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。     

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目的 探讨胆囊癌早期诊治经验。方法 回顾性分析1993－2000年腹腔镜术中发现的41例胆囊癌临床资料。结果 术中探查结合活检明确诊断36例（87．8％）,术后病理诊断5例。I期胆囊癌行腹腔镜胆囊切除术（LC）者,3年生存率100％;Ⅱ期胆囊癌行LC者,3年生存率77．7％,行根治术者,3年生存率100％;Ⅲ期胆囊癌行根治术者,2年生存率75％,3年生存率50％;Ⅳ期胆囊癌行根治术者,2年生存率33％,3年生存率为0;Ⅲ期胆囊癌1例,仅行LC,术后5个月死于肝转移。15例中转剖腹行根治术者,5例未切除套管孔,其中1例切口种植。结论 现代腹腔镜技术可弥补影像学的不足。早期发现胆囊癌并对Ⅱ期以上胆囊癌行根治术,能提高术后生存率,效果优于仅行LC者,对LC中转剖腹手术者,应切除套管孔以防切口种植。     

原发性胆囊癌50例临床分析

目的探讨原发性胆囊癌的临床特点、诊断及治疗。方法回顾性分析13年问行手术治疗的50例原发性胆囊癌的临床资料。结果术前B-US、PTC、ERCP、CT和MRCP检查的诊断符合率分别为60％(30／50)、40％(2／5)、100％(2／2)、80％(16／20)和100％(3／3)。本组无手术死亡，术后无严重并发症。随访32例，随访时间为4个月至7年，其中NevinⅠ期2例、Ⅱ期3例、Ⅲ期5例、Ⅳ期7例及Ⅴ期15例：Ⅰ期术后7年仍存活，Ⅱ期、Ⅲ期、Ⅳ期及V期中行根治术或扩大根治术者术后平均存活时间分别为44、28、22及13个月，姑息性手术或剖腹探查活检共15例，平均生存时间仅3个月。结论B-US、CT、MRCP是诊断胆囊癌的有效无痛方法。根治性手术或扩大根治术是提高胆囊癌生存期的重要手段。     

胆囊癌手术方式的选择

目的 探讨胆囊癌治疗的手术方式。方法 对1980－1999年收治132例胆囊癌患者的临床资料进行回顾性分析。结果 本组患者的平均年龄为55岁,女与男之比为1．5：1。80％的胆囊癌合并胆囊结石。胆囊癌以腺癌为主（87．1％）。前期组（1990年12月前）：单纯胆囊切除11例,胆囊癌根治术9例,胆囊癌扩大根治术5例,姑息性内或外引流术15例,剖腹活检术30例,手术死亡4例,术后并发症20例,其中胆漏4例,胰漏2例。后期组（1991年元月起）：根治性单纯胆囊切除3例,单纯胆囊切除2例,胆囊癌根治术16例,胆囊癌扩大根治术24例,姑息性内或外引流术9例,剖腹活检术8例,手术死亡1例,术后出现并发症12例,其中胆漏1例,胰漏1例。胆囊癌前期组根治切除率35．7％,后期组根治切除率72．6％。结论 外科技术提高和新的手术器械彭氏多功能解剖器（PMOD）的应用能提高胆囊癌切除率。扩大根治术是治疗中晚期胆囊癌积极和有效的措施。     

腹腔镜胆囊切除术意外胆囊癌的诊断与治疗:附23例报告

目的:探讨腹腔镜胆囊切除术(LC)意外胆囊癌的诊断和治疗。方法:回顾性分析1998年1月—2007年1月收治的23例意外胆囊癌患者的临床资料。结果:15例术中快速冷冻病理证实为胆囊癌,其中13例中转开腹行胆囊癌根治术;8例术后病理证实,其中7例行二次开腹手术。全组术后5年生存率为78.3%,患者预后与其临床分期密切相关。结论:意外胆囊癌多为早期胆囊癌,高危病例应重视术中快速病理检查及标本检查;T1b-T2期宜扩大根治,晚期患者视情况行根治性手术或姑息治疗。     

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。     

原发性胆囊癌的诊治分析（附36例报告）

目的探讨原发性胆囊癌（PCG）的诊断与治疗方法。方法回顾性分析我院2001年7月至2008年7月经手术治疗的36例原发性胆囊癌病人的临床资料。结果本组Ⅰ期4例,Ⅱ期4例,Ⅲ期5例,Ⅳ期7例,Ⅴ期16例;根治性切除22例（61．1％）,其中扩大根治手术6例（16．7％）,各种姑息手术10例（27．8％）,另有4例仅行活检术;术后并发症发生率为19．4％（7／36）,围手术期死亡率为2．8％（1／36）。结论胆囊癌早期诊断是提高生存率的关键。手术切除仍是最有效的治疗方法,切除可获得较高生存率。对局部进展的中晚期患者,积极进行扩大根治术有望提高生活质量及延长生存时间。     

