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胆道外科万里行胆道外科万里行西安站西安站胆道外科万里行西安站胆道外科万里行西安站1华中科技大学同济医学院关于意外胆囊癌的几个问题关于意外胆囊癌的几个问题邹邹 声声 泉泉华华中科技大学同中科技大学同济济医学院关于意外胆囊癌的几个医学院关于意外胆囊癌的几个问题邹问题邹 声声 泉泉2n n因胆囊良性疾病行胆囊切除术中/术后和因其它疾病诊治过程中偶然发现的胆囊癌称为意外胆囊癌。(unsuspected/unexpected/incidental/inapparent gallbladder carcinoma,UGC)邹声泉邹声泉邹声泉邹声泉.中华外科杂志中华外科杂志中华外科杂志中华外科杂志,2019,43(13):833-,2019,43(13):833-,2019,43(13):833-,2019,43(13):833-5.5.5.5.一一引言 因胆囊良性疾病行胆囊切除因胆囊良性疾病行胆囊切除术术中中/术术后和因其它疾病后和因其它疾病诊诊治治过过程中偶然程中偶然3一一引言 n n早在1961年,就有在胆囊炎中发现意外胆囊癌的报道。MARCIAL-ROJAS RA,MEDINA R.MARCIAL-ROJAS RA,MEDINA R.MARCIAL-ROJAS RA,MEDINA R.MARCIAL-ROJAS RA,MEDINA R.Unsuspected carcinoma of theUnsuspected carcinoma of theUnsuspected carcinoma of theUnsuspected carcinoma of the gallbladder in acute and chronic cholecystitis.Annals gallbladder in acute and chronic cholecystitis.Annals gallbladder in acute and chronic cholecystitis.Annals gallbladder in acute and chronic cholecystitis.Annals of Surgery of Surgery of Surgery of Surgery,1961196119611961,153153153153:289-98.289-98.289-98.289-98.n n随着腹腔镜技术的广泛应用,LC手术量增大,发现意外胆囊癌的数量也增加,引起人们对其高度重视。一一 引言引言 早在早在1961年,就有在胆囊炎中年,就有在胆囊炎中发现发现意外胆囊意外胆囊4二二 流行病学意外胆囊癌发生的例数占同期胆囊癌发生总数比例n nAndersson,德国,1976年,26.7%(32/120)Andersson A.Andersson A.Andersson A.Andersson A.Zentralbl Chir,1976,101(21):1314-7.Zentralbl Chir,1976,101(21):1314-7.Zentralbl Chir,1976,101(21):1314-7.Zentralbl Chir,1976,101(21):1314-7.n nKaul,印度,1989年,22%(8/36)Kaul V.Kaul V.Kaul V.Kaul V.Indian J Pathol Microbiol,1989,32(3):146-51.Indian J Pathol Microbiol,1989,32(3):146-51.Indian J Pathol Microbiol,1989,32(3):146-51.Indian J Pathol Microbiol,1989,32(3):146-51.n nOrth,德国,1991年,37.5%(15/40)Orth K.Orth K.Orth K.Orth K.Z Gastroenterol,1991,29(12):631-6 .Z Gastroenterol,1991,29(12):631-6 .Z Gastroenterol,1991,29(12):631-6 .Z Gastroenterol,1991,29(12):631-6 二二 流行病学流行病学意外胆囊癌意外胆囊癌发发生的例数占生的例数占 5二二流行病学意外胆囊癌发生的例数占同期胆囊癌发生总数比例n n王炳生,上海,2019年,20%(78/390)王炳生王炳生王炳生王炳生.中华外科杂志中华外科杂志中华外科杂志中华外科杂志,2019,2019,2019,2019,43434343(7 7 7 7):):):):455-9.455-9.455-9.455-9.n n田华,杭州,2019年,29.5%(18/61)田华田华田华田华.中华外科杂志中华外科杂志中华外科杂志中华外科杂志,2019,43(13,2019,43(13,2019,43(13,2019,43(13):):):):836-8836-8836-8836-8.n n邹声泉,武汉,2019年,35.4%(23/65)邹声泉邹声泉邹声泉邹声泉.