19例原发性胆囊癌疗效分析

目的:探讨浸润肌层的胆囊癌是否是局部疾病,行单纯胆囊切除术后是否要行二次根治手术治疗方法:回顾分析了19例浸润肌层的原发性胆囊癌患者,8例行单纯胆囊切除术,11例行根治性淋巴结清扫术68个区域淋巴结被检查平均随访时间97个月结果:组织学检查均未发现血管浸润,1例有淋巴管浸润淋巴结均未见转移10年生存率为89%,单纯胆囊切除术与根治术结果相比,差别无统计学意义.2例行根治术的患者死于肿瘤复发结论:多数浸润肌层的早期原发性胆囊癌仅是局部扩散,行单纯胆囊切除术后不需再行根治术。     

Contribution of silent gallstones in gallbladder cancer

Silent (asymptomatic) gallstones are detected frequently with the widespread use of abdominal ultrasonography. The presence of gallstones is found strongly associated with gallbladder carcinoma. Studies on the natural history and most decision analysis studies do not favor prophylactic cholecystectomy for patients with silent gallstones. Gallbladder carcinoma is known to be highly aggressive and lethal disease with a poor outcome. It is rarely diagnosed early and only 10-30% patients are offered radical surgery on presentation. This has lead to a dilemma leading most surgeons to opt for an expectant management of silent gallstones. It thus raises the important question of the implications of leaving asymptomatic gallstones untouched. In this paper the author has reviewed the current understanding on silent gallstones and gallbladder carcinoma.     

Port-site metastasis following laparoscopic cholecystectomy: a review of the literature and a case report.

Port-site metastasis following laparoscopic cholecystectomy with unsuspected gallbladder carcinoma is a serious problem. We reviewed 45 such cases reported in the English literature to date, and add another case which occurred in a 72-year-old female 13 months after a laparoscopic cholecystectomy for gallstones, who also had an unapparent gallbladder carcinoma. Pre-operative diagnosis of gallbladder carcinoma is possible in less than 10% of cases, with a high index of suspicion. If detected during laparoscopy early conversion to open procedure is recommended. If diagnosed later, however, to contemplate further radical operation depending on histopathology would be unwise as a universal approach, because of increased associated morbidity and mortality. The prospect of cure is also very unrealistic in this condition.     

Surgical strategies in patients with gallbladder cancer: nihilism to optimism

INTRODUCTION: Gallbladder cancer is an aggressive disease with dismal results of surgical treatment and a poor prognosis. However, over the last few decades selected groups have reported improved results with aggressive surgery for gallbladder cancer. METHODS: Review of recent world literature was done to provide an update on the current concepts of surgical treatment of this disease. RESULTS: Long-term survival is possible in early stage gallbladder carcinoma. Tis and T1a gallbladder carcinoma can be treated with simple cholecystectomy only. However, in T1b and beyond cancers, aggressive surgery (extended cholecystectomy) is important in improving the long-term prognosis. Laparoscopic cholecystectomy should not be performed where there is a high index of suspicion of malignancy due to the frequent association with factors (such as gallbladder perforation and bile spill) which may lead to implantation of cancer cells and dissemination. Surgical resection for advanced carcinoma gallbladder is recommended only if a potentially curative R0 resection is possible. Aggressive surgery with vascular and multivisceral resection has been shown to be feasible albeit with an increase in mortality and morbidity. However, the true benefit of these radical resections is yet to be realized, as the actual number of long-term survivors of advanced gallbladder carcinoma is few. CONCLUSIONS: Surgery for gallbladder carcinoma, like other malignancies, has the potential to be curative only in local or regional disease. Pattern of loco-regional spread of disease dictates the surgical procedure. Radical surgery improves survival in early gallbladder carcinoma. The long-term benefit of aggressive surgery for advanced disease is unclear and may be offset by the high mortality and morbidity.     