腹腔镜胆囊切除术术中或术后意外胆囊癌的处理对策

目的：探讨腹腔镜胆囊切除术（ LC）意外胆囊癌（ UGC）的处理对策。方法回顾性分析我院2005年1月至2012年10月3355例LC,术中和术后发现的8例UGC的临床资料。结果8例UGC,占同期LC的0.24％（8/3355）,术中发现4例,术后发现4例。根据TNM分期（第7版,2009）,其中pTis 2例,pT1b 1例,pT23例,pT42例。pTis及pT1b患者仅行LC,术后均长期存活,最长已超过5年;pT2中2例中转开腹行胆囊癌根治术,术后存活已达半年以上;1例因术后发现,患者拒绝再次手术,术后半年复发;pT4中1例因累及肝脏及肝外胆管,拒绝进一步手术,仅行LC,术后3个月出现戳孔种植,术后6个月死于腹腔广泛转移;1例中转开腹行姑息胆囊切除并取活检,3个月后死于多脏器衰竭。无围手术期死亡患者。结论重视胆囊癌高危因素、完善的术前检查、术中对胆囊标本仔细剖检和快速冰冻检查以及确诊后必要的中转开腹是提高胆囊癌早期确诊率、改善胆囊癌预后的关键。术中应切实采取相关措施降低肿瘤细胞腹腔转移与切口种植的发生率。     

腹腔镜胆囊切除术意外胆囊癌58例诊治分析

[摘 要] 目的 探讨腹腔镜胆囊切除术（LC）意外胆囊癌的诊断与治疗。方法 回顾性分析2007 年5 月至2017 年5 月武警安徽省总队医院收治的意外胆囊癌患者58 例临床资料。结果 LC术中发现24 例,术后发现34例;TNM分期T1b 12例,T2 34例,T3 6例,T4 6例。24例术中快速冰冻病理检查证实为胆囊癌,其中22例中转开腹行胆囊癌根治术;34例术后病理证实,其中24例行二次开腹手术。非根治组：12例,仅行单纯胆囊切除术,术后1、2、3年累积生存率分别为65.0%、42.5%、18.0%。根治组：46例,行胆囊癌根治术,术后1、2、3年累积生存率分别为82.5%、62.5%、45.7%,两组生存曲线比较差异有统计学意义（P＜0.05）。结论 胆囊癌患者预后与手术方式、临床分期密切相关,对存在胆囊癌高危因素的患者,建议尽早行胆囊切除术。意外胆囊癌多为早期胆囊癌,应重视术中检查及病理检查,T1b～T3 期宜行根治手术,晚期患者应根据病情行姑息手术。     

122例原发性胆囊癌外科治疗体会

目的 探讨原发性胆囊癌治疗的措施。方法 对我院1998年4月至2003年2月外科治疗的122例原发性胆囊癌患者的临床资料，结合部分患者随访结果进行分析总结。结果 19例Ⅰ、Ⅱ及Ⅲ期胆囊癌患者手术治疗效果满意；103例Ⅳ、V期胆囊癌患者中34例行根治或扩大根治术，根治切除率为33．O％，余69例行姑息性手术治疗，行胆囊癌根治术后患者的平均生存时间明显长于姑息性手术者(17．6个月vs7．3个月)。结论 对胆囊癌应采取积极的、个体化的治疗措施。扩大根治术可使部分Ⅳ、Ⅴ期胆囊癌患者受益。应注意淋巴结清扫的范围和做到无残留癌的根治性切除。对综合治疗的研究还需进一步深入。     

Laparoscopic cholecystectomy in the treatment of patients with gall bladder cancer

