T2期胆囊癌最佳肝切除范围的Meta分析

背景与目的：胆囊癌（GBC）是胆道系统恶性肿瘤中最常见的肿瘤,占全球胆道恶性肿瘤的80%～95%,预后较差,5年总生存（OS）率仅为10%～25%。目前,根治性切除是唯一可能治愈GBC的方法,但对于T2期GBC的肝切除范围各指南推荐不一。因此,本研究对T2期GBC最佳肝切除范围进行系统评价。方法：计算机检索Pub Med、Embase、Web of science、Cochrane Library、中国生物医学文献数据库、中国知网、万方数据库、维普数据库,根据纳入和排除标准选取文献,使用NOS评分评估纳入文献的质量,采用Rev Man 5.4版软件分析评估各组患者1、3、5年的生存差异。结果：最终纳入8篇文献,8篇文献均纳入T2期GBC,其中2篇文献纳入T2a期和T2b期GBC。Meta分析结果显示,T2期GBC行距胆囊床2 cm以上的肝组织切除术及肝IVb+V段切除术,R0与R1切除的1、3、5年OS率差异均无统计学意义（OR=0.70,95%CI=0.45～1.09,P=0.12;OR=1.10,95%CI=0.79～1.53,P=0.58;OR=1.18,95%CI=0.89～1...     

Predictors of long-term survival in patients with gallbladder cancer

The aim of this study was to examine the predictors of long-term survival (>24 months) in patients with gall bladder cancer. A retrospective review of 117 cases of gall bladder cancer resected between 1989 and 2000. The resections included 80 simple cholecystectomies and 37 extended procedures. Patients with survival >24 months (n=44) were compared with those having survival <24 months (n=73) for 17 prognostic factors. Overall median survival was 16 months with a 5-year survival of 27%. T status (P=.000) and adjuvant chemoradiotherapy (P=.001) were independent predictors of long-term survival. Survival advantage was seen in T3N+ve disease (P=.007) with extended procedures. Complete (R0) resection was attained in 30 patients with a 5-year survival advantage of 30% as compared with incomplete (R1) resection (P=.0002). Adjuvant chemoradiotherapy improved survival in simple cholecystectomy group (P=.0008) but no advantage was seen after extended procedures. Stage III (P=.001) and node-positive disease (P=.0005) had significant benefit with adjuvant therapy. Poor differentiation and vascular invasion were associated with poor long-term survival. R0 resection was associated with prolonged survival. Extended procedures improved survival in patients with T3N+ve disease. Addition of chemoradiotherapy made significant improvement in long-term survival in stage III and node-positive lesions and in patients undergoing simple cholecystectomy. R0 resection predicted long-term survival in gall bladder cancer. T3 N+ve disease had better survival after extended procedures. Adjuvant chemoradiotherapy improved survival in stage III and node-positive disease. Poor differentiation and vascular invasion were adverse predictors of survival.     

T1b/T2期胆囊癌根治性手术中肝切除术时机与临床疗效及预后的关系

背景与目的：胆囊癌（GBC）是最常见的胆道系统恶性肿瘤,根据AJCC TNM分期系统（第8版） T1b/T2期GBC患者需要接受包括胆囊切除术、肝切除和区域淋巴结清扫在内的GBC根治性手术进行治疗。手术时机选择包括胆囊切除联合肝切除和术后病理提示GBC而行二期肝切除手术。目前,GBC根治性手术中关于肝脏切除时机的研究较少。因此,本研究探讨GBC根治性手术中肝脏切除时机选择对患者围术期指标和远期预后的影响。方法：回顾性收集浙江大学医学院附属邵逸夫医院2011年1月—2018年8月行GBC根治性手术的114例T1b/T2期GBC患者资料,其中82例行胆囊切除术同时联合肝切除（一期组）,32例行胆囊切除术后再行二期肝切除手术（二期组）。采用倾向性评分匹配（PSM）平衡两组患者基线资料后,比较两组患者的总生存期（OS）和无病生存期（DFS）的差异,分析影响患者OS和DFS的危险因素,并比较两组患者手术时间与住院时间的差异,此外,进一步单独比较二期组中不同手术时间间隔（间隔≤20 d与>20 d）患者围术期指标与预后的差异。结果：按1∶1 PSM后,两组各28例,除GBC诊断时间差异有统计...     

