Is combined extra-hepatic bile-duct resection justified for advanced gallbladder carcinoma?

联合肝外胆管切除应用于进展期胆囊癌是否合理?

Background:Whether the extra-hepatic bile duct(EHBD)should be routinely resected for gallbladder carcinoma(GBC)remains controversial.The current study aimed to determine the clinical impact of combined EHBD resection during curative surgery for advanced GBC.Methods:In total,213 patients who underwent curative surgery for T2,T3 or T4 GBC were enrolled.The clinicopathological features were compared between the patients treated with EHBD resection and those without EHBD resection.Meanwhile,univariable and multivariable Cox-proportional hazards regression models were used to identify risk factors for overall survival(OS).Results:Among the 213 patients identified,87(40.8%)underwent combined EHBD resection.Compared with patients without EHBD resection,patients with EHBD resection suffered more post-operative complications(33.3%vs.21.4%,P=0.046).However,the median OS of the EHBD resection group was longer than that of the non-EHBD resection group(25 vs.11 months,P=0.008).Subgroup analyses were also performed according to tumor(T)category and lymph-node metastasis.The median OS was significantly longer in the EHBD resection group than in the non-EHBD resection group for patients with T3 lesion(15 vs.7 months,P=0.002),T4 lesion(11 vs.6 months,P=0.021)or lymph-node metastasis(12 vs.7 months,P<0.001).No survival benefit of EHBD resection was observed in GBC patients with T2 lesion or without lymph-node metastasis.T category,lymph-node metastasis,margin status,pre-operative CA19-9 level and EHBD resection were identified as independent prognostic factors for OS of patients with advanced GBC(all P values<0.05).Conclusions EHBD resection can independently affect the OS in advanced GBC.For GBC patients with T3 lesion,T4 lesion and lymph-node metastasis,combined EHBD resection is justified and may improve OS.

背景:胆囊癌手术中,肝外胆管是否应常规切除仍然存在争议。本研究旨在探讨联合肝外胆管应用于进展期胆管癌根治性手术的临床意义。方法:213例行根治性手术的T2-T4期胆囊癌患者纳入研究。比较术中联合与未联合胆外胆管切除患者的临床病理特征。同时,采用单因素和多因素Cox比例风险回归模型来明确影响总体生存(OS)的危险因素。结果:213例入组患者中,87例(40.8%)行联合肝外胆管切除。与未行肝外胆管切除者相比,联合肝外胆管切除者术后并发症发生率更高(33.3%vs 21.4%,P=0.046)。然而,联合肝外胆管切除者中位OS显著延长(25 vs 11个月,P=0.008)。按T分期和N分期进行的亚组分析显示,在T3、T4或有淋巴结转移病例中,联合肝外胆管切除者中位OS均优于未行肝外胆管切除者(T3:15 vs 7个月,P=0.002;T4:11 vs 6个月,P=0.021;N+:12 vs 7个月,P<0.001);而在T2或无淋巴结转移病例中,联合肝外胆管切除则未显示出生存获益。多因素预后危险因素分析显示,T分期、淋巴结转移、切缘状态、术前CA19-9水平及肝外胆管切除是进展期胆囊癌患者总体生存的独立预后因素(均P<0.05)。结论:联合肝外胆管切除可独立影响进展期胆囊癌患者的总体生存时间。对于T3、T4或有淋巴结转移的胆囊癌,联合肝外胆管切除是合理的,可改善患者总体生存。