腹腔镜胆囊切除术与意外胆囊癌的临床分析
摘要
目的
总结腹腔镜胆囊切除术中、术后意外胆囊癌的临床特点,探讨避免其漏诊和提高远期疗效的对策。
方法
回顾性分析我院2000年1月～2007年12月间腹腔镜胆囊切除术中或术后发现的51例意外胆囊癌的临床资料及随访结果。
结果
51例(100%)均符合胆囊癌高危人群。按Nevin分期,Ⅰ期4例,Ⅱ期5例,Ⅲ期24例,Ⅳ期5例,Ⅴ期13例。22例由术中冰冻切片检查后诊断,29例术后诊断。2例未随访,49例随访2～92个月,中位随访期为12月,平均随访期为(20.8±21.7)个月。其中6例随访期间失访,失访时间为2～18个月。随访全组中位生存期24个月,4例1期患者行腹腔镜胆囊切除术后已生存13～92个月,其余各期中位生存期及平均生存期分别为:Ⅱ期20月、(19.7±4.7)个月;Ⅲ期27月、(34.5±4.9)个月;Ⅳ期11月、(33.3±12.4)个月;Ⅴ期5月、(5.1±1.1)个月。Ⅱ期中1例行根治性手术,术后9月失访,4例仅行LC,术后仅生存9～34个月,Ⅲ期组病人中,行再次根治术者10例,仅行LC者12例,两组生存期比较,差别有统计学意义(P=0.010)。Ⅳ期中3例行根治性手术,2例已生存57、58个月,1例术后2月失访。2例仅行LC,术后仅生存6、11个月。Ⅴ期组病人中,行再次扩大根治性手术5例,姑息性手术者3例,仅行活检术者5例,三组生存期相比,生存期差别无统计学意义(P=0.182、P=0.916、P=0.156)。
结论
提高对意外胆囊癌的认识,术前仔细分析临床资料,术中仔细检查标本,对可疑标本行术中快速冰冻切片检查能有效避免意外胆囊癌的漏诊。Ⅰ期的意外胆囊癌仅行LC勿需行根治性手术;Ⅱ(尤其侵犯胆囊肌层)、Ⅲ、Ⅳ期的意外胆囊癌应行根治性手术,可以改善预后;Ⅴ期行扩大根治性手术或姑息性手术,不能改善预后。
Objective
The aim of this study is to analyze clinical characters of unsuspected gallbladder carcinoma in laparoscopic cholecystectomy and to discuss the methods of avoiding loss of diagnosis and improving the treatment.
Methods
We performed a retrospectively analysis of 51 patients who were treated from January 2000 to December 2007 in our hospital for unsuspected gallbladder carcinoma during or after laparoscopic cholecystectomy.
Results
In the 51 cases,the clinical characters were all in accordance with high-risk of gallbladder carcinoma.22 cases were diagnosed intraoperation by frozen section examination.29 cases were diagnosed postoperation.4 cases were stageⅠ,5 were stageⅡ,24 were stageⅢ,5 were stageⅣ,13 were stageⅤ,according to Nevin classification,respectively.Two cases lose after outpatient,49 cases follow up from 2 to 92 months,meadian time of follow-up is 12 months,mean time of follow-up is (20.8±21.7)months.6 cases lose during follow-up,they only follow-up from 2 to 18 months.The meadian survival time of 49 cases was 24 months;All cases of stageⅠare alive during the follow-up,The meadian and mean survival time of stageⅡis 20 months and(19.7±4.7)months,stageⅢis 27months and(34.5±4.9)months,stageⅣis 11months and(33.3±12.4)months,stageⅤis 5 months and(5.1±1.1)months.For the cases of stageⅢ,10 cases were performed radical reoperation,12 cases only LC were performed.The survival time between radical reoperation and LC group is difference,(P=0.010).For the cases in stageⅤ,5 cases were performed extend radical reoperation,3 cases were performed palliative operation,5 cases were only performed biopsy.The survival time between extend radical reoperation、palliative operation and biospy group is similar(P=0.182、P=0.916、P=0.156).
