意外胆囊癌手术治疗七例分析

目的探讨在腹腔镜切除(LC)术中意外发现胆囊癌的处理方法。方法回顾性分析2009年7月至2012年1月221例行LC的患者中,术中意外发现胆囊癌患者7例的临床资料及治疗方法。结果全组意外胆囊癌的发生率为3.17%。未发现NevinⅠ期病例,Ⅱ期患者2例行单纯LC,3例Ⅲ期和1例Ⅳ期患者行LC+局部淋巴结清扫术,1例Ⅴ期患者中转开腹行胆囊切除加T管引流术。Ⅱ期患者术后最长随访3年未见复发,Ⅲ期患者有3例,2例随访2年无复发,1例1年后复发再次行T管外引流+胃空肠吻合术,随访至今半年仍健在。而Ⅳ期患者预后较差,于半年内死亡。结论Ⅰ、Ⅱ期的意外胆囊癌行LC可达到根治目的。Ⅲ、Ⅳ期的患者,对于熟练掌握腔镜技术的术者可以行LC+局部淋巴结清扫术,术中做到无瘤的原则,可以提高胆囊癌的预后。     

腹腔镜手术中意外胆囊癌的临床处理分析

目的:探讨在腹腔镜胆囊切除术(LC)中意外发现胆囊癌的治疗方法。方法:对14例LC时意外发现的胆囊癌患者的临床资料进行回顾性分析。结果:4例NevinⅠ、Ⅱ期患者行单纯LC,2例Ⅲ期和3例Ⅳ期患者行LC中转开腹+局部淋巴结清扫术+肝脏楔形切除术,5例Ⅴ期患者行胆囊姑息性切除术。全组意外胆囊癌的发生率为0.06%。结论:Ⅰ期的意外胆囊癌行LC可达到根治目的,Ⅱ期行胆囊切除+肝脏部分切除+术后化疗,Ⅲ、Ⅳ期需行胆囊癌根治术,Ⅴ期根据情况行胆囊切除或姑息手术。     

意外胆囊癌临床分析

目的探讨意外胆囊癌的临床特点及有效治疗方法。方法回顾性分析我院1990年1月至2002年12月间所发现意外胆囊癌26例的临床资料。结果行开腹胆囊切除术发现5例，小切口胆囊切除术发现15例，腹腔镜胆囊切除术发现6例，其中NevinⅠ期11例，Ⅱ期10例，Ⅲ期3例，Ⅳ期2例。Ⅰ、Ⅱ期均随访3年以上长期存活，Ⅲ期病例均术后2年内复发死亡，Ⅳ期1年内死亡。结论重视胆囊癌的高危因素，所有病例均行冰冻切片检查，手术为胆囊癌最有效的治疗手段，早期发现、合理治疗为提高胆囊癌生存的有效措施。     

腹腔镜胆囊切除术在60岁以上患者中的应用

目的 探讨60岁以上患者腹腔镜胆囊切除术（laparoscopic cholecystectomy,LC）的安全性. 方法 2001年11月～2005年12月,施行513例60岁以上的LC,其中急性胆囊炎62例,慢性胆囊炎、胆囊结石435例（合并胆总管结石2例）,胆囊息肉样病变16例.393例（76.6%）有合并症.＂三孔法＂行LC.气腹压力＜12 mm Hg. 结果 494例成功实施LC,其中2例同时行腹腔镜胆总管切开取石,2例行肺癌切除术（1例胸腔镜,1例开放手术）.全组发现11例意外胆囊癌,其中8例NevinⅠ～Ⅱ期行单纯LC,未作进一步治疗,术后随访1.5～4年未发现复发;3例（NevinⅢ期1例,Ⅳ期2例）中转行胆囊癌切除术联合局部淋巴结清扫术,均于术后0.5～2年肿瘤复发死亡.中转开腹手术19例（3.7%）,其中15例因胆囊与周围组织粘连严重,1例因胆囊管开口于右肝管且周围组织粘连,术中右肝管损伤（行右肝管吻合、T管引流术,恢复顺利,6个月后拔除T管,无右肝管狭窄）,另3例为意外胆囊癌Nevin Ⅲ期、Ⅳ期. 结论 60岁以上老年人LC手术安全可行,但要重视意外胆囊癌及严重腹腔粘连的发生.     

