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.     

Histogram analysis of computed tomography numbers of clinical T1 N0 M0 lung adenocarcinoma, with special reference to lymph node metastasis and tumor invasiveness

PURPOSE: To predict lymph node metastasis and tumor invasiveness in lung adenocarcinoma from computed tomography findings, we examined computed tomography number histograms of clinical T1 N0 M0 lung adenocarcinomas. PATIENTS AND METHODS: Histograms of pixel computed tomography numbers were made for 100 patients with clinical T1 N0 M0 lung adenocarcinoma. Pathological tumor stages were N0 in 80 patients, N1 in 7, N2 in 9, and T4 due to intrapulmonary metastasis in 4. RESULTS: The histogram showed 3 patterns: 1 peak at a low computed tomography number (n = 18), 1 peak at a high computed tomography number (n = 54), and 2 peaks at both low and high computed tomography numbers (n = 28). Histologically, adenocarcinoma with 1 peak at a low computed tomography number showed a large area of bronchioloalveolar carcinoma-like spread with little area of solid growing tumor or central fibrosis, whereas those with 1 peak at a high computed tomography number showed a large area of solid growing tumor or central fibrosis with little bronchioloalveolar carcinoma-like spread. Adenocarcinomas with 2 peaks had both types of areas. Lymph node or pulmonary metastases were seen in none (0%) of the adenocarcinomas with 1 peak at a low computed tomography number, in 1 (4%) with 2 peaks, and in 20 (37%) with 1 peak at a high computed tomography number. The former 2 types had metastases less frequently than those with 1 peak at a high computed tomography number (P <.01). In the 79 patients with pathological T1 N0 M0, tumor involvement of the intratumoral vessels or pleura was seen in 1 of 18 (6%) adenocarcinomas with 1 peak at a low computed tomography number, which was significantly less frequent than the 18 of 34 (53%) with 1 peak at a high computed tomography number (P <.001) and 10 of 27 (37%) with 2 peaks (P <.05). CONCLUSION: Clinical T1 N0 M0 adenocarcinomas with 1 peak at a low computed tomography number on histogram seldom had lymph node metastasis or tumor involvement of vessels or pleura. Limited surgical resection could be indicated for this type of adenocarcinoma, especially for elderly patients or patients with poor pulmonary function.     

Do complications related to laparoscopic cholecystectomy influence the prognosis of gallbladder cancer?

Background: Laparoscopy is thought to worsen the prognosis of gallbladder cancer (GBC) discovered unexpectedly at laparoscopic cholecystectomy (LC). However, laproscopy has never been shown to have an influence on patient survival in clinical series. Methods: We Performed a two-center retrospective analysis of 28 patients with GBC (11 previously known, 17 unexpectedly discovered by LC) to determine whether laparoscopy and complications related to LC had any influence on the prognosis of GBC. Resectability for cure after LC, survival, and recurrence related to both the procedure itself and complications associated with LC were analyzed. Results: Of the 17 patients with unexpected GBC, 16 were considered resectable for cure at the time of LC. Advanced disease was detected in eight patients by re staging (n = 5) or exploration (n = 3). Seven patients (43.8%) underwent reoperation for cure. Mean survival of patients with unexpected GBC was 26.5 months. Mean survival was shorter when complications (bile spillage, injury of common bile duct, or tumor violation) occurred during LC (10.2 vs 33 months, p = 0.016). If bile spillage was the only complication at LC, there was also a trend to shorter survival (12 vs 33 months, p = 0.061). Conclusion: Complications during LC significantly worsen the prognosis of GBC. Therefore, bile spillage and excessive manipulation of the gallbladder should be avoided.     

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.     

Laparoscopic cholecystectomy for gallbladder carcinoma: results of a Japanese survey of 498 patients