Conclusions
The surgeon should pay attention to the diagnosis of unsuspected gallbladder carcinoma for laparoscopic cholecystectomy patients.To analyze the preoperative clinical data of patients and to inspect,palpate the specimen carefully,and frozen section examination for any suspicion of cancer,seems to be useful for the diagnosis of unsuspected gallbladder carcinoma.For the cases of stageⅠ,only LC is enough;For the cases ofⅡ、Ⅲ、Ⅳstage,radical reoperation can improve the prognosis;For the cases of stageⅤ,extend radical or palliative operation can not improve the prognosis.
总结腹腔镜胆囊切除术中、术后意外胆囊癌的临床特点,探讨避免其漏诊和提高远期疗效的对策。
方法
回顾性分析我院2000年1月～2007年12月间腹腔镜胆囊切除术中或术后发现的51例意外胆囊癌的临床资料及随访结果。
结果
51例(100%)均符合胆囊癌高危人群。按Nevin分期,Ⅰ期4例,Ⅱ期5例,Ⅲ期24例,Ⅳ期5例,Ⅴ期13例。22例由术中冰冻切片检查后诊断,29例术后诊断。2例未随访,49例随访2～92个月,中位随访期为12月,平均随访期为(20.8±21.7)个月。其中6例随访期间失访,失访时间为2～18个月。随访全组中位生存期24个月,4例1期患者行腹腔镜胆囊切除术后已生存13～92个月,其余各期中位生存期及平均生存期分别为:Ⅱ期20月、(19.7±4.7)个月;Ⅲ期27月、(34.5±4.9)个月;Ⅳ期11月、(33.3±12.4)个月;Ⅴ期5月、(5.1±1.1)个月。Ⅱ期中1例行根治性手术,术后9月失访,4例仅行LC,术后仅生存9～34个月,Ⅲ期组病人中,行再次根治术者10例,仅行LC者12例,两组生存期比较,差别有统计学意义(P=0.010)。Ⅳ期中3例行根治性手术,2例已生存57、58个月,1例术后2月失访。2例仅行LC,术后仅生存6、11个月。Ⅴ期组病人中,行再次扩大根治性手术5例,姑息性手术者3例,仅行活检术者5例,三组生存期相比,生存期差别无统计学意义(P=0.182、P=0.916、P=0.156)。
结论
提高对意外胆囊癌的认识,术前仔细分析临床资料,术中仔细检查标本,对可疑标本行术中快速冰冻切片检查能有效避免意外胆囊癌的漏诊。Ⅰ期的意外胆囊癌仅行LC勿需行根治性手术;Ⅱ(尤其侵犯胆囊肌层)、Ⅲ、Ⅳ期的意外胆囊癌应行根治性手术,可以改善预后;Ⅴ期行扩大根治性手术或姑息性手术,不能改善预后。
Objective
The aim of this study is to analyze clinical characters of unsuspected gallbladder carcinoma in laparoscopic cholecystectomy and to discuss the methods of avoiding loss of diagnosis and improving the treatment.
Methods
We performed a retrospectively analysis of 51 patients who were treated from January 2000 to December 2007 in our hospital for unsuspected gallbladder carcinoma during or after laparoscopic cholecystectomy.