BACKGROUND: Surgical procedures based on the depth of the primary tumor invasion (pT category) have been proposed in the treatment of gallbladder cancer (GBC). Trocar site metastases have been reported in patients who underwent laparoscopic cholecystectomy (LC) for preoperatively undiagnosed GBC. STUDY DESIGN: The aim of this study was to clarify the role of LC as a surgical strategy for GBC. From 1986 to 1998, 56 patients with GBC underwent surgical resection. Survival rates were compared retrospectively according to pT category and use of LC. RESULTS: Five-year survival was 91% for pT1 (n = 13), 64% for pT2 (n = 25), 34% for pT3 (n = 14), and 0% for pT4 tumors (n = 4; p<0.0001). LC was performed on 11 patients (4 with pT1, 5 with pT2, and 2 with pT3 tumors). Of the seven patients with pT2 or pT3 tumors, three underwent a second radical operation, three had an open radical operation to which the procedure was converted from LC, and one underwent no additional procedures. For pT1 tumors, one patient died of trocar site metastasis from bile spillage after LC. For pT2 or pT3 tumors, 5-year survival was 63% for radical surgery (n = 35) and 0% for cholecystectomy alone (n = 4; p<0.05). For pT2 or pT3 tumors treated by radical surgery, 5-year survival was 75% for laparoscopic approach (n = 6) and 60% for open surgery (n = 29; not significant). CONCLUSIONS: LC may help to establish the diagnosis and to determine the surgical strategy for undiagnosed GBC. It is important to prevent spillage or implantation of malignant cells during LC. For pT2 or pT3 tumors diagnosed laparoscopically, a second or converted open radical surgery is necessary.     

动脉置入导管化疗后二期切除治疗晚期直肠癌

目的探讨晚期直肠癌动脉栓塞化疗后二期切除的远期疗效。方法对９６例不能手术根治切除的晚期直肠癌行髂内动脉、直肠上动脉置管栓塞化疗,对其中部分缓解且无远处或局部广泛转移的３１例进行二期切除。结果获随访２９例,死亡８例,２１例健在,其中无癌生存１６例,１,３,５年生存率（寿命表法）分别为９３０％,７８０％,７０８％。结论髂内动脉、直肠上动脉置管栓塞化疗后二期切除晚期直肠癌,提高了根治性切除率和远期疗效。     

Is There a Role for Cholecystectomy in Gallbladder Carcinoma Discovered to be Unresectable for Cure at Laparotomy?

BACKGROUND: Palliative operative resection in patients with locally advanced cancer of the gallbladder (GBC) found not to be amenable to radical resection for cure at exploration has received little attention. This article evaluates the benefits, if any, of cholecystectomy with biliary drainage in such patients. METHODS: Available records of locally advanced but nonmetastatic GBC patients treated in the Department of Surgical Oncology, B.H.U., Varanasi, India, during the last 8 years were retrospectively reviewed. Of these, 30 patients (group I) with GBC (T(3-4),N(0-1),M(0)) treated with cholecystectomy +/- biliary bypass were selected and compared with equal number of controls matched for age (+/-5 years), sex, histopathology, stage, residence, and postoperative chemotherapy who underwent biopsy +/- biliary bypass only (group II) followed by chemotherapy during the same period. Survival rates were calculated by using Kaplan-Meier curves. Follow-up ranged from 1-15 months. RESULTS: The median survival was 7 and 2 months for groups I and II (P < 0.0001), respectively. The 30-day postoperative mortality and morbidity was 3% vs. 12% and 13% vs. 16% in groups I and II, respectively. CONCLUSIONS: Results suggest that a better median survival can be achieved after cholecystectomy in locally advanced unresectable GBC compared with only bypass and biopsy procedures. These findings may justify a palliative cholecystectomy in selected patients with locally advanced GBC.     

Incidentally Detected Gallbladder Cancer- The Controversies and Algorithmic Approach to Management

Incidentally discovered gallbladder cancer (IGBC) is defined as the gallbladder cancer (GBC) diagnosed during or after the cholecystectomy done for unsuspected benign gallbladder disease. Laparoscopic cholecystectomy (LC) is the most common procedure performed for benign gallbladder disease worldwide. Majority of GBC patients have associated gallstones. With the advent of ultrasonography more patients are being diagnosed with gallstones and are being subjected to cholecytectomy. IGBC is found in 0.2–2.9 % of all cholecytectomies done for gallstone disease. It represents 27–41 % of all GBC. Patients with IGBC having Tis and T1a stage, with negative cystic duct margin can be treated by simple cholecystectomy alone. Patients with stage T1b and beyond should undergo restaging, and should be treated with radical re - resection (R0). Residual disease is found in 40–76 % patients on re-exploration. The survival rates of patients undergoing re resection for IGBC is similar to those undergoing primary radical surgery. LC is contraindicated in patients with GBC. Patients presenting post LC should undergo radical re- resection and additional port site excision, as they have a high incidence of port site metastasis. At cholecystectomy for benign gallbladder disease all gallbladder specimens should be opened before closing abdomen and if available all suspicious specimens should be sent for immediate frozen section. All gallbladder specimens should be subjected to histopathology examination to avoid missing GBC. The surgeon should have a high index of suspicion for GBC if encountering difficult cholecystectomy for a benign disease, and in patients with atypical clinical and ultrasound findings in high incidence areas.     

