晚期胆囊癌的外科治疗

目的：提高晚期胆囊癌的生存率及治疗效果。方法：对1990年1月至2001年6月我科手术治疗的80例晚期胆囊癌患者的资料进行回顾性分析。其中71例伴有阻塞性黄疸，15例扪及腹部包块，对已润周围器官及胆管但尚无肝脏广泛转移或远处转移的39例晚期胆囊癌进行了扩大根治术（其中11例合并胰十二指肠切除术），结果：该39例术后丰活8－37个月（平均存活18．1个月），1，2，3年生存率分别为43．6％，20．5％及5．1％，对另41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，术后随访除1例存活19个月外，其余均于1年内死亡，结论：对晚期胆囊癌的治疗应尽可能地行扩大根治术。     

胆囊癌的外科治疗

探讨各种手术对胆囊癌预后的影响。方法 ６０例胆囊癌患者病变早期组５例，行单纯胆囊切除术；晚期组５５例，行探查活检术２４例，姑息切除２６例，根治性切除术５例结果 早，晚期组１，３，５年生存率分别为１００％，６０％，２０％和１８．２％，５．５％，１．８％，晚期组探量活检术者均在１年内死亡；姑息性切除术者１年生存率２３．１％，无３年，５年生存；根治性切除术者１，３，５年生存率分别为８０％，６０％，２０％     

原发性肝癌的外科治疗

作者报告了１９６０年￣１９９３年经手术切除原发性肝癌２０５１例，其中肝细胞癌占９４．１％，合并肝硬变或慢性肝炎者占８６．５％，肿瘤直径≤５ｃｍ者占２５．１％，其中≤３ｃｍ者１７６例，４４．０％为局部根治性肝切除。手术后１个月内死亡率为１．１％，全组术后５年生存率为３６．１％，肿瘤≤５ｃｍ者，无手术死亡，术后５年生存率为７９．８％，而肿瘤≤３ｃｍ者，术后５年生存率８５．３％。作者认为，以下几点对提高     

门奇静脉断流术治疗门静脉高压症

１９８８年１月至１９９３年２月作者为１１６例肝硬变门静脉高压症患者施行了断流术，其中Ｈａｓ－ｓａｂ手术３７例，扩大Ｈａｓｓａｂ手术３６例，联合断流术３３例，经胸断流术１０例。全组手术死亡率为６．９％，近期出血率为８．６％，随访期出血率为１８．５％；１年及３年生存率分别为９４．２％和８１．８％。不同术式的临床资料分析表明扩大Ｈａｓｓａｂ手术和经胸断流术疗效较好。     

304例胃癌手术后疗效因素分析

报道３０４例胃癌手术治疗后随访分析。手术切除２３２例，术后总的１、３、５年生存率分别为８６．６４％、５０．４９％、２６．３１％。其中行根治性切除１２４例，根治术后１、３、５年生存率分别为９８．３９％、７９．４４％及４２．３５％。本文着重分析影响胃癌术后疗效的主要因素，提出对进展期胃癌应行Ｄ２或选择性Ｄ３的标准术式，对晚期患者应尽可能行姑息性切除术，对胃癌患者手术后应给予正规的化疗。     

肺转移瘤的外科治疗

报告３７例肺转移瘤的外科治疗，６７．５％的病人无症状，均在原发瘤术后随诊作Ｘ线胸片或胸透时发现，部分病人有咳嗽，咯血，胸闷和胸痛。本组手术死亡率５．４％，住院死亡率２．７％，术后１、３、５和７年生存率分别为９１．８％，４３．３％，３６．８％和２１．４％，讨论了肺转移瘤的诊断，治疗及预后，作者认为对肺转移瘤外科治疗应持积极态度。     