胆囊癌与胆囊结石关系的临床分析

目的　探讨胆囊癌与胆囊结石的关系。方法　对所收集的胆囊癌病人 47例 ,胆囊结石病人 2 86 3例进行了分析。结果　 47例胆囊癌病人均伴有胆囊结石 ,全部经手术治疗。其生存率 :1年为 46例 ( 97.87% ) ,2年 32例 ( 6 8.0 8% ) ,3年 2 8例 ( 5 9.5 7% ) ,4年 12例 ( 2 5 .5 3% ) ,年 2例 ( 4 .2 5 % )。胆囊结石病人 2 86 3例 ,经手术治疗 10 6 9例。结论　胆囊癌与胆囊结石的关系极为密切 ,胆囊结石是诱发胆囊癌的重要因素之一。对胆囊结石的病人行胆囊切除是预防胆囊癌发生的较为有效的方法之一。     

胆囊癌的临床治疗分析

目的　探讨胆囊癌的临床治疗方法及其预后。方法　回顾性分析 161例胆囊癌的临床资料 ,其中单纯胆囊切除 48例 ,根治性胆囊癌切除 41例 ,胆囊癌扩大切除 2 0例 ,胆囊加胰十二指肠切除 3例 ,单纯探查术 7例 ,介入及放化疗 42例。随访 6个月至 5年。结果　行探查术患者 1年内全部死亡 ,单纯胆囊切除和根治性胆囊癌切除患者的 5年生存率分别为 69%、5 9% ,放疗和介入治疗患者的 5年生存率为 0。结论　胆囊癌早期发现 ,并行根治性切除 ,可显著提高 5年生存率     

Laparoscopic cholecystectomy for treatment of unexpected early-stage gallbladder cancer

BACKGROUND AND OBJECTIVES: Laparoscopic cholecystectomy (LC) may result in the incidental diagnosis of early stage (T1 and T2) gallbladder cancer. LC is useful for T1 patients, however, its role in T2 patients remains controversial. We sought to determine the effect of initial LC on patient outcome in early-stage gallbladder cancer. METHODS: Twenty-nine patients with T1 or T2 disease were reviewed retrospectively to assess preoperative diagnosis, intraoperative findings, and outcomes. RESULTS: Diagnoses included gallbladder stones (5), gallstones with polyps (5), and gallbladder polyps (19). Malignancy was suspected in 15 patients (14 polyp lesions and 1 gallbladder stone with wall thickening). After frozen sections, two T2 patients were immediately treated with radical operation owing to positive margins. Of 14 patients diagnosed by pathology, 4 T2 patients with positive margins underwent a second radical operation. Five-year survival rate was 100% and 49.6 % (T1 and T2 patients). No mortality or recurrence was detected in T1 patients (mean follow-up, 45.8 months; range, 6-98 months). Three T2 patients died, and one T2 patient relapsed after LC. No port site metastasis was detected. CONCLUSIONS: LC for T1a and T1b gallbladder cancer needs no additional treatment, however, radical operation for T2 patients is recommended, regardless of the margin condition.     

Incidental carcinoma of the gallbladder.

Incidental gallbladder carcinoma (GBC) is a difficult management issue as there are no established guidelines. Laparoscopic cholecystectomy is associated with increased dissemination of the tumour cells (both in the peritoneal cavity and port sites). Depth of tumour invasion (T stage) and positive surgical margins are the most important prognostic factors, although tumour differentiation, lymphatic, perineural and vascular invasion may also affect the outcome. Simple cholecystectomy is adequate for mucosal (T1a) lesions only. For T1b tumours port site/wound excision with second radical operation (probably extended cholecystectomy -- wedge liver excision with regional lymphadenectomy) should be advised. T2 tumours should be treated with second radical operation (extended cholecystectomy or excision of medial liver segments 4b and 5 or 4, 5 and 8 with regional lymphadenectomy with or without excision of the extra-hepatic bile duct). Few T3 tumours can be cured and in some survival time may be prolonged by a second radical operation. More extensive liver resection (segments 4b and 5 or segments 4, 5 and 8) with regional lymphadenectomy with excision of the extra-hepatic bile duct should be advised. A second radical operation may palliate some T4 tumours. In the absence of extensive nodal disease, this operation may prolong the survival time. Excision of the extra-hepatic bile duct should be undertaken whenever the tumour involves the cystic duct margin or the extra-hepatic biliary tree. Epidemiology, risk factors, aetiopathogenesis and the modes of spread of GBC are discussed in relation to appropriateness of the second radical operation. Indications, types and role of the second radical operation are discussed.     