Treatment outcomes associated with surgery for gallbladder cancer: A 20-year experience

The aim of this study was to evaluate contemporary outcomes associated with the management of gallbladder cancer. The medical records of 48 consecutive patients with gallbladder cancer treated at our institution from January 1981 through November 2001 were reviewed. Survival was analyzed using the Kaplan-Meier method (mean follow-up period 24 months) and the log-rank test. Prognostic factors were analyzed using Cox regression. Mean patient age was 68 years. Sixty percent of patients were female. Thirty-nine patients (81%) underwent laparotomy or laparoscopy. Eighteen patients (38%) underwent complete resection (10 simple cholecystectomies and 8 radical cholecystectomies). There were no procedure-related deaths. The overall 5-year survival rate was 13%. Patients who underwent complete resection had a higher 5-year survival rate (31%) than patients who underwent palliative surgery or no surgery (0%; P < 0.05). For patients who underwent radical cholecystectomy, the 5-year survival rate was 60%. For the 18 patients who underwent curative resection, positive lymph node metastasis and patient age over 65 were factors predictive of significantly worse survival. Overall survival rates for patients with gallbladder cancer remain poor. Although radical surgery can be performed safely, it is associated with long-term survival only in a highly select subset of patients with gallbladder cancer. Presented at the Fourth Americas Hepato-Pancreato-Biliary Association Congress, Miami Beach, Florida, February 27–March 2, 2003.     

极量肝切除治疗肝细胞癌的适应证与疗效

临床对原发性肝细胞癌(HCC)的手术治疗已取得了长足进步,其中极量肝切除是高难度手术的典型代表。极量肝切除术疗效显著,但必须严格掌握适应证。笔者分别从极量肝切除术治疗HCC的适应证、术前评估、提高手术疗效和减少手术并发症、争议与建议等方面就其治疗现状与进展作一总结。     

Prognostic significance of regional lymphadenectomy in T1b gallbladder cancer: Results from 24 hospitals in China

BACKGROUNDWhether regional lymphadenectomy (RL) should be routinely performed in patients with T1b gallbladder cancer (GBC) remains a subject of debate. AIMTo investigate whether RL can improve the prognosis of patients with T1b GBC.METHODSWe studied a multicenter cohort of patients with T1b GBC who underwent surgery between 2008 and 2016 at 24 hospitals in 13 provinces in China. The log-rank test and Cox proportional hazards model were used to compare the overall survival (OS) of patients who underwent cholecystectomy (Ch) + RL and those who underwent Ch only. To investigate whether combined hepatectomy (Hep) improved OS in T1b patients, we studied patients who underwent Ch + RL to compare the OS of patients who underwent combined Hep and patients who did not.RESULTSOf the 121 patients (aged 61.9 ± 10.1 years), 77 (63.6%) underwent Ch + RL, and 44 (36.4%) underwent Ch only. Seven (9.1%) patients in the Ch + RL group had lymph node metastasis. The 5-year OS rate was significantly higher in the Ch + RL group than in the Ch group (76.3% vs 56.8%, P = 0.036). Multivariate analysis showed that Ch + RL was significantly associated with improved OS (hazard ratio: 0.51; 95% confidence interval: 0.26-0.99). Among the 77 patients who underwent Ch + RL, no survival improvement was found in patients who underwent combined Hep (5-year OS rate: 79.5% for combined Hep and 76.1% for no Hep; P = 0.50).CONCLUSIONT1b GBC patients who underwent Ch + RL had a better prognosis than those who underwent Ch. Hep + Ch showed no improvement in prognosis in T1b GBC patients. Although recommended by both the National Comprehensive Cancer Network and Chinese Medical Association guidelines, RL was only performed in 63.6% of T1b GBC patients. Routine Ch + RL should be advised in T1b GBC.     

