意外胆囊癌的外科临床策略

第33卷第4期2021年4月V ol.33 No.4Apr. 2021肝 胆 胰 外 科 杂 志Journal of Hepatopancreatobiliary Surgery·讲　座·意外胆囊癌的防范和外科治疗王恒杰１，张宝华２，顾卯林１，黄永刚１（1.昆山市中医医院 肝胆外科，江苏 苏州 215300；2.海军医科大学第三附属医院/东方肝胆外科医院胆道二科，上海 200082）2020-06-09王恒杰（1985-），男，江苏苏州人，副主任医师，硕士。

［收稿日期］［第一作者简介］［摘　要］ 随着胆囊良性病变行手术切除病例的增多，意外胆囊癌的数量也在不断上升，虽然发病率较低，但其恶性程度高、预后差，因此临床医师在行胆囊良性疾病外科治疗时，应从围手术多方面着手，重视意外胆囊癌的防范，规范意外胆囊癌的外科治疗，避免不必要的误诊和漏诊，以提高意外胆囊癌患者的远期疗效。

[关键词] 意外胆囊癌；高危因素筛查；术前辅助检查；手术选择；术后病理；误诊和漏诊[中图分类号] R735.8 [文献标识码] A doi:10.11952/j.issn.1007-1954.2021.04.002开放科学标识码(OSID)意外胆囊癌（unexpected gallbladder carcinoma ，UGC ）是指术前拟诊断为胆囊良性疾病，在胆囊切除术中或术后发现的胆囊癌。

随着腹腔镜胆囊切除术成为治疗胆囊良性疾病的金标准，意外胆囊癌的发病率很低，但发展迅速，预后极差，5年生存率仅为5%～12%[1-3]，故临床上需予以重视。

意外胆囊癌一般分期较早，以T2期为主[2]，对于早期胆囊癌，有研究表明若能根据T 分期施行相应的根治手术，可将5年生存率提高至75%以上[4]。

因此，对于早期胆囊癌的明确诊断以及精准的外科手术治疗是提高患者预后的关键。

１　意外胆囊癌的防范措施1.1 重视意外胆囊癌的高危因素筛查胆囊癌发生的高危因素包括胆囊结石、胆囊息肉、慢性胆囊炎、胰胆管汇合异常等。

胆囊癌的外科治疗发布时间：2022-07-30T03:41:22.641Z 来源：《医师在线》2022年10期作者：胡向贇[导读] 胆囊癌（GBC）是常见的胆道恶性肿瘤，也是消化系统常见的肿瘤之一。

目前，治疗GBC最理想的策略是手术切除，但只有将近10%的患者接受手术治疗，因为大多数患者就诊时已经失去了手术机会。

本文就现阶段胆囊癌的外科治疗方法做一总结。

胡向贇内蒙古医科大学呼和浩特 010110摘要：胆囊癌（GBC）是常见的胆道恶性肿瘤，也是消化系统常见的肿瘤之一。

目前，治疗GBC最理想的策略是手术切除，但只有将近10%的患者接受手术治疗，因为大多数患者就诊时已经失去了手术机会。

本文就现阶段胆囊癌的外科治疗方法做一总结。

关键词：胆囊癌外科治疗中图分类号：R735.81 外科手术胆囊癌的外科手术治疗方式，现在主要根据TNM分期进行选择。

虽然目前有关胆囊癌的外科术式已经有了较为统一的标准，但是在某些分期中的治疗方案仍然存在分歧。

本文按照AJCC第八版来进行分期。

对于病理学上患有Tis或T1a的GBC患者，并且尚无淋巴结转移，通常行单纯的胆囊切除术(在Calot三角水平剥离、结扎、横断胆囊管和动脉，剥离囊板)就可治愈。

曾有调查研究显示90%以上的病例可通过单纯胆囊切除术治愈[1]。

但是也有人提出对于T1a期的胆囊癌患者，都应该进行淋巴结的清扫，以最大程度的达到根治的目标[2]。

然而对于T1a期的胆囊癌患者进行胆囊切除+淋巴结清扫是否比单纯胆囊切除预后更好还有待研讨。

关于T1b期的胆囊癌的治疗也存在争议，此期的患者行单纯胆囊切除术已无法达到R0切除，现阶段大部分医生认为应该实施胆囊切除术+胆囊窝水平肝楔形切除术(深度3cm)，确保胆囊管切缘和肝组织切缘阴性，并同时进行淋巴结的清扫，清扫的淋巴结包括肝总动脉周围的淋巴结（No.8）、肝十二指肠韧带的淋巴结（No.12）以及胰十二指肠背侧上缘的淋巴结（No.13a）。