意外胆囊癌:附15例报告

目的 探讨意外胆囊癌的诊断和处理方法 .方法 回顾性分析近10年来2所医院15例意外胆囊癌患者的临床资料.结果 开腹手术发现8例,腹腔镜胆囊切除术发现7例,其中Nevin Ⅰ期3例,Ⅱ期9例,Ⅲ期2例,Ⅳ期1例.其中10例首次手术中施行根治术,3例术后确诊再行根治术,另2例Ⅰ期患者行单纯胆囊切除术后病理诊断为癌,未再行手术.Ⅰ、Ⅱ期均随访2年以上仍存活,Ⅲ期病例均术后2年内复发死亡,Ⅳ期半年内死亡.结论 早期胆囊癌术前诊断困难,重视其高危因素,术中对可疑病例行快速冰冻切片检查有助于诊断;根治性手术为胆囊癌最有效治疗方法.     

意外胆囊癌的临床处理与预后分析

目的 总结意外胆囊癌的临床病理特点、诊断与治疗方案的选择,分析与预后有关的因素,指导意外胆囊癌的规范化治疗.方法 回顾性分析北京协和医院1999年1月至2009年10月收住院治疗的27例意外胆囊癌的临床资料,应用Kaplan-Meier法对比单纯胆囊切除术组、胆囊癌根治术组以及NevinⅠ、Ⅱ期与Ⅲ、Ⅳ、Ⅴ期患者的累积生存率,对意外胆囊癌的治疗方法与预后进行分析.结果 27例患者以胆囊良性疾病的术前诊断行胆囊切除术,术前诊断以急慢性胆囊炎、胆囊结石和胆囊息肉为主.术后病理学检查证实为胆囊癌,其中低分化腺癌9例,中分化腺癌9例,高分化腺癌4例,腺瘤癌变5例.按Nevin分期,Ⅰ期2例,Ⅱ期5例,Ⅲ期8例,Ⅳ期5例,Ⅴ期7例.胆囊癌根治术组患者累积生存率好于单纯胆囊切除术组(x2=4.450,P=0.035);Nevin Ⅰ、Ⅱ期患者预后显著优于Ⅲ、Ⅳ、Ⅴ期(x2=6.825,P=0.014).结论 意外胆囊癌临床表现缺乏特异性,容易导致误诊,术中快速病理切片检查是明确诊断的重要方法,确诊后首选根治性切除术.     

16例意外胆囊癌的诊治分析

目的探讨意外胆囊癌的诊断和治疗。方法回顾性分析2006年1月至2012年12月胆囊切除术中或术后病理发现的原发性胆囊癌16例临床病例资料。结果术前诊断2例为胆囊息肉,14例为胆囊炎胆囊结石;常规开腹胆囊切除术(OC)2例,腹腔镜胆囊切除术(LC)14例;术后病理Nevin分期,Ⅰ期2例,Ⅱ期7例,Ⅲ期4例,Ⅳ期3例。;2例术中怀疑,经术中快速病理证实,1例单纯胆囊切除,1例术中再次行部分肝切除+肝十二指肠韧带周围淋巴结清扫术;术后病理证实14例,3例单纯胆囊切除,未再次手术;5例再次行肝十二指肠韧带周围淋巴结清扫术;3例再次手术行部分肝切除+肝十二指肠韧带周围淋巴结清扫术,3例放弃再次手术;随访时间至2013年4月,已有12例死亡,6例仍存活,最长者已存活40个月,最短者在术后3个月内死亡,4例存活期超过36个月。结论术前应重视胆囊癌的高危因素和增强对胆囊癌的诊断意识,以减少意外胆囊癌的发生;Nevin分期Ⅰ期和Ⅱ期侵犯胆囊粘膜患者可行LC,Ⅱ期侵犯肌层及其以上分期患者需再行开腹胆囊癌根治术。     

MC中意外胆囊癌的处理及相关问题探讨

临床上因良性疾病行胆囊切除术中或术后发现胆囊癌的病例．称其为意外胆囊癌（unexpected gallbladder canrcinoma,UGC）。如何处理好该类病人，对提高胆囊癌的总体疗效意义重大。我院1990年3月至2004年12月，实施小切口胆囊切除术（minicholecystectomy，MC）25000例，发现UGC128例。按Nevin分期：Ⅰ期34例，Ⅱ期64例，Ⅲ期17例．Ⅳ期9例，Ⅴ期4例。处理方法：单纯胆囊切除术75例；附加肝十二指肠韧带淋巴清扫35例；附加肝脏楔形切除和肝十二指肠韧带淋巴清扫15例；有3例在肝脏部分切除、淋巴清扫的基础上，切除肝门部受累胆管并行胆肠吻合术：现结合临床丁作中的体会，进行回顾与探讨：     