快速康复外科联合肝切除术的安全性和有效性的Meta分析

目的：系统评价快速康复外科（FTS）联合肝切除手术的安全性和有效性。
　　方法：检索多个国内外文献数据库,收集关于肝切除手术围手术期应用FTS的随机对照试验（RCT）或临床对照试验（CCT）,截止日期为2014年10月,筛选符合入组标准的文献提取相关数据,并使用RevMan5.2.3软件进行Meta分析。
　　结果：最终纳入5项RCT和11项CCT研究,共有1529例患者,其中766例采用FTS治疗联合肝切除手术（FTS组）,763例采用传统围手术期处理联合肝切除手术（对照组）。Meta分析结果显示, FTS组较对照组术后首次肛门排气时间、进食时间明显提前,住院时间明显缩短,住院费用明显减少,各项肝功能指标恢复时间明显缩短,术后总并发症发生率明显降低（均P<0.05）。
　　结论：FTS联合肝切除手术安全有效,且利于患者术后恢复。     

腹腔镜肝癌切除术15例报告

目的探讨腹腔镜肝癌切除的可行性与适应证. 方法 1998年8月～2004年9月采用多功能手术解剖器(Peng's multifunctional operative dissector,PMOD)刮吸法断肝技术对15例肝癌行腹腔镜肝癌切除术. 结果 14例腹腔镜肝癌切除术成功,1例因术中出血中转开腹肝癌切除术.腹腔镜肝癌切除术手术时间60～240 min,平均125 min.术中出血量50～2 000 ml,平均501 ml.切除肝脏最大体积10 cm×9 cm×7 cm.术后无并发症发生.术后24 h均能下床活动,术后1～3 d即能进食.术后住院5～10 d,平均6.5 d. 结论对位于肝脏边缘、右肝表面或左半肝的恶性肿瘤,采用PMOD行腹腔镜肝癌切除是可行和安全的.     

快速康复外科在开腹肝癌切除术中应用的Meta分析

目的:评价在开腹肝癌切除术围手术期应用快速康复外科(ERAS)的安全性、有效性及对患者术后恢复的影响。方法:检索多个国内外数据库收集有关开腹肝癌肝切除中应用ERAS的随机对照研究(RCT),对纳入的文献进行质量评价和数据提取后,应用RevMan5.3软件进行Meta分析。结果:最终纳入RCT研究16篇,1770例患者,其中ERAS组888例,对照组882例。Meta结果显示,与对照组比较,ERAS组术后并发症的发生率明显降低(MD=0.47,95%CI=0.35～0.63,P0.001);术后首次排气时间明显缩短(SMD=-3.64,95%CI=-4.72～2.56,P0.001);术后第3、7天丙氨酸氨基转移酶水平(MD=-50.23,95%CI=-59.35～-41.11,P0.001;MD=-37.48,CI=-42.19～-32.78,P0.001)与术后第1、3天C-反应蛋白水平(MD=-38.64,95%CI=-61.14～-16.14,P0.001;MD=-26.75,95%CI=-46.03～-7.47,P0.01)均明显降低;术后住院时间(MD=-2.71,95%CI=-3.86～-1.55,P0.001)和总住院时间(MD=-2.86,95%CI=-4.11～-1.62,P0.001)及住院费用(MD=-1.20,95%CI=-1.84～-0.57,P0.05)均明显减少。结论:开腹肝癌切除术围术期实施ERAS方案安全、有效,有利于患者术后恢复,减少住院时间和降低医疗费用。     

腹腔镜结合开腹手术治疗原发性胆囊癌

目的 探讨腹腔镜结合开腹治疗原发性胆囊癌的方法与疗效。方法 腹腔镜胆囊切除(LC)术中疑为胆囊癌即送标本作快速冰冻病检，Nevin分期I～Ⅱ期，腹腔镜下清除胆囊床和肝门疏松组织即可，Ⅲ期以上即中转开腹行根治术或扩大根治术。结果 共行腹腔镜手术34例，术中中转开腹6例，腹腔镜术后再开腹7例，1例放弃治疗。无术中术后严重并发症，1例并发剑突下戳孔肿瘤种植。随访：腹腔镜手术15例，生存2年～8年，5年存活率80％(12／15)，开腹手术8例，生存8月～4年。结论 腹腔镜结合开腹手术治疗不同分期原发性胆囊癌是行之有效的方法。     

