胆囊癌规范化诊治中外科手术的地位与价值

Status and value of radical resection in the standardized diagnosis and treatment of gallbladder carcinoma

胆囊癌的首选治疗方法仍然是手术切除。对病理学检查结果证实的Tla期胆囊癌均推荐实施肝十二指肠韧带骨骼化清扫，以确保手术治疗可以最大限度地达到根治目标。对T1b期胆囊癌应重视肝十二指肠韧带骨骼化清扫，腹腔镜下胆囊癌根治术仍不宜常规开展，目前仍处于探索阶段。对T2期胆囊癌，一般应距离胆囊2—3cm行胆囊床楔形切除并行肝十二指肠韧带淋巴清扫。对于邻近胆囊床侧的肿瘤，可适当扩大肝楔形切除范围。对于T3、T4期的进展期胆囊癌，单纯手术切除很难取得满意疗效，且扩大根治手术（如肝胰十二指肠切除）仅对于可能通过手术获得R0切除的病人有确切益处。目前亦不主张常规行预防性肝外胆管切除。对于意外胆囊癌，Tis、T1a期病变行胆囊切除术后无需再次手术。而对T1b、T2、T3期胆囊癌均应及早再次施行根治性切除。腹腔镜术后的再次手术应将原trocar通道一并切除。对于术前已经确认无法切除的晚期胆囊癌或术后复发、无再次手术机会的胆囊癌，重点在于改善生活质量，不推荐进行手术探查。胆囊癌的规范化治疗仅初具雏形，仍有很多争议，未来亟需大量的前瞻性研究进一步提高胆囊癌的根治性切除率和存活率。

Surgical resection is the only curative option for patients with gallbladder cancer （GBC）. According to author＇s experience , lymphadenectomy around the hepatoduodenal-liga-ment region is recommended to ensure the curative effect. For Tlb GBC, cholecystectomy with lymph node dissection is opti- mal, and the role of laparoscopic radical surgery remained uncertain. For T2 GBC, a wedge resection of the GB bed or a seg- mentectomy IVb/V can be performed accompanied with ex- tended lymphadeneetomy around the hepatoduodenal ligament. For lesion adjacent to the GB bed, a larger extension of wedge resection is beneficial. For T3,T4 GBCs, the benefit of surgery alone is very limited. Prophylactic extrahepatic bile duct resection should not be seen as mandatory in radical oper-ation. With respect to incidental GBC, re-operation is not required for Tis,Tla stage GBCs. However, a second radical sur- gery is always necessary for Tlb, T2, and T3 GBCs. Especial- ly, the trochar ports should be resected simultaneously in ease of metastasis. For unreseetable or recurrent GBC, radical surgery is always no longer applicable and surgical exploration is not recommended. The primary focus tends to be the improve- ment of life quality. The standard surgical regimens for GBC remained controversial. Large prospective studies are warranted to further improve resectability and prolong the survival.