regional lymphadenectomy along the hepatoduodenal ligament, behind the duodenum and pancreatic head, common hepatic artery and celiac axis. Controversies regarding extent of liver resection, lymphadenectomy and role of multiorgan resection have been discussed. Incidental gallbladder cancer is often detected on histopathologic examination of the simple cholecystectomy specimen removed for a presumed gallstone disease. Revision surgery should be performed for incidental cancers that invade muscularis propria or beyond (T1b or more). Advanced gallbladder cancer should be treated non-operatively with a palliative intent. Obstructive jaundice in the setting of an advanced gallbladder cancer can be palliated with biliary stenting by endoscopic or transhepatic means. Occasionally, a surgical biliary bypass may be indicated to relieve intractable pruritus in a jaundiced patient with gallbladder cancer. There is no role of a planned R2 resection of advanced gallbladder cancer for the purpose of cytoreduction. Further improvement in the management of gallbladder cancer will need integration of systemic chemotherapy with radical surgery.     

晚期胆囊癌的手术治疗（附40例报告）

为提高晚期胆囊癌的手术切除率及生存率，作者对１９８９年５月至１９９５年１２月手术治疗的４０例晚期胆囊癌患者进行了回顾性分析，其中３４例伴有阻塞性黄疸，８例扪及腹部包块。作者对已浸润周围器官及胆管、但尚无肝脏广泛转移或远处转移的１１例晚期胆囊癌进行了扩大根治术（其中３例合并胰十二指肠切除术）。该１１例术后存活８～３２个月。１、２年生存率分别为５４．５％及２７．３％。对另２９例已有肝脏转移或腹膜种植转移的晚期胆囊癌仅行姑息性手术，术后随访均于１年内死亡。作者认为晚期胆囊癌治疗应行扩大根治术。     

胆囊癌外科治疗与临床预后分析

目的 研究胆囊癌临床特征,分析探讨影响其预后的有关因素,为提高胆囊癌预后提供临床依据。方法 选取我院2008年1月至2014年12月96例胆囊癌患者的临床资料,采用Kplan-Meier法对确定的单因素进行生存分析,用Cox回归法进行多因素分析。结果 单因素生存分析显示,手术方式（x²=32.209,P<0.001）、TNM分期（x²=109.408,P<0.001）、淋巴结转移（x²=69.691,P<0.001）、肿瘤部位（x²=10.667,P= 0.014）、p53（P<0.05）、MSH2（P<0.05）和CK7（P<0.05）影响胆囊癌预后,而年龄（x²=10.039,P=0.844）、性别（x²=0.664,P=0.415）等与胆囊癌预后无关。Cox多因素分析发现：TNM分期（P<0.001）、手术方式（P= 0.004）、淋巴结转移（P=0.008）为影响胆囊癌预后的独立危险因素。结论 胆囊癌呈现发病隐匿、临床症状无特异性、恶性程度高且预后差等特点。其中多数患者伴有腹痛、胆囊结石、黄疸、淋巴结转移,TNM分期越高的患者预后更差,根治性切除术可改善患者的预后。多因素分析表明TNM分期、手术方式、淋巴结转移为影响胆囊癌预后的独立危险因素。     

原发性胆囊癌69例的外科治疗

目的 总结原发性胆囊癌的治疗经验,探讨提高原发性胆囊癌生存率的方法。方法 回顾性分析了我院１９８６－１９９９年收治的６９例胆囊癌病例资料。本组诊断依赖于临床表现和影像学检查,Ⅰ期４％,Ⅱ期７％,Ⅲ期１５％,Ⅳ期１７％,Ⅴ期５７％。６８％的病例行手术治疗。结果 本组术前诊断率８４％,Ｂ超和ＣＴ是提高诊断率的重要手段。手术切除率４９％,长期存活者仍以Ⅰ、Ⅱ期病例为主,单纯胆囊切除术即可获得良好的存活率,３年为１００％,Ⅲ期病例术后２年存活率为５０％。结论 手术是治疗Ⅰ、Ⅱ、Ⅲ期病例的首选方法。手术能使Ⅳ、Ⅴ期患者的短期存活率稍有延长,早期诊断和手术切除是提高手术疗效的关键。对于有高危因素的无症状胆囊结石和隆起样病变患者,应行预防性胆囊切除。     

