25例胆囊癌的CT分析

目的观察CT对各型胆囊癌的诊断水平及对各期胆囊癌治疗效果的评估。方法对25例经手术和(或)病理活检证实胆管癌的临床和影像学资料进行回顾性分析。结果(1)胆囊壁局限或弥漫性不规则增厚6例;(2)胆囊腔内软组织肿块4例;(3)胆囊窝部软组织肿块侵及周围组织9例;(4)胆囊窝肿块侵及周围组织及有远近转移6例。10例可根治性手术切除。CT分期:Ⅰ期3例、Ⅱ期7例、Ⅲ期9例、Ⅳ期6例。结论CT是诊断各型胆囊癌的重要手段,并且是胆囊癌分期及预后评估的可靠方法之一。

超声对早期胆囊癌的诊断

原发性胆囊癌近年来发病率有增加的趋势,因其预后极差而倍受关注。早期胆囊癌由于缺乏明显而又特异的症状与体征,诊断困难,临床发现的病例大多为中晚期或常规胆囊切除术后意外病理发现。因此,要提高胆囊癌的治疗效果,应争取尽早发现和诊断早期胆囊癌。彩色多普勒超声显像、三维超声显像及内镜超声等现代超声诊断技术可较大地提高早期胆囊癌检出率,减少其漏诊率,为外科医师准确地判断病情和预后、制订手术方案提供了更加可靠的信息。

意外胆囊癌的外科诊治

意外胆囊癌(IGBC)在外科进一步治疗时面临诸多问题与争议。笔者就其外科诊治方面的某些问题进行综述。主要包括IGBC的术前、术中诊断,不同T分期的IGBC手术方式及其预后,以及IGBC的补救性手术策略。

A case of gallbladder carcinoma associated with pancreatobiliary reflux in the absence of a pancreaticobiliary maljunction:A hint for early diagnosis of gallbladder carcinoma

A 62-year-old man with progressive thickening of the gallbladder wall visited our outpatient clinic. The biliary amylase level in the common bile duct was 19900 IU/L and that of the gallbladder was 127000 IU/L, although endoscopic retrograde cholangiopancreatography revealed no pancreaticobiliary maljunction. Histology demonstrated a moderately differentiated adenocarcinoma of the gallbladder. Pancreatobiliary reflux and associated gallbladder carcinoma were confirmed in the present case, in the absence of a pancreaticobiliary maljunction. Earlier detection of the pancreatobiliary reflux and progressive thickening of the gallbladder wall might have led to an earlier resection of the gallbladder and improved this patient＇s poor prognosis.

Unsuspected Gallbladder Cancer During or After Laparoscopic Cholecystectomy

Objective To summarize the clinical features and outcomes of unsuspected gallbladder carcinoma （HGC） detected during or after laparoscopic cholecystectomy. Methods Medical records of 8005 patients, who underwent laparoscopic cholecystectomy in Peking Hnion Medical College Hospital between June 1993 and June 2011, were reviewed. Patients that pathologically diagnosed as HGC were retrospectively studied in terms of clinical features, preoperative and postoperative diagnosis, surviving period, and complications. Results In the 8005 patients who received laparoscopic cholecystectomy, 36 （0.45%） were diagnosed as LIGC during （25 patients） or after （11 patients） laparoscopic cholecystectomy. The gallbladder cancer was staged as T1 in 16 patients, T2 in 11 patients, and T3 in 9 patients. The 1-, 3-, and 5-year survival rates of all the patients were 88.9% （32/36）, 63.9% （23/36）, and 58.3% （21/36）. The 5-year survival rates in T1 stage, T2 stage, and T3 stage patients were 100%, 75.0%, and 0.0%, respectively. Conclusions The survival rate of HGC is associated with tumor stage, not with operation approaches. Laparoscopic cholecystectomy is appropriate for T 1 patients.

A clinicopathological analysis in unsuspected gallbladder carcinoma: A report of 23 cases

AIM： To study the clinicopathological characteristics of unsuspected gallbladder carcinoma （UGC）. METHODS： We retrospectively studied 23 cases of UGC in Tongji Hospital, and compared their clinicopathological characteristics with 33 cases of preoperatively diagnosed gallbladder carcinoma （PDGC）. RESULTS： The proportion of UGC coexisting with cholecystolithiasis was significantly higher than that of PDGC （x^2 = 13.53, P 〈 0.01）. The infection rate of hepatitis B virus was 21.74% （5/23） in UGC and 30.30% （10/33） in PDGC. Nine （39.13%） of 23 patients with UGC and 8/33 （24.24） PDGC had contact with schistosome pestilent water. The rate of multiple pregnancies was 56.52% （13/23） in the patients with UGC and 42.42% （14/33） in PDGC. The primary location of the UGC was mostly in the neck and body of the gallbladder, and that of the PDGC was often in the body and bottom. The incidence of Nevin stage I and 11 UGC was significantly higher than that of PDGC （x^2 = 4.44, P 〈 0.05 and 2 = 4.96, P 〈 0.05） while that of Nevin stage V UGC was significantly lower than that of PDGC （x^2 = 7.59, P 〈 0.01）. According to the grading of carcinoma, the incidence of well-differentiated UGC was significantly higher than that of PDGC （2 = 4.16, P 〈 0.05）, and that of poorlydifferentiated UGC was significantly lower than that of PDGC （x^2 = 4.48, P 〈 0.05）.CONCLUSION： There are different characteristics between UGC and PDGC, such as in primary location, malignant degree and incidence of coexistence with cholecystolithiasis. Cholecystolithiasis, hepatitis B, schistosome and multiple pregnancies were high risk factors for gallbladder carcinoma.