胆囊癌89例临床分析

目的 探讨提高胆囊癌疗效的途径。方法 对１９８５－１９９６年间收治的８９例胆囊癌患者的临床资料进行回顾性分析。结果 ８９例患者中男３１例,女５８例。男：女之比为１：１.８７。胆囊癌合并胆囊结石者占４０％,术前Ｂ超论断符合率为７９％（６２／７８）。ＣＴ诊断符合率为９２％（４３／４７）,术中及术后病理确诊占１８％（１６／７７）。本组７例漏诊,７７例行探查手术,５０例切除胆囊。切除率６５％,其中根治 切除２８例,根治率３6％。本组行根治性切除者１、３、５年生存率分别为７７％、５４％和２７５;行姑息性切除者１、３、５年生存率分别为４１％、１２％和６％（与根治切除相比Ｐ均＜０.０５）。仅行探查术者中位生存期３个月,且均在１年内死亡。结论 早期发现和根治性手术是提高胆囊癌患者生存率的有效方法,避免术中漏诊对预后有重要意义,对晚期胆囊癌应行扩大根治术。     

肺癌侵犯胸壁的外科治疗

自１９７８年１月至１９９４年１月间我们共作非小细胞型肺癌手术４８５例，其中属侵犯胸壁的Ⅲａ期肺癌２８例，占５．８％。对胸膜外肺切除组（Ａ）１７例及胸壁、肺整块切除组（Ｂ）１１例的外科治疗结果进行了随访和分析。全组无手术死亡，Ａ组５年生存率为１１．８％，Ｂ组５年生存率为１８．２％，但去除淋巴转移的病例后，Ａ组的５年生存率为２５％，而Ｂ组则达４０％。文中对Ⅲａ期肺癌的术前诊断与估计，影响手术预后的因素和切除后胸壁重建等问题进行了讨论，认为影响手术预后的因素是手术方式、淋巴结的转移和术中病灶的残留。在重建胸壁时采用自行研制的人工胸壁，置换获得成功。     

男性乳癌(附11例报告)

目的 探讨男性乳癌的临床特点、诊断及治疗方法。方法 回顾性分析１１例男性乳癌的临床及病理资料。结果 １１例术前均明确了诊断,Ⅰ期１例,Ⅱ期３例,Ⅲ期６例,Ⅳ期１例。本组均手术治疗,行乳腺单纯切除术１例,简化根治术２例,根治术８例,术后分别给予放疗及化疗。５年生存率为４５．５％。结论 男性乳癌发病年龄大,预后差,大多以乳腺肿块为首发症状,腋下淋巴结转移存率为４５．５％。结论 男性乳癌发病年龄大,预后     

再次瓣膜替换术64例报告

作者报告１９８８年２月至１９９６年５月间，行再次瓣膜替换术病例６４例，其中生物瓣衰坏４６例，机械瓣功能障碍９例，瓣周漏９例。按照术前的心功能状态，９例因机械瓣急性功能障碍，引起急性充血性心力衰竭或心源性休克，施行急症手术，其余５５例行择期手术。早期死亡８例（１２．５０％），其中择期手术后死亡３例（５．５０％），急症手术后死亡３例（３３．３％）。长期生存者５６例，随访时间３个月至７年（平均２．１年），晚期死亡３例（５．３％）。生存１年以上的４８例中，心功能恢复至Ⅰ级者４２例，Ⅱ级５例，Ⅲ级１例。作者对再次瓣膜替换术的手术时机与手术操作的重点作了讨论。     

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。     

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.     

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.     

158例原发性胆囊癌根治性手术临床疗效及预后因素分析

目的 探讨经根治性手术治疗的原发性胆囊癌临床疗效及预后影响因素.方法 回顾性分析2012年1月至2019年9月苏州大学附属第一医院收治的158例原发性胆囊癌患者的临床及病理资料.应用Kaplan-Meier法绘制生存曲线计算生存率,单因素分析采用Log-rank检验,多因素分析采用Cox比例风险回归模型.结果 158例...     

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 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.     