早期胆囊癌中肿瘤直接扩散的手术学意义研究

目的 相当部分的胆囊癌主瘤附近伴随着肿瘤的直接蔓延,因此,早期胆囊癌行胆囊切除术时必须避免手术切缘残留肿瘤细胞.方法 于第二军医大学长征医院普外科经胆囊切除的36例侵犯不超过肌层胆囊癌病例入选,标本分别在显微镜下和肉眼下观察,以明确临床病例特征和肿瘤表面直接扩散的危险因素.结果 70%(25例)标本主瘤附近出现肿瘤直接蔓延,比较有、无直接蔓延的两组病例,表明肿瘤侵犯胆囊擘的深度有决定性意义,多变量分析表明,表面隆起类型是肿瘤直接蔓延的独立预后因素,位于胆囊颈部的表面直接蔓延较之位于胆囊底部生长显著.而且,肿瘤进展期越高,表面直接蔓延越广泛.结论 邻近主瘤表面直接蔓延是非常频繁的,特别是在表面隆起的类型,必须保证切缘的阴性,可以在术中经冰冻切片来确认.     

Trimodality therapy for advanced gallbladder cancer

We conducted a retrospective review of all patients who underwent surgical extirpation for stage III, stage IV, or recurrent carcinoma of the gallbladder. Between 1991 and 1999 ten patients underwent surgical resection for advanced gallbladder cancer. All patients received adjuvant therapy either pre- or postoperatively. Radiotherapy was used in all patients and chemotherapy in 90 per cent of patients. Two patients subsequently underwent resection for locally recurrent disease. An additional patient with stage II disease initially was also treated surgically for a local recurrence. Surgical management involved cholecystectomy and resection of various amounts of liver surrounding the gallbladder bed and regional lymphadenectomy. Contiguously involved structures were resected en bloc. Resection of recurrent disease included excision of all gross tumor. The median overall survival excluding the one 30-day mortality was 53.6 months (range 8-73 months). Four patients have survived 4 or more years, and currently four patients are alive and disease free at 73, 49, 33, and 8 months. Median disease-free interval after each resection of recurrent disease was 13.8 months (range 4-28 months). We conclude that trimodality therapy in selected patients with stage III, IV, or recurrent carcinoma of the gallbladder is possible and may result in prolonged survival.     

Surgical therapy of liver cancer

An account is given in this paper of surgical treatment of malignant tumors of the liver of patients in the Surgical Department of Charité over the past six years, with reference being made to both indications for surgery and therapeutic results. - In the period under review, treatment was applied to 335 patients with malignant tumors of the liver, among them 168 with liver metastases. Thirty-eight per cent of all tumours treated were localised in the right lobe and 19 per cent in the left. The portal hilum was affected in 15 per cent of all cases and the entire liver in 28 per cent. Promising curative therapy was considered practicable for 67 patients, whereas three underwent palliative surgery. Liver transplantation was performed on 21 patients with malignant tumours not accessible to meaningful surgical approach. The resection rate in cases of liver malignoma was 14.6 per cent. The record included 14 hemihepatectomies on the right side and eleven on the left as well as 24 instances of atypical or segment removal, primarily in cases of liver metastasation. Surgical lethality amounted to 6.1 per cent, while the three-year survival rate was 55 per cent, with the most favourable results being recorded from hepatocellular carcinoma with 81 per cent. Only seven per cent of 265 patients with inoperable malignant liver tumours were left alive after one year. Impaired wound healing, the most common postoperative complication, had to be coped with in 21 per cent of all cases. The rate of complications proved to be substantially controllable by pre-operative conditioning and careful postoperative intensive care.     

