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.     

意外胆囊癌的临床处理对策与预后

目的探讨意外胆囊癌的临床处理对策与预后。方法回顾性分析意外胆囊癌51例,对其治疗与预后进行统计分析。生存分析采用Kaplan-Meier法,组间比较采用Log-rank检验,多因素分析采用Cox比例风险模型。结果多因素分析表明肿瘤位置、Nevin分期及手术方式是影响预后的独立因素;对于Ⅱ期体底部胆囊癌和Ⅲ、Ⅳ期体底部胆囊癌以及颈部胆囊癌,胆囊癌根治术组优于单纯胆囊切除术组,其差异有统计学意义(P值分别为0.014、0.001及0.018);对于Ⅰ期体底部胆囊癌,单纯胆囊切除术组与胆囊癌根治术组病人的生存率差异无统计学意义(P=0.312)。结论对于NevinⅠ期体底部胆囊癌病人,单纯胆囊切除术已达到根治效果;对于NevinⅠ期颈部胆囊癌及NevinⅡ期以晚的胆囊癌,胆囊癌根治术能有效改善其预后。     

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.     

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.     

Extended hepatic resection for gallbladder cancer

BACKGROUND: Although radical cholecystectomy is the standard of care for gallbladder cancers that invade perimuscular connective tissue or perforate visceral peritoneum, the role of extended right hepatectomy in achieving negative resection margins is not clear. METHODS: Clinicopathologic, perioperative, and long-term outcome data were reviewed from patients who underwent hepatic resection for gallbladder cancer. RESULTS: From 1995 to 2005, 22 consecutive patients underwent hepatic resection for gallbladder cancer, and 11 underwent extended hepatectomy. Negative resection margins were achieved in all patients. There were no significant differences in postoperative morbidity, mortality, and long-term survival after extended and minor hepatectomy. T3 tumors negatively predicted overall and recurrence-free survival. COMMENTS: Extended hepatectomy achieves negative resection margins for patients with gallbladder cancer and is associated with acceptable morbidity and long-term survival.     

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。     

Present status of the diagnosis and treatment of gallbladder carcinoma

Because early carcinoma of the gallbladder causes no specific signs or symptoms, most patients with this disease are diagnosed with advanced-stage tumors. High-resolution ultrasonography and a low index of suspicion for polypoid masses or asymmetric gallbladder thickening represent the best method of early detection. Despite regular preoperative gallbladder imaging, many cancers are only detected intraoperatively or incidentally on pathologic examination. All known or suspected gallbladder cancers should be definitively treated with a laparotomy, not laparoscopic surgery. For early gallbladder cancers (Tis and T1 cancers), simple cholecystectomy is adequate therapy. More advanced-stage carcinomas without distant metastases should routinely be managed with a radical cholecystectomy, which includes partial hepatectomy and regional lymphadenectomy. Any adherent organs should be resected en bloc with the cancer. Pancreatoduodenectomy has been performed in several Japanese centers, but is rarely performed in the West for locally advanced gallbladder cancers. Most patients who undergo curative resection will develop recurrent disease, but there is currently no proven effective adjuvant therapy. Received: February 13, 2001 / Accepted: June 18, 2001     

Port-sites excision for gallbladder cancer incidentally found after laparoscopic cholecystectomy

Port-site recurrence represents a severe complication in the case of incidental gallbladder cancer (ICG) discovered after laparoscopic cholecystectomy, and is reported to occur in 17% of cases. For this reason port-sites excision is an essential surgical step during the second operation, which includes liver resection (segments 4b and 5) and lymph node dissection (hepatic pedicle and retroduodeno-pancreatic region). In this article we describe a simple technique to obtain a radical port-site excision with the aim to standardize this surgical step and to perform it in a radical way. Port-sites excision is the accurate and complete excision of the parietal channel created by the trocar during the previous cholecystectomy. This channel is often Z-shaped. In the second operation, the presence of peritoneal adhesions helps to identify exactly the previous site of entry of the trocar in the peritoneal cavity. Trocar reinsertion through the abdominal wall along the correctly identified original path allows the excision of a perfect cylinder of abdominal wall including all of the layers from the skin to the peritoneum.     

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。     

Unexpected gallbladder cancer and laparoscopic surgery

Case histories of three patients who underwent laparoscopic cholecystectomy for unexpected gallbladder cancer are reviewed. Port-site recurrence was observed in two of them. In one patient whose abdominal wall recurrent tumor was excised, a new recurrence developed, but after the reexcision she is symptom-free 10 months after the last procedure. The surgeon has to be aware of the fact that the survival rate can be doubled in stage pT2 if cholecystectomy is followed by extended radical operation. Only gallbladder cancer in stage pT1 does not need further procedure, except for excision of port sites. In case of uncertain diagnosis preoperative frozen section is recommended. Port-site recurrence does not mean an incurable stage of the disease or a sign of diffuse metastases. Even after reexcision of abdominal wall metastasis patients might be free from other detectable recurrences.     

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。     

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.     

