腹腔镜胆囊切除术后“意外”胆囊癌行开放根治性切除术疗效分析

Clinical efficacy analysis of secondary radical resection for incidental gallbladder cancer after laparoscopic cholecystectomy

目的探讨腹腔镜胆囊切除术(LC)术后“意外”发现胆囊癌再行开放胆囊癌根治性切除术的远期疗效。方法回顾性分析2015—2021年海军军医大学第三附属医院收治的106例胆囊癌病人的临床资料。根据手术方式将其分为直接根治组(74例,直接行开放胆囊癌根治术)和二次根治组(32例,LC术后再行开放胆囊癌根治切除术)。对比分析两组病人临床资料及术后随访情况。通过Kaplan-Meier生存曲线、COX比例风险模型分析术后疗效及影响因素。结果直接根治组与二次根治组病人在年龄、性别等基线资料差异无统计学意义(P>0.05),在手术时间、术中出血量、手术切缘、病理分化程度、病理类型、肿瘤部位、术后并发症等方面差异无统计学意义(P>0.05)。两组病人总体生存期和无复发生存期整体分布差异有统计学意义(P=0.044、0.041);达到R0和R1切除的病人总体生存率和无复发生存率差异有统计学意义(P=0.002、0.001)。单因素及多因素分析显示,直接行胆囊癌根治切除(P<0.001、0.001)、R0切缘(P=0.03、0.025)及较早的病理学分期(P=0.001、0.002)是病人总体生存和无复发生存的独立保护因素。结论应慎重对待LC术中发现的胆囊癌,先行LC术后再行开放胆囊癌根治切除术的远期效果并不理想,直接行胆囊癌根治性切除有更多的生存获益。

Objective To explore the long-term efficacy of laparoscopic cholecystectomy(LC)followed by an open radical resection of gallbladder cancer in the treatment of gallbladder cancer(GBC).Methods Retrospective analysis was conducted on 106 patients with gallbladder cancer who were treated between 2015 and 2021 in the Third Affiliated Hospital of the Naval Medical University.According to the surgical methods,the patients were divided into direct radical group(74 cases,directly treated with open radical resection of GBC in our center)and secondary radical group(32 cases,diagnosed as GBC after LC in other hospitals and then underwent open radical resection in our center).The clinical data and postoperative follow-up of the two groups were analyzed to compare the efficacy of the two treatment methods.The postoperative efficacy and influencing factors were analyzed by Kaplan-Meier survival curve and COX proportional hazards model.Results There was no significant difference in baseline data between patients in the direct radical group and the secondary radical group,such as age,sex,etc.(P>0.05).There were no significant differences in operation time,intraoperative blood loss,surgical margin,pathological differentiation,pathological type,tumor location and postoperative complications between the two groups(P>0.05).Kaplan-Meier analysis showed significant difference in the overall distribution of overall survival(OS)and disease-free survival(DFS)between the two groups(P=0.044 and P=0.041),there was significant difference in OS and DFS in cases of R0 and R1 resection(P=0.002 and P=0.001).Cox regression analysis showed that directradical resection of GBC(P<0.001 and P<0.001),R0 surgical margin(P=0.03 and P=0.025)and earlier pathological stage(P=0.001 and P=0.002)were independent protective factors for OS and DFS.Conclusion GBC should be treated with caution.The prognosis of LC followed by radical re-resection of GBC is not ideal.Direct open radical resection of GBC has more long-term survival benefits.