Laparoscopic cholecystectomy and gallbladder cancer

Heightened awareness of the possible presence of gallbladder cancer (GBC) and the knowledge of appropriate management are important for surgeons practising laparoscopic cholecystectomy (LC). Long-term effects of initial LC versus open cholecystectomy (OC) on the prognosis of patients with GBC remain undefined. Patients who are suspected to have GBC should not undergo LC, since it is advantageous to perform the en-bloc radical surgery at the initial operation. Since preoperative diagnosis of early GBC is difficult, preventive measures, such as preventing bile spillage and bagging the gallbladder should be applied for every LC. Many port-site recurrences (PSR) have been reported after LC, but the incidence of wound recurrence is not higher than after OC. No radical procedure is required after postoperative diagnosis of incidental pT1a GBC. It is unclear if patients with pT1b GBC require extended cholecystectomy. In pT2 GBC, patients should have radical surgery (atypical or segmental liver resection and lymphadenectomy). In advanced GBC (pT3 and pT4), radical surgery can cure only a small subset of patients, if any. Additional port-site excision is recommended, but the effectiveness of such measure is debated.     

The surgical management of incidental gallbladder carcinoma.

AIMS: To report the surgical management of carcinoma of the gallbladder. METHODS: A retrospective study in 65 patients who underwent simple (SC) or extended (EC) cholecystectomy for gallbladder carcinoma. RESULTS: 28 patients underwent extended cholecystectomy (EC) and 37 had simple cholecystectomy (SC). The multivariate analysis showed that lymph-node status (positive vs negative, p=0.001, Hazard Ratio [HR]:14.2, 95% Confidence Interval [CI]:3.1-62.8) and type of surgery (SC vs EC, p=0.01, HR:10.2, 95% CI:1.7-62.8) were the most important prognostic factors related to death. This analysis indicated that EC in those with pT(2) or pT(3) was associated with a reduce hazard of death by 90% in the follow-up period. CONCLUSIONS: In gallbladder cancer patients who diagnose after simple cholecystectomy, those with pT(1) with clear margins need no further surgery. In patients with pT(2) or pT(3) incidental carcinoma, the completion radical re-operation is the only chance for long-term survival.     

Laparoscopic cholecystectomy and unsuspected gallbladder cancer.

Gallbladder cancer is a relatively uncommon malignancy. Its presentation is similar to that of gallstone disease and sometimes with non-specific symptoms. Laparoscopic cholecystectomy has become the method of choice for removing the gallbladder in most benign conditions. Occasionally, unsuspected gallbladder carcinoma is encountered in association with laparoscopic cholecystectomy. Overall gallbladder cancers have a poor prognosis, despite surgery or adjuvant therapies. However, in selected cases, a favourable outcome can be expected and the less favourable predicted outcome can be improved. Management of patients with gallbladder cancer in different situations is discussed: gallbladder cancer noted post-operatively on final pathology, gallbladder cancer noted after removal of the gallbladder and opening of the specimen at the time of surgery, difficulty encountered at the time of dissection and resultant suspicion of gallbladder cancer, and diagnosis of extensive disease at initial placement of the laparoscope. Copyright Harcourt Publishers Limited.     

Diagnosis and surgical treatment of cancer of the gallbladder and extrahepatic bile ducts]

Data on 148 cases of cancer of the gallbladder and extrahepatic bile ducts were studied. Jaundice proved the cardinal symptom. No clear-cut clinical picture of the disease was identified. Diagnostic procedure should start with ultrasonography. Cholangiectasia and the enlarged pancreatic head make the case for fiber bronchoscopy and hypotonic duodenography. Cancer-negative patients should further undergo transcutaneous transhepatic cholangiography and, if proving still negative, retrograde cholangiopancreatography. Resection of bile ducts with simultaneous lymphadenectomy is considered radical. The authors suggest a surgical procedure for cancer of the gallbladder which includes resection of the liver, hepatico-choledoctomy and cholecystectomy with formation of cholangio-jejuno-anastomosis using disposable transhepatic drains. Recanalization of bile ducts by transhepatic drain is considered optimal for palliation. Survival depends upon extent of surgery and level of bile duct obstruction.     

Overexpression of p53 protein in gallbladder carcinoma in North India.

