腹腔镜胆囊切除术术中或术后意外胆囊癌的处理对策

Treatment strategies for unsuspected gallbladder carcinoma during or after laparoscopic cholecys-tectomy

目的：探讨腹腔镜胆囊切除术（ LC）意外胆囊癌（ UGC）的处理对策。方法回顾性分析我院2005年1月至2012年10月3355例LC，术中和术后发现的8例UGC的临床资料。结果8例UGC，占同期LC的0.24％（8/3355），术中发现4例，术后发现4例。根据TNM分期（第7版，2009），其中pTis 2例，pT1b 1例，pT23例，pT42例。pTis及pT1b患者仅行LC，术后均长期存活，最长已超过5年；pT2中2例中转开腹行胆囊癌根治术，术后存活已达半年以上；1例因术后发现，患者拒绝再次手术，术后半年复发；pT4中1例因累及肝脏及肝外胆管，拒绝进一步手术，仅行LC，术后3个月出现戳孔种植，术后6个月死于腹腔广泛转移；1例中转开腹行姑息胆囊切除并取活检，3个月后死于多脏器衰竭。无围手术期死亡患者。结论重视胆囊癌高危因素、完善的术前检查、术中对胆囊标本仔细剖检和快速冰冻检查以及确诊后必要的中转开腹是提高胆囊癌早期确诊率、改善胆囊癌预后的关键。术中应切实采取相关措施降低肿瘤细胞腹腔转移与切口种植的发生率。

Objective To explore the treatment strategIES for unsuspected gallbladder carcinoma （ UGC）during or after laparoscopic cholecystectomy（ LC）. Methods The clinical data of 8 UGCs in 3355 cases of LC from January 2005 to October 2012 at the First Affiliated Hospital of Harbin Medical Universi-ty were analyzed retrospectively. Results In the 8 cases of UGC,4 were discovered intraoperatively and 4 were discovered postoperatively,accounting for 0. 24%（8/3355）of LC. According to the TNM system（7th edition,2009）,Pathological stage was pTis in 2 cases,pT1b in 1 case,pT2 in 3cases,and pT4 in 2 cases. Simple LC was only performed in patients of stage pTis and pT1b. These patients had a long-term survival and the longest had reached more than 5 years. In patients of stage pT2,2 patients were converted to open radical resection and they had survived for more than 6 months postoperatively. The rest refused reoperation and recurred 6 months after operation. In patients of stage pT4,one refused further surgery because of the involvement of liver and extrahepatic duct. The patient received LC only and trocar site seeding was ob-served after 3 months. At the six month after LC,the patient died of widespread metastasis in the abdomen. The other one was converted to open cholecystectomy and biopsy and died of multiple organ failure（ MOF） after 3 months. No one died during the perioperative period. Conclusion Attention of risk factors,suffi-cient preoperative examination,careful intraoperative autopsy,fast frozen section and essential conversion to open surgery are crucial for the improvement of early diagnosis and prognosis of gallbladder carcinoma. However,practical measures should be intraoperatively taken to reduce the rate of widespread metastasis and trocar site seeding.