Abstract. Background/Purpose: The long-term effects of initial laparoscopic cholecystectomy on the prognosis of patients with GBC remain unknown because of the limited numbers of patients reported from single institutions. This study was designed to determine the long-term prognosis of patients with gallbladder carcinoma (GBC) who had undergone laparoscopic cholecystectomy (LC), and to clarify the role of LC for the treatment of GBC and the benefit of aggressive additional excision. Methods: The clinical courses and outcomes of 498 patients with laparoscopically removed GBC registered in a nationwide survey were examined. Written questionnaires sent to members of the Japanese Society of Biliary Surgery included questions on Preoperative diagnosis, timing and methods to obtain final diagnosis, depth of invasion, second surgical procedure, prognosis of patients, and type of recurrence, if any. Results: The 5-year survival rates of patients after LC according to the depth of invasion were as follows: 99% in those with pT1a (limited to the mucosa), 95% in those with pT1b (muscularis), 70% in those with pT2 (subserosa), 20% in those with pT3 (serosa), and 0% in those with pT4 (serosa with invasion to adjacent organs). Perforation of the gallbladder during LC was found in 20% of the patients. Patients with gallbladders perforated during LC showed a significantly lower survival rate than did those without perforated gallbladders (P < 0.01). Additional excision during or after LC was carried out in 48% of the patients, and the frequency of additional excision increased in accordance with the depth of invasion. Compared with patients who underwent LC only, additional excision resulted in better survival in patients with pT2 or pT3 tumors (P= 0.051 and P < 0.05, respectively), but this difference was not found in patients with pT1 or pT4 tumors. Conclusions: LC is not likely to worsen the survival rate of patients with GBC compared with the survival rate of patients undergoing a standard open radical procedure, as long as additional excision is conducted for patients with laparoscopically removed pT2 or pT3 GBCs. Special attention should be paid to prevention of bile spillage during LC. Received: November 16, 2001 / Accepted: February 8, 2002     

Long-term Survival of Patients with Gallbladder Cancer Detected during or after Laparoscopic Cholecystectomy

Little evidence is available regarding long-term survival of patients with gallbladder cancer that is discovered at the time of laparoscopic cholecystectomy (LC). Therefore the present study was performed to evaluate long-term outcomes of this disease. Of 1546 patients who underwent LC for benign gallbladder disease between January 1992 and January 2002, 8 patients (0.5%) had cancers that were found during or after LC. The median follow-up period was 55 months (range: 36–142 months). The gallbladder was resected without perforation in all cases. During surgery there was a suspicion of malignancy in 6 of 8 cases. Frozen section analysis showed that 2 had TNM stage Tis tumors, 2 had T1a tumors, and 2 had T2 tumors. Two patients with T2 tumors were immediately converted to extended cholecystectomy. The final pathology revealed another 2 tumors, and demonstrated that 3 patients had Tis tumors, 3 had T1a tumors, and 2 had T2N0M0 tumors. None of the patients underwent additional surgery. All patients survived with no evidence of recurrence during the median follow-up of 55 months. In conclusion, before and during LC, we have not overlooked T2 or more advanced tumor, which requires additional procedures for curative resection. This might result in good survival. We consider that an intensive preoperative work-up and meticulous inspection of the opened gallbladder should be mandatory to detect gallbladder cancer in patients who undergo LC. At present, this is not routinely practiced.     

Cáncer de vesícula biliar en un hospital comarcal

Objectives

To assess the management of gallbladder cancer (GBC) in our region.

Material and methods

Data on 372 patients who underwent cholecystectomy were identified from our database (January 2003 to February 2008) and 6 patients were found to have GBC.

Results

Four patients had incidental carcinoma, one case was preoperatively suspected, and one patient presented with jaundice and locally advanced neoplasia. The incidence was 2 per 100,000 inhabitants per year; incidental carcinoma in 1.1% of cholecystecomies. The ultrasonography showed multilithiasis in 2 patients, sludge and neoplasia in 1, gallstones more than 3 cm in 2, and tumor mass only in 1 case. T stage: 1 case of T0 (in situ), 1 of T1, 2 of T2 and one T4. Incidental carcinomas were reoperated on when a T2 was established: 2 underwent lymphadenectomy and cystic stump resection, 1 segmentectomy IVb-V and lymphadenectomy. In the preoperative suspected neoplasia a cholecystectomy, lymphadenectomy, and partial hepatic gallbladder bed resection was initially performed.

Conclusions

GBC has a low incidence but it will be found in 1% of cholecystectomies. There is no adjuvant treatment and T-based surgical treatment is the is the only opportunity to reach cure in those patients. A national GBC database would be helpful in the publication of national guidelines for this disease.     

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.     

Should laparoscopic cholecystectomy be performed in patients with thick-walled gallbladder?