AIMS: p53 mutations are one of the most frequent genetic alterations in human cancers and are thought to play a role in pathogenesis of several malignancies. Overexpression of p53 in gallbladder cancer has not previously been reported from North India which has one of the highest incidence of this malignancy in the world. The present work is aimed at studying the overexpression of p53 in gallbladder carcinoma occurring in North India. METHODS: p53 overexpression by immunohistochemistry was studied in 20 operative specimens of gallbladder carcinoma. The clinico-pathological observations of these patients were correlated with the extent of p53 overexpression. RESULTS: Seventy per cent (14/20) of specimens of gallbladder carcinoma overexpressed p53 protein. There was a significant correlation between presence of gallstones, T stage, grade of tumour and liver invasion with p53 overexpression. There was no significant correlation with other factors studied viz. age, sex, nodal status and histological type. CONCLUSIONS: The results show a strong association between gallstones and p53 protein overexpression in gallbladder carcinoma. The causal relationship in this association, however, still remains unproven.     

Clinicopathological Study of Gall Bladder Carcinoma with Special Reference to Gallstones: Our 8-year Experience from Eastern India

Gallbladder carcinoma (GBC) is the commonest cancer of the biliary tree and the most frequent cause of deathfrom biliary malignancies. The incidence of GBC shows prominent geographic, age, race, and gender-relateddifferences and is 4-7 times higher in patients with gallstones. This prompted us to study the clinicopathologicalaspects of the disease and the incidence of gallstones in gallbladder carcinoma patients, in this part of India. Inthis, combined retrospective (Jan 2004-March 2010) and prospective study (April 2010-Dec 2011) of eight years,198 patients of gallbladder carcinoma (50 males and 148 females), (range 28-82 years; mean 55 years) were studied.Most of the patients were poor and presented with abdominal pain and mass, with abnormal lab parameters.Gallstones were present in 86% of patients. Surgical exploration was performed in 130, with gallbladder resectionin 60 (including 7 incidental GBC). Adenocarcinoma (87.7%) was the commonest histological type. The studyindicates that GBC is common in our scenario. It is a disease of elderly females, has a strong association withgallstones and every cholecystectomy specimen should be examined histopathologically.     

中晚期胆囊癌手术方式的临床分析

目的：探讨中晚期胆囊癌手术方式与预后关系。方法：回顾性分析1997年1月至2005年1月间收治的85例中晚期胆囊癌的临床资料，施行胆囊癌根治性切除术40例，扩大根治术25例，姑息性手术20例。结果：均获得病理诊断，腺癌51例（60％），最为常见。65例行根治术＋扩大根治术和85例总的术后的1年、3年、5年生存率分别为80．0％、61．5％、49．2％；67．1％、47．1％、37．6％。结论：胆囊癌根治术＋扩大根治术是提高中晚期胆囊癌切除率和疗效的有效方法。     

Treatment of primary carcinoma of the gallbladder--report of 33 cases

33 cases of primary carcinoma of the gallbladder confirmed by operation from 1962 to 1983 are reported. It comprises 2.7% of all patients undergoing cholecystectomy during the same period. One was diagnosed preoperatively. The lesions were resected in 17 (51.5%), of which 12 were associated with gallstones, and survived for an average of 21 months, while those unresected survived for 3 months. The overall 5-year survival rate was 4.5%. The correlation of the gallbladder cancer with cholecystitis, gallstones and other related organic changes is discussed. The diagnosis is difficult and prognosis remains poor unless the cancer is diagnosed by operation at early stage. For this reason, it is suggested that preventive cholecystectomy on elderly patients with cholecystitis and gallstones be likely to lead to better results.     

Gallbladder cancer: a global perspective

Gallbladder cancer, the commonest malignancy of the biliary tract worldwide, is common in northern India. It can be clinically obvious, an unexpected finding at laparotomy, detected incidentally on histological examination or may be missed only to present with recurrence during follow up. US, CECT, uppeer gastro-intestinal endoscopy, and laparoscopy are useful for diagnosis and staging. We have adopted a 'middle path'--between pessimistic nihilism of the West and aggressive radicalism of Japan--of management, i.e., extended cholecystectomy for early disease confined to the gallbladder and hepato-dudodenal ligament, and non-surgical palliation for advanced disease. The aetiological role of gallstones in the causation of gallbladder cancer needs to be investigated to decide the place of prophylactic cholecystectomy, if any.     

