安 鑫 薛冰川 張文龍

(山西醫(yī)科大學(xué)第三醫(yī)院普外科，太原 030053)

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腹腔鏡膽囊手術(shù)中意外膽囊癌的診治對(duì)策

安 鑫*薛冰川①?gòu)埼凝?/p>

(山西醫(yī)科大學(xué)第三醫(yī)院普外科，太原 030053)

目的 探討腹腔鏡手術(shù)意外膽囊癌的臨床特點(diǎn)及治療方法。方法回顧性分析1997年9月～2015年9月我院4620例腹腔鏡膽囊切除(laparoscopic cholecystectomy，LC)手術(shù)中意外膽囊癌12例的臨床資料。1例術(shù)中冰凍病理診斷膽囊癌Nevin Ⅲ期，中轉(zhuǎn)開腹行膽囊癌根治術(shù)；11例術(shù)后病理診斷膽囊癌，Nevin Ⅰ期1例和Ⅱ期1例未補(bǔ)充手術(shù)，Ⅲ期9例中5例拒絕手術(shù)，4例術(shù)后10～18 d(平均14 d)開腹行膽囊癌根治術(shù)。結(jié)果5例Nevin Ⅲ期LC后拒絕手術(shù)者失訪。Ⅰ、Ⅱ期各1例LC術(shù)后隨訪63個(gè)月和6個(gè)月無復(fù)發(fā)，Ⅲ期行膽囊癌根治術(shù)5例中，2例分別術(shù)后8、10個(gè)月因腹腔廣泛轉(zhuǎn)移，死于惡病質(zhì)，3例術(shù)后10、28、32個(gè)月膽囊癌肝轉(zhuǎn)移死亡。結(jié)論腹腔鏡膽囊手術(shù)時(shí)應(yīng)高度警惕意外膽囊癌的發(fā)生，應(yīng)及時(shí)行合適的補(bǔ)充治療。

腹腔鏡膽囊切除術(shù)； 意外膽囊癌

意外膽囊癌(unexpected gallbladder carcinoma，UGC)是術(shù)中或術(shù)后偶然發(fā)現(xiàn)的膽囊癌，發(fā)生率逐年升高，文獻(xiàn)報(bào)道為0.2%～0.9%[1]。腹腔鏡膽囊切除術(shù)(laparoscopic cholecystectomy，LC)是治療膽囊良性疾病的金標(biāo)準(zhǔn)[2～5]，隨著LC廣泛開展，UGC越來越多，應(yīng)及時(shí)行合適的補(bǔ)充治療。1997年9月～2015年9月我院行4620例LC，發(fā)生UGC 12例(0.26%)，本文對(duì)其進(jìn)行回顧性分析，探討腹腔鏡手術(shù)UGC的臨床特點(diǎn)及治療方法。

1 臨床資料與方法

1.1 一般資料

本組12例，男3例，女9例。年齡42～69歲，平均58.8歲。10例有反復(fù)發(fā)作右上腹疼痛、向右肩部放射痛，病史8～22年，平均11年；2例自訴上腹部不適，自覺“胃疼”，病史分別為6、8年。均無體重減輕。均行超聲檢查，提示膽囊結(jié)石12例(結(jié)石大小1.2～3.5 cm)，伴膽囊息肉樣病變2例(均為膽囊頸部腺瘤樣息肉，大小0.5 cm和1.1 cm)，其中11例膽囊壁不均勻增厚(0.4～0.9 cm)。2例檢查腫瘤標(biāo)志物(CEA、CA19-9)，均未見異常。術(shù)前肝功能檢查均在正常范圍。