腹腔镜胆囊手术中意外胆囊癌的诊治对策安鑫;薛冰川;张文龙【摘要】Objective To explore clinical characteristics and treatment for unexpected gallbladder carcinoma during laparoscopic surgery . Methods A retrospective analysis was made on clinical data of 12 cases of unexpected gallbladder carcinoma out of 4620 cases of laparoscopic cholecystectomy (LC) in our hospital from September 1997 to September 2015.Intraoperative frozen pathological diagnosis showed gallbladder cancer Nevin stage Ⅲin 1 case, and a conversion to open surge ry of gallbladder cancer was conducted .The remaining 11 cases of gallbladder carcinoma were diagnosed by pathology after surgery .One case of Nevin stage Ⅰand 1 case of stage Ⅱwere not surgically treated .Of the other 9 cases of Nevin stage Ⅲ, there were 5 patients who refused surgery and 4 patients received open radical resection of gallbladder cancer at 10-18 d (mean, 14 d) postoperatively. Results The 5 cases of Nevin stage Ⅲwho refused open radical surgery were lost to follow-up.Two cases of stageⅠandⅡwere followed up for 63 months and 6 months after LC without recurrence .Of the 5 cases of stageⅢundergoing open radical surgery , 2 cases dead at 8 and 10 months postoperatively because of abdominal extensive metastasis and cachexia , and 3 cases dead at 10, 28, and 32 months postoperatively because of gallbladder carcinoma liver transfer . Conclusions The occurrence of unexpected gallbladder cancer should be taken into consideration during laparoscopic cholecystectomy .Timely andappropriate complementary therapy should be given .%目的探讨腹腔镜手术意外胆囊癌的临床特点及治疗方法。

腹腔镜胆囊切除术中意外胆囊癌的临床诊治体会王明俊;张银新;祁玉波【摘要】Objective:To summarize the clinical and pathological characteristics of unexpected gallbladder carcinoma (UGC)in laparoscopic cholecystectomy ( LC), and investigate the operative methods and strategies for the prevention of metastasis and recurrence.Methods:Between Aug. 1997 and Nov. 2008,26 UGC patients were discovered among 5 586 cases of LC. A retrospective study was performed based on the clinical data of these patients. The cumulative survival rate between simple cholecystectomy group and radical operation for gallbladder carcinoma group, pTis, pT1 patients and pT2, pT3, pT4 patients were compared by Kaplan-Meier analysis.Results: All the preoperative tentative diagnosis of 26 cases was benign disease,including cholecystolithiasis and gallbladder polyp. According to pathologic T stage,two cases were on the stage of pTis,4 on pT1a ,3 on pT1b ,10 onpT2 ,5 on pT3 and 2 on pT4. The cumulative survival rate of radical operation for gallbladder carcinoma group was better than that of simple chotecystectomy group ;The prognosis of patients on stages pTis and pT1 were better than those who were on stages pT2, pT3 and pT4. Conclusions: Attention should be paid to the high risk population. The preoperative clinical data of patients should be analyzed roundly, the gallbladder should be examined carefully during operation, and frozen section examination for the specimen should be done. Once the diagnosis is confirmed,standard radical resection should be performed in early stage, and the effective measures should be taken to avoid tumor implantation and metastasis.%目的:总结腹腔镜胆囊切除术(laparoscopic cholecystectomy,LC)中意外胆囊癌(unexpected gallbladder carcinoma,UGC)的临床病理特点,探讨手术方法及预防转移复发的对策.方法:回顾分析1997年8月至2008年11月5 586例LC术中26例(0.47%)UGC患者的临床资料,应用Kaplan-Meier法对比单纯胆囊切除术组、胆囊癌根治术组及pTis、pT1期与pT2、pT3、pT4期患者的累积生存率.结果:26例UGC患者中,术前诊断以胆囊结石和胆囊息肉为主.按病理分期,pTis期2例,pT1a期4例,pT1b期3例,pT2期10例,pT3期5例,pT4期2例.胆囊癌根治组患者累积生存率优于单纯胆囊切除组;pTis、pT1期患者预后显著优于pT2、pT3、pT4期.结论:具有胆囊癌高危因素的患者,术前应全面分析临床资料,术中仔细剖检胆囊,标本行冰冻切片检查,一旦确诊应早期行根治性切除术,术中需采取措施预防肿瘤种植和转移.【期刊名称】《腹腔镜外科杂志》【年(卷),期】2011(016)007【总页数】3页(P522-524)【关键词】胆囊切除术,腹腔镜;胆囊肿瘤;意外【作者】王明俊;张银新;祁玉波【作者单位】南通大学附属建湖医院,江苏,盐城,224700;南通大学附属建湖医院,江苏,盐城,224700;南通大学附属建湖医院,江苏,盐城,224700【正文语种】中文【中图分类】R657.4随着微创外科的发展,腹腔镜胆囊切除术(laparoscopic cholecystectomy,LC)已广泛普及,意外胆囊癌(unexpected gallbladder carcinoma,UGC)的发现率随之增加。