加速康复外科在腹腔镜肝切除术应用安全性与有效性的Meta分析

目的：评价加速康复外科（FTS）在腹腔镜肝切除围手术期应用的安全性和有效性。 方法：计算机检索1996年1月—2014年6月国内外数据库有关FTS在腹腔镜肝切除围手术期应用的随机对照试验（RCT）或临床对照试验（CCT）,采用RevMan 5.2软件进行Meta分析。 结果：最终纳入3项RCT和2项CCT,共有247例患者,其中134例采用FTS（FTS组）,113例采用传统围手术期处理（对照组）。Meta分析结果显示,与对照组比较,FTS组住院时间明显缩短（WMD=-2.19,95% CI=-2.94~-1.43,P<0.00001）,术后并发症发生率降低（RR=0.60,95% CI=0.38~0.92,P=0.02）,但两组手术时间、中转开腹发生率和住院费用无统计学差异（均P>0.05）。 结论：FTS在腹腔镜肝切除围手术期应用可有效缩短住院时间,减少术后并发症,加速患者康复。上述结果仍须更多设计严密的大样本、高质量的RCT进一步验证。     

腹腔镜肝切除术12例临床分析

目的探讨腹腔镜肝切除术（LH）的可行性与适应证。方法回顾分析12例行LH患者（LH组）与20例同期行开腹肝切除术（OH）患者（OH组）的临床资料,比较两组手术时间、术中出血量、切口长度、肛门排气时间等指标。结果所有手术均获成功。LH组切口长度、术后肛门排气时间、术后禁食时间、留置引流时间、术后住院时间等与OH组比较具有明显的优势,差异有统计学意义（P〈0.01）。在手术时间、术中出血量、总住院时间及住院总费用上两组间差异无统计学意义（P〉0.05）。结论对位于肝脏边缘、右肝表面或左半肝的恶性肿瘤,行LH是可行和安全的。     

A meta-analysis of the three-dimensional reconstruction visualization technology for hepatectomy

This meta-analysis was conducted to systematically evaluate the short-term efficacy and safety of the three-dimensional (3D) reconstruction visualization technology (3D-RVT) technique for hepatectomy. A systematic literature search was used to gather information on the 3D reconstruction visualization technology technique for hepatectomy from retrospective cohort studies and comparative studies. The retrieval period was up to March 2022. Publications and conference papers in English were manually searched and references in bibliographies traced. After evaluating the quality of selected studies, a meta-analysis was conducted using Review Manager 5.1 software. We included 12 studies comprising 2053 patients with liver disease. Our meta-results showed that 3D-RVT significantly shortened operation times [weighted mean differences (WMD) = ?29.36; 95% confidence interval (CI): ?55.20 to ?3.51; P = 0.03], reduced intraoperative bleeding [WMD = ?93.53; 95% CI: ?152.32 to ?34.73; P = 0.002], reduced blood transfusion volume [WMD = ?66.06; 95% CI: ?109.13 to ?22.99; P = 0.003], and shortened hospital stays [WMD = ?1.90; 95% CI: ?3.05 to ?0.74; P = 0.001]. Additionally, the technique reduced the use of hepatic inflow occlusion and avoided overall postoperative complications [odds ratio (OR) = 0.60; 95% CI: 0.46 to 0.79; P < 0.001]. 3D-RVT is safe and effective for liver surgery and provides safety assessments before anatomical hepatectomy.     