中华外科杂志中华外科杂志中华外科杂志中华外科杂志,2019,43(13):833-5.,2019,43(13):833-5.,2019,43(13):833-5.,2019,43(13):833-5.仅为术后病例仅为术后病例二二 流行病学流行病学意外胆囊癌意外胆囊癌发发生的例数占生的例数占 6二二流行病学开腹胆囊切除术发现意外胆囊癌的比例 n nBosmans,比利时,1990年,2.3%(23/1000)Bosmans E.Bosmans E.Bosmans E.Bosmans E.Acta Chir Belg.1990,90(5):207-12.Acta Chir Belg.1990,90(5):207-12.Acta Chir Belg.1990,90(5):207-12.Acta Chir Belg.1990,90(5):207-12.n nOrth,德国,1991年,1.7%(15/903)Orth K.Orth K.Orth K.Orth K.Z Gastroenterol,1991,29(12):631-Z Gastroenterol,1991,29(12):631-Z Gastroenterol,1991,29(12):631-Z Gastroenterol,1991,29(12):631-6.6.6.6.n n邹声泉,武汉,2019年,0.41%(23/5582)邹声泉邹声泉邹声泉邹声泉.中华外科杂志中华外科杂志中华外科杂志中华外科杂志,2019,43(13):833-5.,2019,43(13):833-5.,2019,43(13):833-5.,2019,43(13):833-5.二二 流行病学流行病学开腹胆囊切除开腹胆囊切除术发现术发现 7二二流行病学LC发现意外胆囊癌比例(亚洲)n nKwon,韩国,2019年,1.89%(10/527)Kwon SY.Kwon SY.Kwon SY.Kwon SY.J Korean Med Sci,2019,12(6):519-22.J Korean Med Sci,2019,12(6):519-22.J Korean Med Sci,2019,12(6):519-22.J Korean Med Sci,2019,12(6):519-22.n nMori,日本,2019年,2.85%(13/456)Mori T.Mori T.Mori T.Mori T.Surg Today,2019,27(8):710-3.Surg Today,2019,27(8):710-3.Surg Today,2019,27(8):710-3.Surg Today,2019,27(8):710-3.n nSuzuki,日本,2000年,0.82%(41/5027)Suzuki K.Suzuki K.Suzuki K.Suzuki K.Surg Endosc,2000,14(8):712-6.Surg Endosc,2000,14(8):712-6.Surg Endosc,2000,14(8):712-6.Surg Endosc,2000,14(8):712-6.二二 流行病学流行病学LC发现发现意外胆囊癌意外胆囊癌 8二二流行病学LC发现意外胆囊癌比例(亚洲)n nYamamoto,日本,2019年,0.54%(9/1663)Yamamoto H.Yamamoto H.Yamamoto H.Yamamoto H.J Hepatobiliary Pancreat Surg.2019 J Hepatobiliary Pancreat Surg.2019 J Hepatobiliary Pancreat Surg.2019 J Hepatobiliary Pancreat Surg.2019,12(5):391-8.12(5):391-8.12(5):391-8.12(5):391-8.n nWeinstein,以色列,2019年,0.35%(6/1697)Weinstein D.Weinstein D.Weinstein D.Weinstein D.Isr Med Assoc J,2019,4(5):334-6.Isr Med Assoc J,2019,4(5):334-6.Isr Med Assoc J,2019,4(5):334-6.Isr Med Assoc J,2019,4(5):334-6.n nBani-Hani,约旦,2019年,0.66%(30/4502)Bani-Hani KE.Bani-Hani KE.Bani-Hani KE.Bani-Hani KE.J Gastroenterol Hepatol,2019,18(8):954-9.J Gastroenterol Hepatol,2019,18(8):954-9.J Gastroenterol Hepatol,2019,18(8):954-9.J Gastroenterol Hepatol,2019,18(8):954-9.