胆囊切除术后意外性胆囊癌的治疗

目的探讨胆囊切除术后意外性胆囊癌的二次手术方式以及对预后的影响。方法对我院自1995年1月~2005年1月因诊断为胆囊良性疾病而行胆囊切除,因术后病理证实为胆囊癌而二次行胆囊癌根治术17例患者进行回顾性分析。结果本组17例均因胆囊良性疾病行开放性单纯胆囊切除手术,术后病理证实为胆囊癌,术后病理:胆囊腺癌13例,鳞癌3例,鳞腺癌1例。初次手术Nevin病理分期:Ⅰ期2例,Ⅱ期4例,Ⅲ期8例,Ⅳ期3例。二次手术发现淋巴结转移11例,3例有肝转移和远处转移,胆囊床转移2例,胆管转移1例,二次手术Nevin病理分期:Ⅰ期2例,Ⅱ期3例,Ⅲ期1例,Ⅳ期8例,Ⅴ期3例,术后随访半年到5年,6例死亡,存活11例。结论术中对于胆囊标本的仔细检查可以减少意外性胆囊癌的发生率。二期根治性手术对于部分意外性胆囊癌是有益的。     

胆囊保留性手术中发现意外胆囊癌的处理：附9例报告

目的:探讨胆囊保留性手术中发现意外胆囊癌的处理方法与对策。方法:回顾性分析2002年7月—2006年7月经腹腔镜胆囊保留手术发现的9例意外胆囊癌患者的临床资料。研究对象外科处理后均随访5年。结果:9例均行手术治疗,其中3例Nevin分期I,II期患者行根治性胆囊切除,术后随访5年仍存活,至今未发现复发;1例Nevin分期III期行开腹胆囊切除术并行局部淋巴结清扫术,随访2.5年时仍存活,但已出现腹腔内多处种植转移及肝内多发转移;3例Nevin分期IV期和1例V期行根治术后1年内发生复发后死亡;1例姑息性外引流术后4个月死亡。结论:具有胆囊癌高危因素的患者应行开腹胆囊切除术,对可疑病灶进行病理学检查,对意外胆囊癌患者建议施行根治性胆囊切除术。     

误诊为胆囊良性疾病的胆囊癌二次根治术

目的探讨误诊为胆囊良性疾病的胆囊癌二次手术方式以及对预后的影响。方法对于1995年6月-2002年12月因误诊为胆囊良性疾病而切除胆囊,因术后病理证实为胆囊癌而二次行胆囊癌扩大根治术的41例患者进行回顾性分析。41例患者中,男12例,女29例,平均年龄51岁,均因胆囊炎(41例)或并发胆囊结石(32例)、胆囊息肉或腺瘤(9例)在第一次手术时行单纯胆囊切除。术后病理：胆囊腺癌32例,鳞癌6例,鳞腺癌3例;Nevin Ⅰ期6例,Ⅱ期16例,Ⅲ期17例,Ⅳ期2例,Ⅴ期0例。二次手术距一次手术间隔时间为6—30d。二次手术均行以改良的Glenn根治性胆囊癌切除术为标准的胆囊癌根治术式。结果二次手术时发现14例患者有淋巴结转移,14例患者有胆囊床转移,6例患者有胆管转移,2例患者有胰腺转移;Nevin Ⅳ期14例,Ⅴ期9例,无Ⅰ、Ⅱ、Ⅲ期者。二次手术后1年后存活率100％(41例),3年存活率53、8％(22例),5年存活率17．5％(7例)。结论扩大根治术是治疗误诊为胆囊良性疾病的胆囊癌的重要方法之一。     