1.2 手術(shù)方法

均在全麻下行常規(guī)三孔LC，膽囊標(biāo)本均置入標(biāo)本袋內(nèi)經(jīng)劍突下切口取出。1例因與周圍組織粘連不容易剝離，剖開膽囊可見膽囊底部與正常黏膜組織質(zhì)地顏色不同，局部菜花樣隆起改變，高度懷疑癌，行術(shù)中冰凍切片診斷為膽囊癌Nevin Ⅲ期，立即中轉(zhuǎn)開腹膽囊連同肝楔形整塊切除(距膽囊床2.0 cm)+肝十二指腸韌帶淋巴結(jié)清掃。其余11例術(shù)中未懷疑惡性，術(shù)后石蠟切片診斷膽囊癌，1例NevinⅠ期、1例Nevin Ⅱ期未再行二次開腹手術(shù)，5例Nevin Ⅲ期患者因經(jīng)濟(jì)條件或年齡偏大拒絕二次手術(shù)，4例Nevin Ⅲ期術(shù)后10～18 d(平均14 d)開腹行膽囊癌根治術(shù)。

2 結(jié)果

石蠟切片病理，高分化腺癌3例，中分化腺癌4例，低分化腺癌4例，未分化癌1例。按Nevin分期，Ⅰ期(局限于黏膜層)1例，Ⅱ期(侵及肌層)1例，Ⅲ期(侵及膽囊壁全層)10例。

5例Nevin Ⅲ期LC后未手術(shù)患者失訪。Nevin Ⅰ期、Ⅱ期各1例僅行LC，術(shù)后隨訪63個(gè)月和6個(gè)月，未見復(fù)發(fā)。Nevin Ⅲ期行膽囊癌根治術(shù)5例中，2例術(shù)后8、10個(gè)月因腹腔廣泛轉(zhuǎn)移死于惡病質(zhì)，3例術(shù)后10、28、32個(gè)月膽囊癌肝轉(zhuǎn)移死亡。

3 討論

3.1 UGC的早期診斷

結(jié)合本組12例UGC及相關(guān)報(bào)道[6，7]分析，LC術(shù)前若出現(xiàn)以下情況應(yīng)引起足夠重視：年齡>60歲，膽囊結(jié)石直徑>3 cm、癥狀反復(fù)發(fā)作病程>5年，膽囊腺瘤樣息肉直徑>1 cm，膽囊壁增厚或萎縮性膽囊。必要時(shí)可以做膽囊區(qū)薄層CT掃描。本組12例UGC中3例結(jié)石>3 cm，12例病程均超過5年，2例膽囊腺瘤樣息肉，11例膽囊壁不均勻增厚。

LC術(shù)中應(yīng)注意觀察膽囊情況，切除的膽囊標(biāo)本要剖視，如發(fā)現(xiàn)有異常，有條件時(shí)盡量做術(shù)中冰凍快速病理檢查。本組僅1例有菜花樣突起的膽囊做術(shù)中快速病理檢查；與肝床、大網(wǎng)膜粘連1例，膽囊壁不均勻增厚且有黏液狀物5例，萎縮性膽囊3例，未見明顯異常2例，均未做術(shù)中病理。

3.2 UGC的處理

應(yīng)該正確掌握UGC二次手術(shù)的指征、手術(shù)時(shí)機(jī)和采取合理的手術(shù)方式。本組12例UGC均為Nevin Ⅲ期及以下患者，故我們認(rèn)為，LC發(fā)現(xiàn)的UGC較多為早期病例(Nevin Ⅲ期及以下)，病灶僅侵犯黏膜和肌層。一般認(rèn)為，Nevin Ⅰ、Ⅱ期因腫瘤組織僅發(fā)生在膽囊黏膜內(nèi)或肌層，未穿破膽囊漿膜，只要將膽囊完整切除取出，無膽汁外漏，切緣無癌組織殘留，行單純LC即可，術(shù)后定期隨訪復(fù)查[8]。Nevin Ⅲ期需再次手術(shù)根治切除。換句話說，UGC二次手術(shù)的指征是病變侵及肌層以外達(dá)漿膜層，能手術(shù)切除和清掃的Nevin Ⅲ期患者。我院行膽囊癌根治性手術(shù)包括切除膽囊附近2 cm肝臟+肝十二指腸韌帶淋巴結(jié)清掃。本組5例Nevin Ⅲ期行開腹膽囊癌根治術(shù)。UGC多屬于早期，行膽囊癌擴(kuò)大根治術(shù)能否改善預(yù)后依據(jù)不足，所以不主張盲目擴(kuò)大UGC的根治范圍。