二二 流行病学流行病学LC发现发现意外胆囊癌意外胆囊癌 9n nHohaus,德国,2019年,0.53%(9/1700)Hohaus T.Hohaus T.Hohaus T.Hohaus T.Zentralbl Chir.2019,123 Suppl 2:80-3.Zentralbl Chir.2019,123 Suppl 2:80-3.Zentralbl Chir.2019,123 Suppl 2:80-3.Zentralbl Chir.2019,123 Suppl 2:80-3.n nFrauenschuh,德国,2000年,0.37%(26/6230)Frauenschuh D.Frauenschuh D.Frauenschuh D.Frauenschuh D.Langenbecks Arch Surg,2000,385(8):495-500.Langenbecks Arch Surg,2000,385(8):495-500.Langenbecks Arch Surg,2000,385(8):495-500.Langenbecks Arch Surg,2000,385(8):495-500.n nGlehen,法国,2000年,1.5%(12/784)Glehen O.Glehen O.Glehen O.Glehen O.Ann Chir,2000,125(2):137-43.Ann Chir,2000,125(2):137-43.Ann Chir,2000,125(2):137-43.Ann Chir,2000,125(2):137-43.n nAntonakis,希腊,2019年,0.2%(11/5539)Antonakis P.Antonakis P.Antonakis P.Antonakis P.Eur J Surg Oncol,2019,29(4):358-60.Eur J Surg Oncol,2019,29(4):358-60.Eur J Surg Oncol,2019,29(4):358-60.Eur J Surg Oncol,2019,29(4):358-60.二二 流行病学LC发现意外胆囊癌 比例(欧洲)Hohaus,德国德国,2019年年,10n nBraghetto,智利,2019年,0.23%(15/6500)Braghetto I.Braghetto I.Braghetto I.Braghetto I.Int Surg,2019,84(4):344-9.Int Surg,2019,84(4):344-9.Int Surg,2019,84(4):344-9.Int Surg,2019,84(4):344-9.二二 流行病学LC发现意外胆囊癌 比例(南美洲)Braghetto,智利智利,2019年年,11n nYeh,台湾,2019年,0.3%(10/3050)Yeh CN.Yeh CN.Yeh CN.Yeh CN.Am Surg,2019,70(3):256-8.Am Surg,2019,70(3):256-8.Am Surg,2019,70(3):256-8.Am Surg,2019,70(3):256-8.n n毛志海,上海,2019年,0.2%(10/4716)毛志海毛志海毛志海毛志海.外科理论与实践外科理论与实践外科理论与实践外科理论与实践.2019,10(4):332-4.2019,10(4):332-4.2019,10(4):332-4.2019,10(4):332-4.二二 流行病学LC发现意外胆囊癌 比例(中国)二二 流行病学流行病学LC发现发现意外胆囊癌意外胆囊癌 12二二流行病学其它疾病诊治过程中发现的意外胆囊癌n nGertschGertsch,胆管癌,胆管癌,7.4%7.4%(4/544/54)Gertsch P.Gertsch P.Gertsch P.Gertsch P.Am J Surg,1990,159(4):386-8.Am J Surg,1990,159(4):386-8.Am J Surg,1990,159(4):386-8.Am J Surg,1990,159(4):386-8.n nChijiiwaChijiiwa,胆管癌,胆管癌,4.84.8%(3/623/62)Chijiiwa K.Chijiiwa K.Chijiiwa K.Chijiiwa K.Aust N Z J Surg,1993,63(9):690-2.Aust N Z J Surg,1993,63(9):690-2.Aust N Z J Surg,1993,63(9):690-2.Aust N Z J Surg,1993,63(9):690-2.n nMoserMoser,MirizziMirizzi,20%20%(2/102/10)Moser JJ.Moser JJ.Moser JJ.Moser JJ.Helv Chir Acta,1993,59(4):577-80.Helv Chir Acta,1993,59(4):577-80.Helv Chir Acta,1993,59(4):577-80.Helv Chir Acta,1993,59(4):577-80.n nRedaelliRedaelli,MirizziMirizzi,27.8%27.8%(5/185/18)Redaelli CA.Redaelli CA.Redaelli CA.Redaelli CA.Surgery,2019,121(1):58-63.Surgery,2019,121(1):58-63.Surgery,2019,121(1):58-63.Surgery,2019,121(1):58-63.n nLa Greca,La Greca,肝癌,肝癌,1 1例例 La GrecaLa GrecaLa GrecaLa Greca G.Chir Ital,2019,56(4):571-4.G.Chir Ital,2019,56(4):571-4.G.Chir Ital,2019,56(4):571-4.G.Chir Ital,2019,56(4):571-4.