临床病理因素和手术方法对胆囊癌预后的影响

目的 分析与胆囊癌预后有关的临床病理因素.方法 回顾性分析2001-2006年61例进展期胆囊癌外科治疗资料.结果 按第6版UICC/AJCC的胆囊癌临床分期标准,ⅠB期8例,ⅡA期22例,ⅡB期11例,Ⅲ期14例,Ⅳ期6例.姑息性胆囊切除和/或胆道引流术26例;胆囊切除、局部淋巴结清扫14例,保留肝外胆管的根治性切除7例,联合肝外胆管切除的根治术13例;肝胆胰脏器联合切除1例.37例中有18例淋巴结阳性.52例术后得到随访.满6个月生存为41例(67.2%);满1年生存26例(42.6%);存活2年以上者10例(16.4%);3年以上存活7例(11.5%);1例存活5年以上(1.6%).术后2年内死亡的51例中,31例随访到死亡前症候:21例有进行性黄疸;14例有肝脏内多个转移;12例有顽固性腹水.非明确胆道病原因死亡者5例.结论 临床分期和手术方式与胆囊癌患者的预后有关.     

直肠癌根治性前切除后复发转移的危险因素

目的 研究直肠癌根治性前切除后复发转移的危险因素。方法 回顾性分析1983—2000年间单个医疗机构直肠癌根治性前切除的957例患者的临床资料，分析复发转移的危险因素。结果 共计有150例患者（15．7％）复发转移，复发转移部位依次为盆腔内局部复发57例（6．0％）、肝脏转移47例（4．9％）、肺部转移40例（4．2％）和其他部位转移6例（0．6％），中位复发转移时间18个月（2—85个月）。复发转移后中位生存8个月（1—62个月）。23例患者（15．3％）切除了肿瘤，术后中位生存30个月，生存超过5年者只有3例（13．0％）。低龄（P=0．024）、有肿瘤家族史（P=0．000）、癌胚抗原（CEA）水平（P=0．003）、肿瘤浸透肌层（P=0．000）、淋巴结转移（P=0．000）、脉管瘤栓（P=0．000）、印戒细胞癌或黏液腺癌（P=0．000）显著增加复发转移的风险。Logistic回归分析发现，肿瘤家族史（P=0．001）、CEA阻性（P=0．033）、肿瘤浸透肌层（P=0．000）、淋巴结转移（P=0．000）、脉管瘤栓（P=0．001）、印戒细胞癌或者黏液腺癌（P=0．012）是有显著统计学意义的复发转移的危险因素。结论 直肠癌根治性前切除后存在特定的复发转移危险因素。盆腔、肝脏和肺是肿瘤复发转移的主要部位。     

Surgical Approaches to Advanced Gallbladder Cancer

Purpose

The aim was to evaluate prognostic factors and factors associated with the resectability of advanced gallbladder cancer (GBC).

Methods

This was a single-institution retrospective review of 274 consecutive surgically-treated cases of advanced GBC (excluding incidental GBC and early GBC). Univariate and multivariate analysis were performed to assess prognostic variables. R0 resection and survival rates were investigated for each local extension factor.

Results

Long-term survival was uncommon among patients with multiple liver metastases (H_2–3: n = 22; 2-year survival, 0 %), dissemination (P_1–3: n = 16; 3-year survival, 0 %), invasion through the hepatoduodenal ligament (Binf₃: n = 45; 5-year survival, 4.6 %), or group 3 lymph node (LN) metastasis including of the para-aortic LN (N₃: n = 52; 13.7 %). Long-term survival rates did not differ significantly between patients who did and did not undergo bile duct resection or pancreaticoduodenectomy. Survival did not differ significantly according to the type of hepatectomy performed.

Conclusion

Surgery may not be indicated for patients with multiple liver metastasis, dissemination, Binf₃, or visible para-aortic LN metastasis. Furthermore, it is important to achieve R0 surgery in cases of GBC.