Results
In the 51 cases,the clinical characters were all in accordance with high-risk of gallbladder carcinoma.22 cases were diagnosed intraoperation by frozen section examination.29 cases were diagnosed postoperation.4 cases were stageⅠ,5 were stageⅡ,24 were stageⅢ,5 were stageⅣ,13 were stageⅤ,according to Nevin classification,respectively.Two cases lose after outpatient,49 cases follow up from 2 to 92 months,meadian time of follow-up is 12 months,mean time of follow-up is (20.8±21.7)months.6 cases lose during follow-up,they only follow-up from 2 to 18 months.The meadian survival time of 49 cases was 24 months;All cases of stageⅠare alive during the follow-up,The meadian and mean survival time of stageⅡis 20 months and(19.7±4.7)months,stageⅢis 27months and(34.5±4.9)months,stageⅣis 11months and(33.3±12.4)months,stageⅤis 5 months and(5.1±1.1)months.For the cases of stageⅢ,10 cases were performed radical reoperation,12 cases only LC were performed.The survival time between radical reoperation and LC group is difference,(P=0.010).For the cases in stageⅤ,5 cases were performed extend radical reoperation,3 cases were performed palliative operation,5 cases were only performed biopsy.The survival time between extend radical reoperation、palliative operation and biospy group is similar(P=0.182、P=0.916、P=0.156).
Conclusions
The surgeon should pay attention to the diagnosis of unsuspected gallbladder carcinoma for laparoscopic cholecystectomy patients.To analyze the preoperative clinical data of patients and to inspect,palpate the specimen carefully,and frozen section examination for any suspicion of cancer,seems to be useful for the diagnosis of unsuspected gallbladder carcinoma.For the cases of stageⅠ,only LC is enough;For the cases ofⅡ、Ⅲ、Ⅳstage,radical reoperation can improve the prognosis;For the cases of stageⅤ,extend radical or palliative operation can not improve the prognosis.
引文
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2.Wullstein C,Woeste G.Barkhausen S,et al.Do complications related to laparoscopic cholecystectomy influence the prognosis of gallbladder cancer? Surg Endosc.2002;16(5):828-832.
3.Benoist S,Panis Y,Fagniez PL.Long-term results after curative resection for carcinoma of the gallbladder cancer?Am J Surg.1998;175:118-122.
4.Box JC,Edge SB.Laparoscopic cholecystectomy and unsuspected gallbladder carcinoma.Semin Surg Oncol.1999;16(4):327-331.
5.Copher JC,Rogers JJ,Dalton ML.Trocar-site metastasis following laparoscopic cholecystectomy for unsuspected carcinoma of gallbladder.Case report and review of the literature.Surg Endosc.1995;9(3):348-350.
6.Wolff S,Kuhn R,Lippert H.Zufallsbefund-Gallenblasenkarzinom nach laparoskopischer cholezystektomie-wann operieren?Viszeralchirurgie.2002;37:305-308.
7.Z'graggen K,Birrer S,Maurer CA et al.Incidence of port site recurrence after laparoscopic cholecytectomy for preoperatively unsuspected gallbladder carcinoma.Surgery.1998;124:831-8.
8.Legorreta AP,Silber TH,Costantino GN,et al.Increased cholecystectomy rate after the introduction of iaparoscopic cholecystectomy.TAMA 1993;270:1429-32.
9.Kazuhiro Sakamoto,Masayuki Kitajima,Shigeru Shirota,et al.Clinicopathological study of unsuspected gallbladder cancer diagnosed after laparoscopic cholecysteteomy.Digestive Endoscopy.2003;15:14-18.
10.Chun-nan yeh,Yi-yin jan,Mhn-fu then.Management of unsuspected gallbladder carcinoma discovered during or following laparoscopic cholecystectomy.The American Sergeon.2004;70:256-258.
11.Tomotaka Akatsu,Masakazu Ueda,Motohide Shimazu,et al.Long-term survival of patients with gallbladder cancer detected during or after laparoscopic cholecystectomy.World J.Surg.2005;29:1106-1109.
12.Chan CP,Chang HC,Chen YL,et al.A 10-year experience of unexpected gallbladder cancer after laparoscopic cholecystectomy,lnt Surg,2003,88:175-179.
13.Hong Defei,Li Songying,Li Junda,et al.Laparoscopic cholecystectomy for missed diagnosed gallbladder carcinoma.Chin J Hepatobiliary Surg,2001,7:103-104.
洪德飞,李松英,李君达,等。腹腔镜胆囊切除误诊胆囊癌。中华肝胆外科杂志,2001,7:103-104.
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