Background/Purpose Laparoscopic cholecystectomy is the procedure of choice for patients with symptomatic cholelithiasis. This procedure is contraindicated in patients with gall-bladder cancer (GBC) because of fear of dissemination of the disease. One of the findings raising the suspicion of GBC is a thick-walled gallbladder (TWGB).Methods A prospective study of patients with TWGB was done over a period of 10 months at a tertiary-level referral hospital in northern India. We studied the clinical profiles, investigations (ultrasound [US] and computerized tomography [CT]) and management plans in these patients.Results A total of 60 patients were included in the study. After cholecystectomy, histopathology of gallbladders showed GBC in 2 (3.3%) patients. The remaining 58 patients had chronic cholecystitis, of whom 28 (48%) had xanthogranulomatous variant chronic cholecystitis. Cholecystectomy by the laparoscopic method was attempted in 46 (77%) patients and by open technique in the remaining 14 (23%) patients. Laparoscopic cholecystectomy was successful in 40 of the 46 (87%) patients in whom it was attempted. Obscure anatomy, suspicion of GBC, and bile duct injury were the causes of conversion, in the remaining 13% (6/46). None of the 11 patients who had a CT examination because of clinical or US suspicion of malignancy turned out to have GBC at final histology. Both the cases of GBC in this study were incidental findings on final histopathology.Conclusions Laparoscopic cholecystectomy can be successfully performed in the majority of patients with diffuse TWGB, with appropriate selection. There is, however, an increased chance of conversion to open cholecystectomy in these patients. If there is an intraoperative suspicion of GBC, early conversion to open cholecystectmy and frozen section/imprint cytology will help to decide the further treatment during surgery.     

胆石病手术治疗方式的选择

目的：探讨胆石病治疗方法的决策.方法：我院近2年收治各种胆石病626例.分别采用开腹手术、腹腔镜胆囊切除术（LC）、内镜下逆行胰胆管造影（ERCP）、内镜下括约肌切开（EST）或网篮套石、术中或术后胆道镜,或联合治疗方式.结果：本组直接行开腹胆囊切除术17例（3%）;行LC 562例（包括ERCP等治疗后行LC者78例）,554例成功施行,术后恢复良好,无并发症,另8例（1.38%）中转开腹胆囊切除术,术中并发症2例（0.45%）;胆囊结石并轻度胆管扩张或黄疸22例中,15例先行ERCP,5例发现有胆总管下端细小结石并成功取出后再作LC,7例直接行LC,术后仅有1例须再作ERCP,取出胆总管下端小结石;胆囊结石并胆总管或肝总管结石68例,作EST或网篮套石,63例（92.5%）成功取尽结石并行LC.肝内胆管结石48例全部施行开腹手术,术前作ERCP、鼻胆管引流术13例,术中均联合用胆道镜取石,并有7例行左肝外叶切除,5例行右肝段或局部病灶切除,1例行胆肠吻合术,2例行肝胆管外引流术,1例肝胆管成形术,术后经T管或U形管窦道胆道镜取石、狭窄肝胆管扩张术21例.全部治愈,无结石残留.本组共有96例经十二指肠镜操作,11例有轻型胰腺炎（淀粉酶增高,轻微上腹疼痛）,治疗2～3 d后恢复,不影响后续治疗,其他20例并发症主要为肝内胆管结石术后,经保守治疗后治愈,全组无死亡病例.结论：腹腔镜、胆道镜和十二指肠镜为胆石病的外科治疗提供了多样化选择,这些内镜或是单独应用,或是与手术相结合,或是相互联合的治疗模式,极大地改善了各种胆石病的治疗效果.     

腹腔镜胆囊切除术术中或术后意外胆囊癌的治疗

目的探讨腹腔镜胆囊切除术（LC）术中发现意外胆囊癌（UGC）的治疗方法。方法回顾分析1996年1月至2010年6月期间5000例行LC患者的临床资料,术后发现UGC12例,结合以往文献对UGC的诊治方法进行分析。结果手术顺利,术中和术后被证实为胆囊癌的患者12例,发生率为0.24%（12/5000）,其中T1期6例,T2期4例,T3期1例,T4期1例。T1期患者仅行LC,除1例于术后第39个月死于其他疾病外均长期存活;T2期仅行LC2例,中转开腹2例,行胆囊癌根治术,术后均长期存活;T3期1例,行LC,于术后第42个月死于肿瘤转移;T4期1例,术中发现腹膜广泛种植,仅行LC,于术后第6个月死亡。有3例发生戳孔种植,T1、T2、T3期各1例。结论胆囊癌存活期短,预后差,但腹腔镜手术发现的UGC大多属早期,采取合适的治疗手段可取得良好的疗效。     