總之，在LC中發(fā)現(xiàn)UGC應(yīng)謹(jǐn)慎處理，目前對(duì)于UGC的診治尚未明確，應(yīng)該提高對(duì)UGC的認(rèn)識(shí)，術(shù)中常規(guī)剖視膽囊標(biāo)本，可疑膽囊癌行術(shù)中快速病理檢查，及早做出診斷，Nevin Ⅲ期應(yīng)行膽囊癌根治性手術(shù)。

1 Kim JH，Kim WH，Kim JH，et al．Unsuspected gallbladder cancer diagnosed after laparoscopic cholecystectomy：focus on acute cholecystitis．World J Surg，2010，34(1)：114-120．

2 葛京平，湯 昊，魏 武，等.機(jī)器人輔助經(jīng)腹腹腔鏡與后腹腔鏡離斷式腎盂成形術(shù)的比較研究.醫(yī)學(xué)研究生學(xué)報(bào),2013，26(12):1272-1274.

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4 Saeb-Parsy K,Mills A,Rang C,et al.Emergency laparoscopic cholecystectomy in an unselected cohort:a safe and viable option in a specialist centre.Int Surg,2010,8,(6):489-493.

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7 Pitt SC,Jin LX,Hall BL,et al.Incidental gallbladder cancer at cholecystectomy:when should the surgeon be suspicious.Ann Surg,2014,260(1):128-133.

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(修回日期：2016-05-23)

(責(zé)任編輯：王惠群)

Diagnosis and Treatment of Unexpected Gallbladder Carcinoma During Laparoscopic Cholecystectomy

AnXin*,XueBingchuan,ZhangWenlong*.

*DepartmentofGeneralSurgery,ThirdHospitalofShanxiMedicalUniversity,Taiyuan030053,China

AnXin,E-mail:anppke@163.com

Objective To explore clinical characteristics and treatment for unexpected gallbladder carcinoma during laparoscopic surgery. Methods A retrospective analysis was made on clinical data of 12 cases of unexpected gallbladder carcinoma out of 4620 cases of laparoscopic cholecystectomy (LC) in our hospital from September 1997 to September 2015. Intraoperative frozen pathological diagnosis showed gallbladder cancer Nevin stage Ⅲ in 1 case,and a conversion to open surgery of gallbladder cancer was conducted. The remaining 11 cases of gallbladder carcinoma were diagnosed by pathology after surgery. One case of Nevin stage Ⅰ and 1 case of stage Ⅱ were not surgically treated. Of the other 9 cases of Nevin stage Ⅲ,there were 5 patients who refused surgery and 4 patients received open radical resection of gallbladder cancer at 10-18 d (mean,14 d) postoperatively. Results The 5 cases of Nevin stage Ⅲ who refused open radical surgery were lost to follow-up. Two cases of stage Ⅰ and Ⅱ were followed up for 63 months and 6 months after LC without recurrence. Of the 5 cases of stage Ⅲ undergoing open radical surgery,2 cases dead at 8 and 10 months postoperatively because of abdominal extensive metastasis and cachexia,and 3 cases dead at 10,28,and 32 months postoperatively because of gallbladder carcinoma liver transfer. Conclusions The occurrence of unexpected gallbladder cancer should be taken into consideration during laparoscopic cholecystectomy. Timely and appropriate complementary therapy should be given.

Laparoscopic cholecystectomy; Unexpected gallbladder cancer

*通訊作者，E-mail：anppke@163.com

①現(xiàn)工作單位：北京北亞骨科醫(yī)院綜合外科，北京 102445

B

1009-6604(2016)09-0858-02

10.3969/j.issn.1009-6604.2016.09.024

2015-12-05)