Early gallbladder carcinoma does not warrant radical resection

BACKGROUND: This study was designed to address whether gallbladder cancer invading the muscle layer (stage pT(1b)) is a local disease and whether radical resection is necessary. METHODS: A retrospective analysis of 25 patients with pT(1b) gallbladder tumours, 13 of whom underwent simple cholecystectomy and 12 radical resection with regional lymph node dissection, was performed. A total of 147 regional lymph nodes was examined for metastasis. The median follow-up time was 95 months. RESULTS: No patient had blood vessel or perineural invasion on histology. Lymphatic vessel invasion was seen in one patient. Both overt metastasis and micrometastases were absent in all lymph nodes examined. Overall 10-year survival was 87 per cent. The outcome after simple cholecystectomy was comparable to that after radical resection (P = 0.16). Two patients who underwent radical resection died from tumour relapse in distant sites. CONCLUSION: Most pT(1b) gallbladder carcinomas spread only locally. Additional radical resection is not necessary when the depth of invasion of gallbladder carcinoma is limited to the muscle layer after simple cholecystectomy.     

Early gallbladder cancer

BACKGROUND: The majority of patients with gallbladder cancer (GBC) have advanced disease at the time of diagnosis and are unresectable. Longterm survival is usually seen in a subset of patients with early GBC (EGBC)-cancer confined to the mucosa (pT1a) and muscularis (pT1b). Management guidelines of EGBC are not yet defined and are controversial. The purpose of this article is to evaluate the diagnostic aspects and effects of resectional procedures on survival outcome in patients with EGBC. STUDY DESIGN: EGBC was defined as cancer confined to the mucosa (pT1a) or muscularis (pT1b) according to the TNM classification. Clinicopathological details and survival data of 14 patients who had EGBC were analyzed. There were 9 women and 5 men, with a mean age of 60 years. RESULTS: A definite preoperative diagnosis was possible in only three patients and three patients were diagnosed at operation; the majority of patients were diagnosed incidentally after cholecystectomy for associated gallstones. Two patients underwent extended cholecystectomy and 12 patients underwent simple cholecystectomy. Two patients had pT1a and 12 had pT1b lesions. Mean (SD) survival was 71.5 (12.2) months and median survival was 42 months. There were five treatment failures with locoregional recurrence and death; all with pT1b tumors were treated by simple cholecystectomy. Cumulative 1-, 3-, and 5-year survival was 92%, 68%, and 68% respectively [corrected]. CONCLUSIONS: Simple cholecystectomy is an adequate treatment only for mucosal GBC. Patients with pT1b tumors require extended cholecystectomy. Incidental GBC extending up to the muscularis merits early reoperation for completion of extended cholecystectomy, which offers the only chance of cure.     

Radical Second Resection Provides Survival Benefit for Patients with T2 Gallbladder Carcinoma First Discovered after Laparoscopic Cholecystectomy

Port site recurrence or peritoneal seeding is a fatal complication following laparoscopic cholecystectomy for gallbladder carcinoma. The aims of this retrospective analysis were to determine the association of gallbladder perforation during laparoscopic cholecystectomy with port site/peritoneal recurrence and to determine the role of radical second resection in the management of gallbladder carcinoma first diagnosed after laparoscopic cholecystectomy. A total of 28 patients undergoing laparoscopic cholecystectomy for gallbladder carcinoma were analyzed, of whom 10 had a radical second resection. Five patients had recurrences; port site/peritoneum recurrence in 3 and distant metastasis in 2. The incidence of port site/peritoneal recurrence was higher in patients with gallbladder perforation (3/7, 43%) than in those without (0/21, 0%) (p = 0.011). The outcome after laparoscopic cholecystectomy was worse in 7 patients with gallbladder perforation (cumulative 5-year survival of 43%) than in those without (cumulative 5-year survival of 100%) (p <0.001). Among 13 patients with a pT2 tumor, the outcome after radical second resection (cumulative 5-year survival of 100%) was better than that after laparoscopic cholecystectomy alone (cumulative 5-year survival of 50%) (p = 0.039), although there was no survival benefit of radical second resection in the 15 patients with a pT1 tumor (p = 0.65). In conclusion, gallbladder perforation during laparoscopic cholecystectomy is associated with port site/peritoneal recurrence and worse patient survival. Radical second resection may be beneficial for patients with pT2 gallbladder carcinoma first discovered after laparoscopic cholecystectomy.