OVERVIEW FOR THE DIAGNOSIS AND TREATMENT OF GALLBLADDER CARCINOMA

Objective. To improve the recognition of diagnosis and treatment of gallbladder cancer. Methods. Retrospective analysis of 52 cases of gallbladder carcinoma in our hospital from 1988 to 1998. Results. Preoperative diagnostic rate was 90.3%, of which 12 cases (23%) were early stage of carcinoma. The total operation resection rate was 55.8%, for which only 17.8% were advance stage of carcinoma. Conclution.The early diagnosis is the key factor of increasing treatment successful rate. The following are the symptoms that raise our special attention to carcinoma of gallbladder: (1) Age over 50 have recurrent cholecystitis and with past history of gallstone; (2) Congenital malformation of bile duct; (3) Local thickening and irregularity of gallbladder wall; (4) Polypoid lesion larger than 1cm inside gallbladder; (5) Atrophic gallbladder; (6) Intraluminal stone of gallbladder does not move when change in body position; (7) Regional lymph node enlargement.

Incidental gallbladder cancer during laparoscopic cholecystectomy:Managing an unexpected finding

AIM:To evaluate the impact of incidental gallbladder cancer on surgical experience.METHODS:Between 1998 and 2008 all cases of cholecystectomy at two divisions of general surgery,one university based and one at a public hospital,were retrospectively reviewed.Gallbladder pathology was diagnosed by history,physical examination,and laboratory and imaging studies [ultrasonography and computed tomography(CT)].Patients with gallbladder cancer(GBC) were further analyzed for demographic data,and type of operation,surgical morbidity and mortality,histopathological classification,and survival.Incidental GBC was compared with suspected or preoperatively diagnosed GBC.The primary endpoint was diseasefree survival(DFS).The secondary endpoint was the difference in DFS between patients previously treated with laparoscopic cholecystectomy and those who had oncological resection as first intervention.RESULTS:Nineteen patients(11 women and eight men) were found to have GBC.The male to female ratio was 1:1.4 and the mean age was 68 years(range:45-82 years).Preoperative diagnosis was made in 10 cases,and eight were diagnosed postoperatively.One was suspected intraoperatively and confirmed by frozen sections.The ratio between incidental and nonincidental cases was 9/19.The tumor node metastasis stage was:pTis(1),pT1a(2),pT1b(4),pT2(6),pT3(4),pT4(2);five cases with stageⅠa(T1 a-b);two with stageⅠb(T2 N0);one with stage Ⅱa(T3 N0);six with stage Ⅱb(T1-T3 N1);two with stage Ⅲ(T4 Nx Nx);and one with stage Ⅳ(Tx Nx Mx).Eighty-eight percent of the incidental cases were discovered at an early stage(≤Ⅱ).Preoperative diagnosis of the 19 patients with GBC was:GBC with liver invasion diagnosed by preoperative CT(nine cases),gallbladder abscess perforated into hepatic parenchyma and involving the transversal mesocolon and hepatic hilum(one case),porcelain gallbladder(one case),gallbladder adenoma(one case),and chronic cholelithiasis(eight cases).Every case,except one,with a T1b or more advanced invasion underwent Ⅳb + Ⅴ wedge liver resection and pericholedochic/hepatoduodenal lymphadenectomy.One patient with stage T1b GBC refused further surgery.Cases with Tis and T1a involvement were treated with cholecystectomy alone.One incidental case was diagnosed by intraoperative frozen section and treated with cholecystectomy alone.Six of the nine patients with incidental diagnosis reached 5-year DFS.One patient reached 38 mo survival despite a port-site recurrence 2 years after original surgery.Cases with non incidental diagnosis were more locally advanced and only two patients experienced 5-year DFS.CONCLUSION:Laparoscopic cholecystectomy does not affect survival if implemented properly.Reoperation should have two objectives:R0 resection and clearance of the lymph nodes.

Gallbladder carcinoma with tumor thrombus in common bile duct: an unusual way of growing invasion

Objective： To summarize the experience of diagnosis and surgical treatment for a rare invasion manner of gallbladder carcinoma, which was combined with tumor thrombus in common bile duct （CBD）. Methods： Between February 2003 and January 2005, 3 patients with gallbladder carcinoma who were identified of tumor thrombus in common bile duct in surgical procedure were retrospectively analyzed. Results： Abdominal ultrasound and magnetic resonance cholangiopancreatography （MRCP） were used for preoperative diagnosis. All 3 patients were given radical operations, which were composed of cholecystectomy, resection of the extrahepatic biliary duct, cuniform hepatectomy of gallbladder bed, skeletonization of the hepatoduodenal ligament, hilar choledochojejunostomy, and clearance of tumor thrombus from bile duct. Three patients were recovered well after surgery, which were respectively alive for 30 months, 17 months and 23 months without tumor recurrence,and 58 months, 41 months and 40 months for survival time after operation. Conclusion： Gallbladder carcinoma with tumor thrombus in common bile duct was very rare but with relatively special clinical manifestation and characteristic radiography manifestation. MRCP was one of the most potent diagnostic method. The prognosis of gallbladder carcinoma with tumor thrombus in common bile duct after surgical procedure was apparently better than gallbladder carcinoma with invasion of hilar tissues. Radical operation was feasible and safe for obtaining longer survival