Biliary patency imaging after endoscopic retrograde sphincterotomy with gallbladder in situ. Clinical impact of nonvisualization

We prospectively performed nuclear biliary patency imaging (HIDA scanning) in 62 patients who had undergone endoscopic retrograde sphincterotomy for management of pancreaticobiliary disease with their gallbladders in situ. Elective cholecystectomy was not recommended because of advanced age, comorbidity, or absence of gallstones. All patients had patent cystic ducts at endoscopic retrograde cholangiopancreatography balloon cholangiography. Eighteen (29.1%) of 62 patients had nonvisualizing HIDA scans, and in 44 (70.9%) of 62 visualization was normal or delayed. Six cholecystectomies were required for colic (n = 1), acute cholecystitis (n = 4), and acute cholecystocholedochal fistula with cholangitis (n = 1). Among the patients with cholelithiasis and nonvisualization (n = 13), five (38.5%) required surgery, whereas only one (4.8%) of 21 patients with cholelithiasis and visualization required surgery. Nonvisualizing HIDA scans are frequent (30%) after endoscopic retrograde sphincterotomy and have no clinical relevance in patients without cholelithiasis but predict the need for cholecystectomy within 16 months in 38.5% of patients with cholelithiasis.     

Unsuspected gallbladder carcinoma after laparoscopic cholecystectomy

Background/Purpose Many cases have been reported of disastrous port-site recurrence after laparoscopic cholecystectomy (LC) revealed unsuspected gallbladder carcinoma (GBC). Some investigators have reported that the prognosis of patients after LC showed unsuspected GBC is not worsened by laparoscopic procedures. We retrospectively reviewed our cases and the literature to reconfirm the intrinsic risks of LC for unsuspected GBC. Methods Of 1663 patients who underwent LC from January 1991 to December 2003 in a single institution, 9 (0.54%) with unsuspected GBC were reviewed. Results These 9 patients consisted of 5 men and 4 women, whose ages ranged from 58 to 87 years, with a median age of 73 years. Two patients with a pT1a tumor (limited to mucosa) and 2 patients with a pT1b tumor (muscle layer) underwent no further operation. The remaining 5 patients with a pT2 tumor (subserosa) underwent further operations with lymph node dissection. Five patients (2 patients with pT1b and 3 patients with pT2) developed recurrence and all of them died within a median period of 19 months (range 14–37 months) after LC. The causes of death were bone metastases in 1 patient (pT2), local recurrence in 2 patients (pT1b and pT2), and peritoneal metastasis in 2 patients (one elderly patient with pT1b who underwent laparoscopic common bile duct exploration, and one patient with pT2 in whom the cystic duct was damaged during surgery). Four patients (2 with pT1 and 2 with pT2) have been doing well with a median follow-up of 39.5 months (range 12–99 months) after LC. Conclusions Surgeons should always prevent bile spillage during LC and when removing the resected gallbladder. When laparoscopic common bile duct exploration is planned, especially for elderly women, surgeons should also bear in mind the increasing possibility of unsuspected GBC.     

Fluorine 18-tagged fluorodeoxyglucose positron emission tomographic scanning to predict lymph node metastasis, invasiveness, or both, in clinical T1 N0 M0 lung adenocarcinoma

OBJECTIVE: We sought to predict lymph node metastasis and tumor invasiveness in clinical T1 N0 M0 lung adenocarcinomas, and we measured fluorodeoxyglucose uptake on positron emission tomography. METHODS: Fluorodeoxyglucose positron emission tomography was performed on 44 patients with adenocarcinomas of 1 to 3 cm in size clinically staged as T1 N0 M0 before major lung resection with lymph node dissection. Fluorodeoxyglucose uptake was evaluated by using the contrast ratio between the tumor and contralateral healthy lung tissue. Lymphatic and vascular invasion within tumors, pleural involvement, and grade of histologic differentiation were examined. RESULTS: The pathologic tumor stage was T1 N0 M0 in 36 patients, and a more advanced stage was found in 8 patients. Although all 22 adenocarcinomas with a contrast ratio of less than 0.5 in fluorodeoxyglucose uptake were pathologic T1 N0 M0 tumors, 8 (36%) of 22 with a contrast ratio of 0.5 or greater were of a more advanced stage than T1 N0 M0, with the difference being significant (P =.002). Adenocarcinomas with a contrast ratio of less than 0.5 showed less lymphatic and vascular invasion and less pleural involvement than those with a contrast ratio of 0.5 or greater (P =.006, P =.004, and P =.02, respectively). The grade of histologic differentiation was well differentiated in 19 of 22 adenocarcinomas with a contrast ratio of less than 0.5 (86%), which was a greater frequency than the 4 (18%) of 22 adenocarcinomas with a contrast ratio of 0.5 or greater (P <.001). CONCLUSION: Clinical T1 N0 M0 lung adenocarcinomas with a contrast ratio of less than 0.5 usually did not have lymph node metastasis, had less tumor involvement of vessels or pleura, and were more frequently well differentiated than those with a contrast ratio of 0.5 or greater. Limited lung resection could be indicated, lymph node dissection or mediastinoscopy could be reduced, or both in this type of adenocarcinoma.     