意外发现的早期胆囊癌的诊断与处理

目的探讨意外发现的胆囊癌早期诊断与处理。方法回顾性总结1993年1月至2003年7月我院收治的64例胆囊癌属意外发现的早期胆囊癌的诊治经验。结果9例属手术意外发现,开腹手术7例,腹腔镜胆囊切除2例。术中快速冰冻切片或术后病理切片均证实为早期胆囊癌(NevinⅡ期)。7例于术中施行了标准的根治术,2例术后确诊再行根治。结论早期胆囊癌术前诊断困难,术中对可疑者做快速冰冻切片检查有助于意外发现早期胆囊癌;一旦确诊即予施行根治术。     

51例意外胆囊癌临床分析

目的分析意外胆囊癌(UGC)患者的临床特征及手术疗效。方法收集北京大学人民医院自1990年6月至2012年4月收治的51例意外胆囊癌患者的病历资料,对其临床特征、手术疗效以及影响预后的因素进行分析。结果 51例意外胆囊癌均经冰冻或石蜡切片病理证实,其中腺癌47例(92.2%),鳞癌2例(3.9%),神经内分泌癌1例(2.0%)及小细胞癌1例(2.0%);根据Nevin分期标准,Ⅰ期5例,Ⅱ期13例,Ⅲ期15例,Ⅳ期16例,Ⅴ期2例;31例(60.8%)改行胆囊癌根治术或扩大根治术,18例(35.3%)仅行胆囊切除术,另有2例行姑息性手术;术后随访33例(64.7%),患者中位生存时间13月(2~60月);Nevin分期(P=0.001)、手术方式(P=0.026)是影响UGC预后的独立因素;根治手术组患者较非根治手术组患者生存率差异有统计学意义(χ2=3.923,P0.05)。结论绝大多数意外胆囊癌患者的病理诊断为腺癌,行根治手术可延长患者的生存时间。应根据病理分期,结合患者自身情况选择切实有效的手术治疗手段。     

Carcinoma of the gallbladder--a clinical appraisal and review of 40 cases

Prognosis of 40 patients with gallbladder carcinoma who had undergone curative resection was investigated. Five-year survival rate calculated from Kaplan & Meier's method was 67% in 16 cases in Stage I, 43% in 8 cases in Stage II and 22% in 10 cases in Stage III, respectively. In 6 cases, classified as Stage IV, no case survived more than 2 years postoperatively. Most patients in Stage I had the tumors of papillary type in macroscopic appearance, papillary adenocarcinoma, and negative vascular and perineural invasions and showed better prognosis. In Stages II, III and IV, in contrast, most tumors were infiltrative or nodular type, tubular adenocarcinoma, and positive vascular and perineural invasions and demonstrated poorer prognosis. Patients in Stage I who had undergone simple cholecystectomy showed 5-year survival rate of 57%, and who underwent cholecystectomy with wedged resection of the gallbladder bed of the liver and regional lymphadenectomy (extended cholecystectomy) showed that of 100%. Extended cholecystectomy, therefore, is the procedure of choice in patients in Stage I. In patients in Stages II, III and IV, extended cholecystectomy yielded 5-year survival rate of 33%. More radical procedure or combined modality therapy must be indicated in advanced stage of the disease.     

Primary carcinoma of the gallbladder

Primary carcinoma of the gallbladder, while infrequent, is the most representative among the malignant neoplasms of the biliary tract. The diagnosis of carcinoma of the gallbladder was made in 22 out of 1252 operations performed for gallbladder disease (1.8%) since January 1980 through June 1988: only in 9% of the subjects a malignant tumor of the gallbladder was suspected preoperatively. In 21 cases the carcinoma was associated with chronic lithiasic cholecystitis. The 22 cases were assessed according to the classification proposed by Nevin. The operations performed were: 4 routine cholecystectomies (stages I and II) 4 cholecystectomies with lymphadenectomy (stages I and II); 4 cholecystectomies with lymphadenectomy and liver wedge resection of the bed of the gallbladder (stages II, III, IV, V); 7 explorative laparotomies and 3 gastrojejunal anastomoses (stage V). A complete follow-up was available for each of the 22 subjects: cumulative survival rates were calculated according to Kaplan-Meyer. The overall 5-year cumulative survival rate after operation was 19% for the whole group, whereas it reached 76% for the subgroup of 9 patients classified in stages I and II. This analysis reinforces the statement that surgical therapy can achieve excellent results if brought about before cancer overwhelms the muscular layer of the gallbladder wall. Thus, as the preoperative diagnosis of gallbladder carcinoma is extremely difficult and uncertain, any delay in performing cholecystectomy seems to be unwise in all those cases of chronic benign disease of the gallbladder (whether lithiasic in nature or not) that are suspected to be a major risk factor for cancer degeneration because of their frequent association with the carcinoma of the gallbladder.     