Unexpected gallbladder cancer:Surgical strategies and prognostic factors

Gallbladder cancer is the most common tumor of the biliary tract and it is associated with a poor prognosis.Unexpected gallbladder cancer is a cancer incidentally discovered,as a surprise,at the histological examination after cholecystectomy for gallstones or other indications.It is a potentially curable disease,with an intermediate or good prognosis in most cases.An adequate surgical strategy is mandatory to improve the prognosis and an adjunctive radical resection may be required depending on the depth of invasion.If the cancer discovered after cholecystectomy is a pTis or a pT1a,a second surgical procedure is not mandatory.In the other cases(pT1b,pT2 and pT3 cancer) a re-resection(4b + 5 liver segmentectomy,lymphadenectomy and port-sites excision in some cases) is required to obtain a radical excision of the tumor and an accurate disease staging.The operative specimens of re-resection should be examined by the pathologist to find any "residual" tumor.The "residual disease" is the most important prognostic factor,significantly reducing median disease-free survival and disease-specific survival.The other factors include depth of parietal invasion,metastatic nodal disease,surgical margin status,cholecystectomy for acute cholecystitis,histological differentiation,lymphatic,vascular and perineural invasion and overall TNM-stage.     

Surgical therapy of thyroid cancer

There are controversial views and discussions on surgical treatment of thyroid cancer. A retrospective study covering the period from 1979 through 1988 has been conducted by the authors to analyse resective approaches to thyroid cancer. Operations were performed on papillary carcinoma in 37.6% and on follicular carcinoma in 31.8% of the cases. An overall five-year survival rate for differentiated thyroid cancer was recorded from 81.5%, with 100% in stage T1N0M0 (microcarcinoma) according to publications. Hence, much less radical procedures like hemithyroidectomy is fully supported by the authors for microcarcinoma. The total thyroidectomy only should be applied to differentiated thyroid cancer in the advanced stages, to medullary and anaplastic carcinoma.     

原发性胆囊癌58例分析

目的　总结原发性胆囊癌的治疗经验 ,探讨提高原发性胆囊癌生存率的方法。方法　回顾性分析了我院 1990～ 2 0 0 0年收治的 5 8例胆囊癌病例的临床资料。结果　 5 8例患者中 ,男性 2 1例 ,女性 37例。B型超声与CT的确诊率分别为 5 9.6 %、72 %。手术切除率为 4 7.4 % ,无手术死亡。Ⅰ、Ⅱ期病例行单纯胆囊切除即可获得良好的生存率 ,其 3年存活率为 10 0 % ,5年存活率为 75 % ,Ⅲ、Ⅳ期病例行根治术后 2年存活率为 4 6 .2 % ,Ⅴ期病例术后存活多不超过 1年。结论　B型超声与CT仍是诊断原发性胆囊癌的重要手段。手术是治疗原发性胆囊癌的首选方法 ,早期诊断和早期根治性手术是提高原发性胆囊癌生存率的关键。对有高危因素的患者 ,应早期行胆囊切除术。     

原发性胆囊癌43例分析

目的 总结原发性胆囊癌的治疗经验，探讨提高原发性胆囊癌生存率的方法。方法回顾性分析我院1995—2005年收治的43例胆囊癌病例的临床资料。结果 43例患者中，男14例，女29例。B型超声与CT的确诊率分别为80．9％、85．7％。Ⅰ、Ⅱ期病例行单纯胆囊切除即可获得良好的生存率，其3年存活率为100％，5年存活率为75％，Ⅲ、Ⅳ期病例行根治术后2年存活率为46．2％，Ⅴ期病例术后存活多不超过1年。结论 B型超声与CT仍是诊断原发性胆囊癌的重要手段。手术是治疗原发性胆囊癌的首选方法，早期诊断和早期根治性手术是提高原发性胆囊癌患者生存率的关键。对有高危因素的患者，应早期行胆囊切除术。     