Male gender: risk factor for severe symptomatic cholelithiasis

The aim of this study was to determine the effect of male gender on the clinical presentation of symptomatic cholelithiasis. Laparoscopic cholecystectomy (LC) has been accepted as standard procedure for the management of symptomatic cholelithiasis even when the gallbladder is acutely inflamed. With the accumulated experience in the management of acute cholecystitis, some factors including male gender were recognized to influence the clinical presentation of symptomatic cholelithiasis and increase the conversion rate during LC. This retrospective study tried to clarify the correlation between male gender and the clinical presentation of symptomatic cholelithiasis. The medical records of all patients presenting with symptomatic cholelithiasis from January 1994 to August 1999 were evaluated. These cases were divided into four groups as follows: (1) elective LC group: patients with a history of biliary colic or acute attack of cholecystitis but whose LC was performed electively without any inflammatory change in the gallbladder during operation; (2) acute LC group: patients presenting with acute cholecystitis, and LC was performed successfully without conversion; (3) acute conversion group: patients who underwent LC during the course of acute cholecystitis but the procedure were disturbed by severe inflammatory change so they were converted to open surgery; (4) acute open group: patients whose acute cholecystitis was managed by direct open surgery due to the preoperative prediction that LC would not succeed. The correlation of gender, age, and operating time were assessed among these four groups. We found that: (1) the male/female ratio increased (in the patient group sequence of simple LC, acute LC, acute open, and acute conversion group); (2) in the acute LC group male patients had significantly (p = 0.04, t-test) longer operating time than females; (3) although there was no significant difference between the mean age of male (55.7 +/- 13.4) and female (56.3 +/- 15.7) patients in the acute cholecystitis groups (i.e., all patients in the acute LC, acute conversion, and acute open groups), the distribution curve by age in male patients showed a significantly shift to a younger age compared with female patients (p = 0.009, Fisher's exact test).     

Symptomatic gallbladder stones

In order to strike the most favorable balance between health benefits and costs, three treatment modalities for symptomatic cholelithiasis were compared in a cost-effectiveness study: extracorporeal shockwave lithotripsy (ESWL), conventional cholecystectomy (CC), and laparoscopic cholecystectomy (LC).Data were analyzed from 55 patients who were treated by ESWL, 45 patients who had CC, and 47 patients who had LC. The study was performed by analysis of patients charts and a written questionnaire.After ESWL 35% of the patients were free of stones, 23% had fragments5mm, and 42% had fragments>5 mm at 1-year follow-up. Persistent complaints were reported by 59% after ESWL, 11% after CC, and 14% after LC (P<0.001). New complaints arose in 12% after ESWL, 11% after CC, and in 5% after LC (P=NS). Patient appreciation score was highest for LC and lowest for ESWL. Mean hospital stay was 2.4 days for ESWL, 10 days for CC, and 3.5 days for LC. Overall costs of treatment were: $5,066 for ESWL; $5,893 for CC; and $3,117 for LC.This study reveals that laparoscopic cholecystectomy is the most effective treatment of the large majority of patients with symptomatic cholelithiasis. ESWL should only be considered in the case of a solitary, relatively small, completely radiolucent stone.     

Laparoscopic cholecystectomy in the obese patient.