Cholecystectomy, liver resection, and pyloruspreserving pancreaticoduodenectomy for gallbladder cancer: Report of five cases

Carcinoma of the gallbladder is an uncommon yet highly malignant disease with a poor overall prognosis. Surgical resection offers the only hope for cure in patients with this type of cancer, but resection is often impossible because of advanced disease at the time of presentation. Patients with locally dvanced gallbladder cancer, however, may occasionally be amenable to management by adding pancreaticoduodenectomy to cholecystectomy and liver resection. A retrospective review of patient records at the Johns Hopkins Hospital identified five patients with gallbladder cancer with peripancreatic lymph node involvement, who were treated by surgical resection including pancreaticoduodenectomy. The preoperative evaluation, operative technique, pathologic findings, and outcome were reviewed for each patient. Follow-up was obtained via clinic visit or telephone contact. All five patients underwent resection of the gallbladder cancer with an operation that included pylorus-preserving pancreaticoduodenectomy to remove the peripancreatic lymph nodes. In addition, four of the five patients underwent a nonanatomic liver resection. There were no in-hospital deaths. Two patients had postoperative complications; one had persistent drainage from a T-tube site and one had an anastomotic leak from the hepaticojejunostomy. Four patients have died of recurrent tumor during follow-up at intervals ranging from 11 months to 23 months. The fifth patient is alive and free of clinical disease at 42 months after operation. Carcinoma of the gallbladder is a highly malignant disease that is often not amenable to surgical cure. There is a select group of patients, however, in whom adding a pylorus-preserving pancreaticoduodenectomy can result in a potentially curative operation by removing extensive regional spread to the peripancreatic lymph nodes.     

Trocar-site metastasis following laparoscopic cholecystectomy for unsuspected carcinoma of the gallbladder

Fifteen cases of trocar-size metastasis from unsuspected gallbladder carcinoma following laparoscopic cholecystectomy have been reported in the literature. We present the case of a 66-year-old woman who developed this complication 2 1/2 months postoperatively. We feel that carcinoma of the gallbladder is a contraindication to laparoscopic cholecystectomy. When unsuspected lesions are discovered, intraoperative frozen-section lesions will facilitate the surgical management.     

原发性胆囊癌的外科治疗

目的探讨原发性胆囊癌病人的手术治疗方法及其治疗效果。方法回顾性分析我院1993年10月-2003年10月对66例原发性胆囊癌行外科手术治疗的临床资料。结果本组总体中位生存时间19．8个月。根治性切除术、姑息性切除术和胆道内或外引流术的生存期分别为37．8、10和2．7个月,具有非常显著性差异（P〈0.01）。根治性切除术1、3、5年生存率分别为78．2％、47．4％和26．3％,优于姑息性切除和胆道内或外引流术,具有非常显著性差异（P〈0．01）。其中,Ⅳ、Ⅴ期行扩大根治性切除术的中位生存时间平均为21个月,扩大根治性切除术明显优于姑息性切除术和胆道内或外引流术,具有非常显著性差异（P〈0．01）。结论肿瘤分期及手术根治程度是影响原发性胆囊癌疗效的主要因素,对中、晚期胆囊癌积极行扩大根治术,能改善病人的生活质量,延长生存期。     

Angiodysplasia of the gallbladder

Introduction

Angiodysplasia is a term used to describe distinct mucosal vascular ectasias found mainly in the gastrointestinal tract. Angiodysplasia of the gallbladder is exceedingly rare.

Presentation of case

We encountered a patient who presented with biliary colic and subsequently underwent an elective laparoscopic cholecystectomy. The angiodysplasia of the gallbladder was found incidentally on histopathological examination of the excised gallbladder.

Discussion

Review of the literature showed only one other reported case of angiodysplasia of the gallbladder. The condition may be found incidentally after histopathological examination of the gallbladder removed for gallstone; or it may present with haemobilia.

Conclusion

We presented an extremely rare case of angiodysplasia of the gallbladder, which was found incidentally after histopathological examination of the gallbladder removed for gallstone. Angiodysplasia of the gallbladder has the potential to bleed. Laparoscopic cholecystectomy is effective in providing a definitive cure.     

意外胆囊癌的外科处理

随着腹腔镜技术的普及,腹腔镜胆囊切除术中、术后发现的意外胆囊癌逐渐增多。高龄、结石病史等胆囊癌高危因素与意外胆囊癌相关;术中操作、人工气腹等原因可导致肿瘤的种植转移。胆囊癌外科治疗的关键在于早期发现,不同分期的胆囊癌应采用不同的手术方式,肿瘤的分期是最重要的预后因素。     

意外胆囊癌的诊断与治疗

意外胆囊癌(unexpected gallbladder carcinoma,UGC)是指术前拟诊断为胆囊良性疾病,在胆囊切除术中或术后发现的胆囊癌.我国的胆囊结石发病率较高,UGC患者也越来越多.2002年8月至2008年8月我科共收治641例胆囊癌患者,其中UGC患者占9.8%.由于缺乏对UGC治疗的大宗病例的临床随机对照研究,因此,国际上尚无统一的治疗标准,尤其在初次LC是否影响UGC患者预后等方面存在许多争议[1].     

意外胆囊癌治疗的研究进展

意外胆囊癌（IGBC）是指因临床诊断为胆囊良性疾病而行胆囊切除术,在术中或术后经病理检查确诊为恶变的胆囊癌。随着腹腔镜胆囊切除术的普及,术中术后意外发现胆囊癌的病例明显增多,同时对于IGBC的治疗也存在诸多争议。笔者对IGBC的治疗进展进行综述,以供临床参考。     

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。