意外胆囊癌的诊治进展

胆囊癌是最常见的胆道恶性肿瘤,早期诊断困难,手术切除率低,预后差.随着腹腔镜技术的普及,腹腔镜胆囊切除术中出现意外胆囊癌的几率逐渐增大.高龄、结石病史长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.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子.本文综述了其临床特征、预后及诊断和治疗的最新进展.     

Gallbladder cancer: the role of laparoscopy and radical resection

OBJECTIVES: We assess how laparoscopy has altered the presentation of patients with gallbladder cancer and determine whether radical resection in patients with gallbladder cancer is beneficial. SUMMARY BACKGROUND DATA: The widespread adoption of laparoscopic cholecystectomy has led to an increased frequency of incidentally discovered gallbladder carcinoma. Little data exist to guide surgeons in the optimum management of patients with gallbladder cancer, particularly with respect to the potential advantages of radical resection. METHODS: Records of 107 patients with gallbladder cancer admitted to a tertiary academic medical center between 1995 and 2004 were reviewed. Gallbladder cancer was found incidentally in 53 patients (50%). Fifty-two of these patients underwent a routine laparoscopic cholecystectomy and were found to have gallbladder cancer intraoperatively or following the operation by subsequent pathologic evaluation of the specimen. Gallbladder cancer had been diagnosed preoperatively by radiology in the other 54 patients (50%). These patients did not undergo laparoscopic cholecystectomy and were explored electively. RESULTS: The median age at presentation was 67 years and 66% were female. Patients who were found to have gallbladder carcinoma incidentally at laparoscopic cholecystectomy had a significant increase in survival when compared with those who were admitted electively with a known diagnosis (P < 0.001). All patients who presented with a known diagnosis had stage II or greater disease, and 36% of these were stage IV carcinomas. However, 82% of those patients who were found incidentally were stage I or II. The overall 5-year survival for all patients was 15%; those discovered incidentally at laparoscopic cholecystectomy had a 5-year survival of 33%. This difference was significant among patients with stage II carcinomas. In the laparoscopic group, there was no difference in survival between the patients who were immediately converted to an open resection when identified to have gallbladder cancer intraoperatively (n = 6) and those who had a completed laparoscopic cholecystectomy and were re-explored at a later point when found to have gallbladder cancer by subsequent pathology (n = 33). There was a significant improvement in survival in 50 patients (47%) who underwent some form of radical resection (P < 0.001). Stage for stage comparison showed that this was significant in stage II disease. Patients who underwent hepatic resection along with lymphadenectomy and extra hepatic biliary resection had similar survival compared with those who had hepatic resection and lymphadenectomy alone. CONCLUSIONS: Laparoscopic cholecystectomy appears to have resulted in the earlier discovery of gallbladder cancer in some patients, resulting in increased probability of survival. Patients discovered with gallbladder carcinoma during a laparoscopic cholecystectomy do not have to be converted immediately to an open resection and should be referred to a tertiary care center for further exploration. Adjunctive radical surgical resection, either at the time of cholecystectomy or subsequently, increases survival significantly in early stage disease.     

腹腔镜胆囊切除术意外胆囊癌28例报告

目的探讨腹腔镜胆囊切除术(laparoscopic cholecystectomy,LC)中意外胆囊癌的诊治方法。方法对2000年1月~2007年5月我院15560例LC中28例意外胆囊癌(unsuspected gallbladder carcinoma,UGC)的临床资料进行回顾性分析。结果术中发现12例和术后发现16例中的5例行胆囊癌根治术,而仅行LC11例。术后病理TNM分期:Ⅰ期3例,Ⅱ期23例,Ⅲ期2例。28例术后随访7~66个月,平均22个月,死亡19例,其中接受胆囊癌根治手术的17例术后1、3、5年的存活率分别为76.5%(13/17)、23.5%(4/17)、11.8%(2/17);而仅行LC的11例术后1年生存率为45.4%,无存活超过2年。结论对高危人群,术中应高度警惕意外胆囊癌的发生,LC意外发现的胆囊癌多为早期,对早期胆囊癌应行标准胆囊癌根治术,仅行单纯的LC是不够的。