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腹腔镜胆囊切除术中或术后意外胆囊癌腹腔镜手术治疗:单中心10年回顾性分析

Laparoscopic treatment for incidental gallbladder cancer: a retrospective 10 years study from a single institution

摘要:

目的 探讨腹腔镜胆囊切除术(LC)术中或术后意外胆囊癌(IGBCA)腹腔镜手术治疗效果及预后因素.方法 回顾性分析2007年1月至2016年12月北京大学第三医院普通外科收治的71例LC术中或术后发现的IGBCA患者的临床病理资料、腹腔镜治疗方法及预后,男性18例,女性53例,年龄23~81岁(中位年龄66岁).分析比较其中行腹腔镜根治手术的65例患者与同期行开腹根治手术的14例患者的生存情况,依据IGBCA在术前超声、CT或MRI中胆囊腔内是否可见明显肿物将其分为肿物组和无肿物组.采用Kaplan-Meier法计算生存率,Log-rank法比较生存率曲线.结果 本组71例患者中65例行根治手术,3例单纯胆囊切除术,3例姑息手术,术后6例患者发生并发症,均经保守治疗好转.术中快速冰冻证实IGBCA 57例,准确率为96.5%,其中48例冰冻评估T分期,准确率为43.8%,术后常规病理学检查结果证实IGBCA 14例;最终石蜡病理T分期为Tis期6例,T1a期5例,T1b期10例,T2期46例,T3期4例,获取淋巴结(4.7±2.9)枚(范围:2~ 12枚),14例有淋巴结转移.肿物组50例,其中21例T分期≤T1b,其余29例T分期≥T2期,无肿物组21例,T分期均≥T2期.71例患者中位生存期为33个月,5年累积生存率为67.3%,其中行根治手术治疗的65例患者5年累积生存率为78.5%,与同时期行开腹根治手术治疗的14例患者比较,生存率差异无统计学意义(P=0.485).单因素分析结果显示,T分期、淋巴结转移、组织学分级、脉管侵犯、神经浸润、急性胆囊炎病史、胆囊破裂、有无肿物及术前CA19-9和癌胚抗原水平为预后因素(P值均<0.05).结论 腹腔镜手术治疗IGBCA效果良好,尤其对于术前影像学检查提示有肿物的患者;冰冻病理学检查对于T分期的评估效果欠佳,合理选择适合腹腔镜手术的患者是目前提高IGBCA外科治疗效果的关键.

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abstracts:

Objective To explore the feasibility of laparoscopic treatment for incidental gallbladder cancer(IGBCA) and analyze the factors influencing prognosis.Methods A retrospective study of 71 patients with IGBCA received laparoscopic treatment at Department of General Surgery,Peking University Third Hospital from January 2007 to December 2016 was conducted,the clinicopathological data and prognosis were analyzed.There were 18 males and 53 females,aged 23 to 81 years.They were divided into two groups based on the presence of intraluminal mass in the gallbladder.Sixty-five of the 71 patients received laparoscopic radical resection,the prognosis of them were compared with 14 patients with open radical resection.Results Among the 71 patients,65 patients received radical resection,3 patients simple gallbaldder resection and 3 patients palliative resection.Postoperative complications occurred in 6 patients.IGBCA were detected by frozen section in 57 patients,with the accuracy of 96.5%,while the accuracy of T stage is 43.8% in the 48 patients received T stage evaluation during frozen section examination.The T stages based on final pathology were Tis(n=6),T1a(n=5),T1b(n=10),T2(n=46),and T3(n=4).The number of harvested lymph node was 4.7±2.9(range:2-12).There are 14 patients with lymph node metastasis.The 50 patients with intraluminal gallbladder mass include 21 patients with ≤T1b stage and 29 patients with ≥T2 stage,while the 21 patients without intraluminal gallbladder mass are all with ≥T2 stage.The median survival time of the 71 patients was 33 months,with the 5-year cumulative survival rate 67.3%.The 5-year cumulative survival rate is 78.5% for the 65 patients who received radical resection,comparable with those who received open radical resection(P=0.485).Univariate analysis demonstrated that T stage,lymph node metastasis,G grade,lymphovascular invasion,neural invasion,acute cholecystectomy,bile spillage,gallbladder mass and preoperative CA19-9/CEA were the most important prognostic factors(P<0.05).Conclusions Laparoscopic treatment for IGBCA is feasible,especially for those with intraluminal gallbladder mass.The accuracy of frozen section examination in evaluating T stage is low.

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