基层医院肝切除治疗原发性肝癌35例分析

目的探讨肝切除治疗原发性肝癌的临床疗效。方法回顾性分析我院2003年4月至2005年4月35例原发性肝癌的手术治疗及随诊情况。其中右半肝切除6例,左半肝切除16例,肝中叶切除3例,单纯肝肿瘤切除10例。结果术后病理证实为肝细胞癌30例,胆管细胞癌5例。术后出血4例,再次手术出血1例,胆瘘1例,手术死亡1例,术后住院死亡1例,半年内死亡2例,1年内死亡6例,25例存活至今。结论严格掌握原发性肝癌切除手术指征及肝切除量,减少术中出血,正确处理肝创面及降低术后并发症发生率,才能保证提高手术治疗的效果。     

加速康复外科理念在腹腔镜精准肝切除术治疗肝血管瘤中的临床应用

目的:探讨加速康复外科(ERAS)理念在腹腔镜精准肝切除术治疗肝血管瘤中应用的安全性、可行性、有效性。方法:回顾性分析2014年1月—2019年1月期间96例因肝血管瘤接受腹腔镜下精准肝切除术患者的临床资料,其中40例采用ERAS理念行围手术期管理(ERAS组),56例按照传统方式行围手术期管理(对照组),比较两组患者术前一般资料、术中指标、术后住院时间、住院费用、术后并发症发生率、肝功能恢复情况、C-反应蛋白(CRP)等实验室检查。结果:两组患者在术前、术中各方面指标差异无统计学意义(均P0.05)。与对照组比较,ERAS组术后住院时间明显缩短、住院费用明显降低(均P0.05)。实验室指标方面,ERAS组术后7 d的CRP水平明显低于对照组(P0.05),两组间其余指标差异均无统计学意义(均P0.05)。两组术后各项并发症发生率及再入院率差异均无统计学意义(均P0.05)。结论:在腹腔镜精准肝切除术患者围手术期开展ERAS是安全及可行的,可以缩短患者住院时间、减少住院费用,减少术后应激反应,加快患者术后康复。     

Incidence and management of gallbladder cancer in cholecystectomy specimens: a 5-year tertiary centre experience

Background

Gallbladder cancer (GBC) is an uncommon, but highly aggressive cancer. Half of these cases are diagnosed pre-operatively, and the remaining cases are discovered incidentally on post-cholecystectomy specimens. There is a significant geographical variability in GBC incidence, with increasing age, female sex, and prolonged duration of cholelithiasis being risk factors for GBC. The primary aim was to define the overall local incidence of GBC incidental GBC and management of these cases. The secondary aim was to determine any pertinent risk factors in our case population.

Methods

A retrospective observational study was performed on all the cholecystectomy specimens at the Gold Coast Hospital and Health Service from 1 January 2016 to 2 December 2021. Data was collected via the electronic medical record. The incidence and management of gallbladder cancers was calculated, and association with body mass index (BMI), smoking status, diabetes, inflammatory bowel disease (IBD) was identified.

Results

3904 cholecystectomy specimens were reviewed. GBC was identified in 0.46% of cholecystectomies. 50% of these cases were found incidentally. Abdominal pain was the most common presenting complaint (94.4%). GBC was associated with increased age and BMI and female sex. There was no association between smoking status, diabetes or IBD with an increased incidence of cancer. Tumour staging guided surgical and/or adjuvant chemotherapy.

Conclusion

GBC is rare. Patients with symptoms are associated with a poor prognosis. Incidental cancers are common, and negative margin resection based on the T stage of the cancer is the most reliable curative option.     

A review of the management of gallstone disease and its complications in pregnancy

Background

Symptomatic gallstone disease is the second most common abdominal emergency in pregnant women. There have been significant developments in the management of gallstone disease, but risk to the fetus has prevented their routine application in pregnant women. We reviewed the literature to find the current best evidence for the management of gallstones and its complications in pregnancy.

Data sources

MEDLINE and PubMed literature searches were performed to identify original studies.

Results and Conclusions

Six studies comparing conservative with surgical management of cholecystitis showed no significant difference in incidence of preterm delivery (3.5% vs 6.0%, P = .33) or fetal mortality (2.2% vs 1.2%, P = .57). There was no maternal or fetal mortality in 20 reports of laparoscopic cholecystectomy and 9 reports of endoscopic retrograde cholangiopancreatography, thus indicating their safety when performed with necessary precautions. Laparoscopic cholecystectomy is a safe procedure in all trimesters. In 12 reports of gallstone pancreatitis, fetal mortality was 8.0% versus 2.6% (P = .28) in conservative and surgical groups, respectively, suggesting the need for earlier surgical intervention.