摘要目的 探讨区域淋巴结清扫范围对T4期胆囊癌患者预后的影响.方法 采用回顾性队列研究方法.收集2013年1月至2016年12月4家医疗中心收治的64例(海军军医大学附属东方肝胆外科医院31例、西安交通大学第一附属医院16例、上海交通大学医学院附属新华医院11例、川北医学院附属医院6例)行胆囊癌根治术的T4期胆囊癌患者的临床病理资料;男27例,女37例;中位年龄为59岁,年龄范围为35～77岁.64例患者均行胆囊癌根治术与区域淋巴结清扫.根据术中淋巴结清扫范围,其中25例患者(海军军医大学附属东方肝胆外科医院13例、西安交通大学第一附属医院6例、上海交通大学医学院附属新华医院4例、川北医学院附属医院2例)淋巴结清扫范围为胆囊管旁、肝十二指肠韧带、胰头后、肝总动脉旁、腹腔干旁的淋巴结设为扩大清扫组;39例患者(海军军医大学附属东方肝胆外科医院18例、西安交通大学第一附属医院10例、上海交通大学医学院附属新华医院7例、川北医学院附属医院4例)淋巴结清扫范围为胆囊管旁、肝十二指肠韧带的淋巴结设为对照组.观察指标:(1)术后并发症情况.(2)随访和生存情况.采用门诊和电话方式进行随访,了解患者术后总体生存情况.随访时间截至2018年1月.正态分布的计量资料以Mean±SD表示,组间比较采用独立样本t检验.计数资料用绝对数或百分比表示,组间比较采用x2检验或Fisher确切概率法.采用Kaplan-Meier法绘制生存曲线.生存情况分析采用Log-rank检验.结果 (1)术后并发症情况:64例T4期胆囊癌患者顺利完成胆囊癌根治术与区域淋巴结清扫,无术中死亡病例.12例患者术后出现了不同程度的术后并发症.7例行扩大根治术的患者中4例发生术后并发症.25例扩大清扫组患者中4例腹腔感染、2例胰液漏,经保守治疗后痊愈;并发症发生率为24.0％(6/25).39例对照组患者中5例腹腔感染、1例胃潴留,经保守治疗后痊愈;并发症发生率为15.4％(6/39).两组并发症发生率比较,差异无统计学意义(x2=0.284,P＞0.05).(2)随访和生存情况:64例T4期胆囊癌患者均获得随访,随访时间为1～60个月,术后总体中位生存时间为11个月.扩大清扫组患者术后中位生存时间18个月,1、3、5年累积生存率分别为80％、16％、9％;对照组患者术后中位生存时间为8个月,1、3、5年累计生存率分别为21％、4％、0.两组患者预后情况比较,差异有统计学意义(x2=14.744,P＜0.05).结论 在手术操作熟练的前提下,扩大淋巴结清扫范围并不增加T4期胆囊癌患者手术并发症发生率;积极扩大淋巴结清扫范围,扩大至肝总动脉旁、腹腔千周围、胰头后淋巴结,可提高患者远期生存率、改善预后.

abstractsObjective To investigate the effects of the extent of regional lymph node dissection on the prognosis of patients with T4 gallbladder carcinoma.Methods The retrospective cohort study was conducted.The clinicopathological data of 64 patients with T4 gallbladder carcinoma who underwent radical cholecystectomy in the 4 medical centers between January 2013 and December 2016 were collected,including 31 in the Eastern Hepatobiliary Surgery Hospital of Naval Medical University,16 in the First Affiliated Hospital of Xi'an Jiaotong University,11 in the Xinhua Hospital Affiliated to Shanghai Jiaotong University School of Medicine and 6 in the Affiliated Hospital of North Sichuan Medical College.There were 27 males and 37 females,aged from 35 to 77 years,with a median age of 59 years.Sixty-four patients underwent radical cholecystectomy and regional lymph node dissection.According to the extent of intraoperative lymph node dissection,25 patients (13 in the Eastern Hepatobiliary Surgery Hospital of Naval Medical University,6 in the First Affiliated Hospital of Xi'an Jiaotong University,4 in the Xinhua Hospital Affiliated to Shanghai Jiaotong University School of Medicine and 2 in the Affiliated Hospital of North Sichuan Medical College) whose extent of lymph node dissection involved lymph nodes next to cystic duct,hepatoduodenal ligament,back of head of pancreas,next to common hepatic artery and celiac trunk were allocated into the extended dissection group,39 patients (18 in the Eastern Hepatobiliary Surgery Hospital of Naval Medical University,10 in the First Affiliated Hospital of Xi'an Jiaotong University,7 in the Xinhua Hospital Affiliated to Shanghai Jiaotong University School of Medicine and 4 in the Affiliated Hospital of North Sichuan Medical College) whose extent of lymph node dissection involved lymph nodes next to cystic duct and hepatoduodenal ligament were allocated into the control group.Observation indicators:(1) postoperative complications;(2) follow-up and survival situations.Follow-up using outpatient examination and telephone interview was performed to detect postoperative overall survival up to January 2018.Measurement data with normal distribution were represented as Mean±SD,and comparison between groups was evaluated with the independentsample t test.Count data were represented as absolute number or percentage,and comparison between groups was analyzed using the chi-square test and Fisher exact probability.The survival curve was drawn using the KaplanMeier method,and the comparison of survival rates was done by the Log-rank test.Results (1) Postoperative complications:64 patients with T4 gallbladder carcinoma underwent successful radical cholecystectomy and regional lymph node dissection,without intraoperative death.Twelve patients had different degrees of postoperative complications.Four of 7 patients undergoing extended radical cholecystectomy had postoperative complications.Twenty-five patients in the extended dissection group were cured by conservative treatment,including 4 with intraperitoneal infection and 2 with pancreatic leakage,with a complication incidence of 24.0％ (6/25).Thirtynine patients in the control group were cured by conservative treatment,including 5 with intraperitoneal infection and 1 with gastric retention,with a complication incidence of 15.4％ (6/39).There was no statistically significant difference in the complication incidence between the two groups (x2=0.284,P＞0.05).(2) Follow-up and survival situations:64 patients were followed up for 1-60 months.The postoperative overall median survival time was l l months.The postoperative median survival time,1-,3-and 5-year cumulative survival rates were respectively 18 months,80％,16％,9％ in the extended dissection group and 8 months,21％,4％,0 in the control group,with a statistically significant difference in the prognosis between the two groups (x2=14.744,P＜ 0.05).Conclusions On the premise of practiced surgical skill,extended regional lymph node dissection cannot increase incidence of surgical complication in patients with T4 gallbladder carcinoma after radical resection.Actively extending lymph node dissection up to near common hepatic artery,peri-celiac trunk and back of head of pancreas can improve long-term survival and prognosis.