摘要目的 探讨腹腔镜胆囊切除术(LC)术中或术后发现意外胆囊癌(IGBC)的外科治疗方法及预后影响因素.方法 回顾性分析2002年1月至2013年12月解放军总医院肝胆外科医院收治的83例LC术中或术后发现的IGBC患者的临床病理特点、外科治疗方法及预后,占同期LC总例数的0.82％ (83/10 080).其中男性26例,女性57例,年龄34 ～ 83岁,中位年龄61岁.治疗方式包括单纯LC治疗47例,中转开腹胆囊癌根治术18例,二期胆囊癌根治术16例,二期开腹探查及活检术2例.采用Kaplan-Meier法计算随访病例的累积生存率,Log-rank法比较生存率曲线,Cox回归模型分析各影响因素与生存期的关系.结果 术中快速冰冻切片证实IGBC 35例,术后常规病理确诊48例.按不同手术方式分为4组:单纯LC组(n=47),中转开腹胆囊癌根治术组(n=18),二期胆囊癌根治术组(n=16),二期剖腹探查及活检术组(n=2);各组患者的5年累积生存率分别为89.4％、38.9％、87.5％、0.病理T分期中T1a期、T1b期、T2期、T3期IGBC患者的5年累积生存率分别为95.7％(22/23)、90.0％(18/20)、75.0％ (15/20)、40.0％(8/20),各组生存率差异有统计学意义(P＜0.05).全组患者中位生存期为26个月.Cox回归多因素分析结果显示,病理T分期、有无淋巴结转移、手术中胆囊破裂是影响IGBC患者预后的独立危险因素(P＜0.05).结论 单纯LC适合治疗T1a期IGBC,若术中有胆囊破裂及胆汁漏出,可行中转开腹胆囊癌根治术;对于可能R0切除的T1b～ T3期IGBC应行标准胆囊癌根治术或扩大根治术.术中注意无瘤操作、仔细剖检胆囊标本、早期发现和早期诊断是提高IGBC外科治疗效果的关键.

abstractsObjective To analyze the surgical management of incidental gallbladder cancer (IGBC) discovered during or after laparoscopic cholecystectomy (LC) and to evaluate the associated factors of survival.Methods A retrospective analysis of patients with IGBC between January 2002 and December 2013 was performed.A total of 10 080 consecutive patients underwent LC operation for presumed gallbladder benign disease in Chinese People's Liberation Army General hospital.And among them,83 patients were histologically diagnosed as IGBC.Data covering clinical characteristics,surgery records,local pathological stage,histological features and factors for long term survival were reviewed.The survival analysis was performed using Kaplan-Meier method,and the results were examined using the log-rank test.For multivariate statistical analyses of prognostic factors,a Cox proportional hazards model was carried out.Results A total of 83 patients with IGBC:68.7％ females (57/83),median age of 61 years (range 34-83 years).There were 47 cases accepted the initial simple LC,18 cases converted to open extended radical cholecystectomy,16 cases with radical second resection,and 2 cases with re-laparotomy; the 5-year survival rates for each group were 89.4％,38.9％,87.5 ％,and 0,respectively.The 5-year survival rates in T1 a,T1 b,T2,and T3 stage patients were 95.7％ (22/23),90.0％ (18/20),75.0％ (15/20),and 40.0％ (8/20),respectively.Univariate analysis for prognostic factors associated with cancer-specific death showed that depth of invasion,lymph-node status,vascular or neural invasion,tumor differentiation,extent of resection,bile spillage during prior LC and type of surgery were statistically significant.In multivariate analysis,depth of invasion,extent of resection and bile spillage were the most important prognostic factors related to both cancer-specific mortality and disease relapse (P ＜ 0.05).Conclusions Simple LC is appropriate for T1 a patients with clear margin and unbroken gallbladder.An extended radical resection in patients with T1 b or more is highly recommended,and provided as a potentially curative R0 resection only if it is necessary.