胆囊癌手术治疗90例分析

目的:探讨胆囊癌手术切除范围的合理选择。方法:回顾性分析1998年1月至2007年6月间由单一手术组完成的90例胆囊癌手术病例的临床与随访资料。结果:全组男35例,女55例,平均年龄57±10岁。按TNM分期,Ⅰa期1例,Ⅰb期4例,Ⅱa期6例,Ⅱb期23例,Ⅲ期36例,Ⅳ期20例。根据所实施手术方式的不同,分为3组,行根治性切除19例,扩大根治性切除31例,姑息性手术40例。全组总体5年累积生存率为26.1%。根治性手术组1、3、5年累积生存率分别为76.5%、59.3%、0%,扩大根治组1、3、5年生存率分别为57.4%、45.9%、45.9%。姑息手术组仅有1年累积生存率,为6.3%。三组比较差异显著,有统计学意义(P<0.05)。胆囊癌淋巴结转移率较高(86.6%),淋巴结转移与否与术后疗效明显相关。胆囊癌扩大根治组各种并发症发生率(48.4%,15/31)明显高于其他两组。结论:根治性或扩大根治性切除对改善胆囊癌的预后有积极意义。手术切除范围应考虑到病人的全身情况、肿瘤局部情况、淋巴结受累情况、医疗条件以及根治性切除是否可以做到局部无癌残留等多种因素。     

胆囊癌新辅助治疗研究现状

胆囊癌发病率逐年增高,目前治疗效果欠佳,为了改善胆囊癌患者的预后,有必要加强胆囊癌新辅助治疗研究.本文通过回顾已发表和正在开展的胆囊癌新辅助治疗研究,跟踪胆囊癌转化治疗(包括肿瘤化疗、放疗、免疫和靶向治疗)最新研究进展,对胆囊癌新辅助治疗研究现状进行阐述.     

Surgical treatment for advanced gallbladder cancer: indications and limitations

We have aggressively performed extensive surgery including major liver resection for advanced gallbladder cancer since 1979. The 5-year survival rates for stage IVa and IVb patients after curative resection were 19% and 6%, respectively. Seven patients in the stage IVa group (n = 69) and one in stage IVb (n = 16) have survived for more than 5 years. The hospital mortality rate including all deaths within and over 30 days of curative operation for stage IV gallbladder cancer was 19%. Although radical resection is the only treatment of choice for advanced gallbladder cancer to obtain long-term survival, there are serious problems in extensive surgery. The most important issue is reduction of the hospital mortality rate. Elucidation of the clinical and molecular characteristics leading to potential long-term survival and development of new strategies for the treatment of recurrent tumors are also important issues.     

Surgical therapy of lung cancer.

A total of 1,615 patients with a confirmed diagnosis of lung cancer were treated at Roswell Park Memorial Institute between 1963 and 1974. Particular emphasis was given in this review to the 295 patients that underwent surgical resection of their primary lung lesion. Factors such as histology, type of resection, sex, age, staging, and degree of dissemination were considered possible influences on survival. The risks and benefits of intentional reductive or palliative surgery are considered along with the risk related to thoracotomies performed for diagnostic purposes.     

萎缩胆囊的外科处理

目的 探讨萎缩性胆囊的外科治疗经验.方法 对2002年10月至2005年10月经手术治疗的萎缩性胆囊(炎)85例进行回顾性分析.结果 术中医源性胆道损伤3例,肠道损伤2例,术后残余小胆囊1例,胆道残余结石1例,胆石性肠梗阻1例,术后死亡2例.结论 萎缩性胆囊炎常伴有许多复杂的临床问题,选择恰当的治疗方法 可降低术后并发症的发生.