The authors' experience with laparoscopic cholecystectomy (LC) in obese (O, n = 96) and morbidly obese (MO, n = 27) patient groups was compared with that in the normal weight (NW, n = 174) group of patients as well as the whole group (WG). There were no operative deaths. There were no significant differences between groups for any of the following: successful intraoperative cholangiography (WG, 52.2%; NW, 52.9%; O, 51.1%; MO, 55.6%), conversion to open cholecystectomy (WG, 9.6%; NW, 9.2%; O, 10.4%; MO, 11.1%), incidence of major complications (WG, 4.1%; NW, 3.4%, O, 5.2%; MO, 0%), incidence of minor complications (WG, 7.4%, NW, 7.5%; O, 6.3%; MO, 3.7%), and length of hospitalization after successful LC (WG, 1.25 days; NW, 1.31 days; O, 1.16 days; MO, 1.13 days). Duration of operation did not differ except LC in the MO group (136.4 +/- 6.9 minutes) was longer when compared with NW patients (123.0 +/- 2.9 minutes, p less than 0.05). The authors conclude LC is a safe and effective treatment for obese patients with symptomatic cholelithiasis.     

腹腔镜胆囊切除术治疗急性胆囊炎的疗效分析(附103例报告)

目的:探讨急性胆囊炎患者行腹腔镜胆囊切除术(laparoscopic cholecystectomy,LC)的可行性及临床价值。方法:回顾分析2006年1月至2008年6月我院为103例急性胆囊炎患者行LC的临床资料。结果:100例成功完成LC;3例中转开腹(2.91%),均为发病72h后行LC,其中1例Calot三角区严重水肿、粘连致密,无法辨清胆管关系,Mirizzi综合征及胆囊十二指肠瘘各1例。手术时间30～140min,平均80min。均痊愈出院,随访6～60个月,平均28.5个月,无并发症发生及死亡病例。结论:急性胆囊炎行LC,难度大,但只要合理选择患者,把握手术时机并注重手术技巧,急性胆囊炎患者行LC是安全可靠的。     

腹腔镜胆囊切除术对意外性胆囊癌预后的影响

目的：探讨腹腔镜胆囊切除术（LC）对意外性胆囊癌的影响。方法：回顾性分析经术后病理证实为胆囊癌者21例临床资料,其中11例行腹腔镜胆囊切除术（LC）,10例行开放性胆囊切除术（OC）,对比两组累积存活比率和5个预后因素,包括组织分级、病理分期、胆汁溢出发生率、手术类型以及附加的外科治疗。结果：8例（72.7%）LC术后及7例OC术后（70.0%）出现肿瘤复发,两者差异无统计学意义（P=0.86）,两组均无腹壁转移。生存率与肿瘤分期和胆汁溢出有关（P=0.006和P=0.003）,生存率与上述两种手术方式无关(P=0.74)。结论：LC不影响意外性胆囊癌的预后。     

Prognostic Significance of Metastatic Lymph Node Ratio in T3Gastric Cancer

The fifth International Union Against Cancer tumor node metastasis (UICC TNM) classification, based on the number of metastatic lymph nodes (LN), has proved to be a reliable and objective method for predicting the prognosis of patients with gastric cancer. However, the prognosis of patients with T3 gastric cancer is still heterogeneous. This study was carried out to investigate the validity of metastatic LN ratio as a prognostic factor in T3 gastric cancer. A retrospective analysis was performed on a total of 833 patients that had either T3N1M0 (n = 504) or T3N2M0 (n = 329) gastric cancer by the fifth UICC classification. A preliminary analysis revealed the cutoff values for T3N1M0 to be 10% and for T3N2M0 to be 25%. The mean metastatic LN ratio was 9.0% for T3N1M0 cancer and 26.9% for T3N2M0 cancer. For the T3N1M0 stage, the patients who showed less than 10% of the metastatic LN ratio were grouped as N1-low with the others grouped as N1-high. For the T3N2M0 stage group, those who had less than 25% of the metastatic LN ratio were grouped as N2-low, the remainder as N2-high. The metastatic LN ratio decreased in proportion to the extent of lymphadenectomy and it increased in relation to the increasing scale of the fourth N classification. The rates of recurrence were significantly different according to the metastatic LN ratio in N1 and N2 classification of the fifth UICC classification (p < 0.05). The 5-year survival rates after gastrectomy decreased significantly by increasing the metastatic LN ratio in both T3N1M0 cancers (p =0.0026) and T3N2M0 cancers (p = 0.0057). The metastatic LN ratio was an independent risk factor for recurrence and poor prognosis. Our data suggest that the metastatic LN ratio is a significant prognostic factor for T3 gastric cancer. Furthermore, the application of the metastatic LN ratio can provide information not only about the extent of LN metastasis but also about the extent of lymphadenectomy in T3 gastric cancer.