Treatment of recurrent Merkel cell carcinoma: an analysis of 46 cases

This report describes the course of recurrent Merkel cell carcinoma and defines possible treatment strategies for recurrent disease as seen in a long-term multisite retrospective analysis. Merkel cell carcinoma is a highly aggressive neuroendocrine skin cancer. Surgery and radiation therapy have been demonstrated ability to control this disease; however, recurrence is common. Systemic chemotherapy has, as yet, no presently defined role in primary treatment, and few conclusions can be reached regarding optimal treatment of disease recurrence. Forty-six patients were identified over the last 15 years in a retrospective analysis of patient records from several hospitals in the San Antonio, TX area. Hospital charts as well as outpatient treatment records were reviewed. Almost all patients developing recurrent disease did so within the first 2 years after primary treatment. Patients presenting distant disease had a median survival of 12 months, faring worse than those who display local or nodal disease. For patients with nodal or local recurrence, the mean survival after combination therapy (chemotherapy, radiation +/- surgery) was 36.5 months as compared with 17.5 months for those treated with a single modality (surgery or radiation or chemotherapy). The overall survival rate for the 46 patients with recurrence was 37%. Multimodality therapy has shown the best results for recurrent Merkel cell carcinoma thus far, and should be used if tolerated by the patient. Aggressive salvage surgery for local or nodal recurrence is encouraged, because this disease has a tendency to become more destructive upon recurrence. Adjuvant radiation therapy should also be used, if the patient has not exceeded their dose limitations. Disseminated disease, whether primary or recurrent, warrants further investigation in terms of optimal treatment.     

Primary carcinoma of gallbladder in Yazd, Iran: A 14-year study (1992–2006)

Aim: To investigate the clinico‐pathological profile and stage of disease at presentation of patients with carcinoma of the gallbladder diagnosed during 1992–2006 in Iran. Methods: During this study period 34 consecutive patients with gallbladder carcinoma were identified using a pathology‐based tumor database. The data extracted for each study patient included their gender, age at diagnosis, signs and symptoms, presence of gallstones and histopathological pattern of the gallbladder carcinoma and the UICC/AJCC TNM staging system was used for labeling the stages of the disease. Results: The median age of the 34 patients studied was 69.50 with most between 61 and 70 years of age. The age range of the men was between 53 and 80 years with a median age of 71.50 years and that of the women was between 33 and 79 years with a median age of 68.50 years. The most common symptom was pain in the right hypochondrium. More women had gallstones (15/34) than men (3/10). Adenocarcinoma was the most common histopathological type (91.18%) with the commonest subtype being papillary (47.06%). Eighteen patients had stage IB and stage IIA (52.94%) carcinomas whereas stages IIB and III were observed in six (17.6%) and seven cases (20.6%), respectively. Only three cases (8.82%) were seen in stage IV. The follow up of gall bladder carcinoma (GBC) patients in this study ranged from 6 to 60 months. However, there was a progressive reduction of patients attending follow‐up oncology clinic, particularly by those who had stages III and IV of the disease. Conclusion: Most patients (52.94%) presented with early disease (stage IB and IIA) which carries a good prognosis. Early detection of GBC and a national consensus for the evidence‐based management of GBC in Iran should be the major components of a strategy aimed at improving therapeutic outcome.     

Laparoscopic cholecystectomy and unsuspected gallbladder carcinoma.

Gallbladder cancer is a relatively uncommon malignancy in the United States. Its presentation is similar to that of lithic disease of the gallbladder. Laparoscopic cholecystectomy has become the method of choice for removing the gallbladder in most benign conditions. Occasionally, unsuspected gallbladder carcinoma is encountered in association with laparoscopic cholecystectomy. Overall, gallbladder cancer portends a poor prognosis. However, in select cases, a favorable outcome can be expected and the less favorable predicted expected outcome can be improved. Management of patients with gallbladder cancer in different situations is discussed: gallbladder cancer noted postoperatively on final pathology, gallbladder cancer noted after removal of the gallbladder and opening of the specimen at the time of surgery, difficulty encountered at the time of dissection and resultant suspicion of gallbladder cancer, and diagnosis of extensive disease at initial placement of the laparoscope. The technique of extended cholecystectomy is outlined.