二二 流行病学流行病学其它疾病其它疾病诊诊治治过过程中程中 13三三 意外胆囊癌的病理资料TNM分期 SchaeffSchaeff对对59例LC术后意外胆囊癌病理学分析:n nT0 Tumor primary not diagnosed 13n nT1 Tumor invades mucosa or muscle layer 9n nT2 Invasion of perimuscular connective tissue 33n nT3 Tumor extends to the liver 3n nT4 Invasion of the liver 2cm 1 Schaeff B,Paolucci V,Thomopoulos J.Schaeff B,Paolucci V,Thomopoulos J.Schaeff B,Paolucci V,Thomopoulos J.Schaeff B,Paolucci V,Thomopoulos J.Port site recurrencesPort site recurrencesPort site recurrencesPort site recurrences after laparoscopic surgery.A review.Dig Surg,2019,15:124-34.after laparoscopic surgery.A review.Dig Surg,2019,15:124-34.after laparoscopic surgery.A review.Dig Surg,2019,15:124-34.after laparoscopic surgery.A review.Dig Surg,2019,15:124-34.三三 意外胆囊癌的病理意外胆囊癌的病理资资料料TNM分期分期 Schaeff对对514三三 意外胆囊癌的病理资料组织类型意外胆囊癌 术前确诊胆囊癌 (2323例)例)(3333例)例)n n腺癌腺癌20202727n n腺瘤恶变腺瘤恶变2 22 2 n n鳞癌鳞癌1 12 2n n未分化癌未分化癌0 02 2 邹声泉,中华普通外科杂志,邹声泉,中华普通外科杂志,邹声泉,中华普通外科杂志,邹声泉,中华普通外科杂志,2019201920192019三三 意外胆囊癌的病理意外胆囊癌的病理资资料料组织类组织类型型 15 意外胆囊癌 术前确诊胆囊癌 (2323例)例)(3333例)例)n n高分化1411n n中分化34n n低分化618 邹声泉,中华普通外科杂志,邹声泉,中华普通外科杂志,邹声泉,中华普通外科杂志,邹声泉,中华普通外科杂志,2019201920192019三三 意外胆囊癌的病理资料分级三三 意外胆囊癌的病理意外胆囊癌的病理资资料料分分级级16 意外胆囊癌意外胆囊癌 术前确诊胆囊癌术前确诊胆囊癌 (2323例)例)(3333例)例)n n 62n n 51n n 78n n 216n n 36 邹声泉,中华普通外科杂志邹声泉,中华普通外科杂志邹声泉,中华普通外科杂志邹声泉,中华普通外科杂志,2019201920192019三三 意外胆囊癌的病理资料Nevin分期 三三 意外胆囊癌的病理意外胆囊癌的病理资资料料Nevin分期分期17 意外胆囊癌 术前确诊胆囊癌 (18例)(43例)n n 20n n 31n n 53n n 535n n 34 田华田华田华田华.中华外科杂志中华外科杂志中华外科杂志中华外科杂志,2019,43(13,2019,43(13,2019,43(13,2019,43(13):):):):836-8836-8836-8836-8.三三 意外胆囊癌的病理资料Nevin分期三三 意外胆囊癌的病理意外胆囊癌的病理资资料料Nevin分期分期18意外胆囊癌意外胆囊癌意外胆囊癌意外胆囊癌 术前确诊胆囊癌术前确诊胆囊癌术前确诊胆囊癌术前确诊胆囊癌 (16161616例例例例 )(21212121例)例)例)例)n n胆囊管11n n胆囊颈部8(56%,9/16)(56%,9/16)3n n胆囊体部56n n胆囊底部06n n胆囊颈体交界部20n n胆囊体部+底部05(81%,17/21)(81%,17/21)邹声泉,中华普通外科杂志,邹声泉,中华普通外科杂志,邹声泉,中华普通外科杂志,邹声泉,中华普通外科杂志,2019201920192019三三 意外胆囊癌的病理资料部位 19四四意外胆囊癌的危险因素 n n胆囊息肉(1cm)n n胆结石(3cm;1015年)n n年龄70岁n n胆囊壁1cm,不规则n n胆囊十二指肠瘘n nMirizzi综合征n n萎缩性胆囊n n多产(3胎),本组比例(57%,13/23)n n家族史(遗传?)四四 意外胆囊癌的危意外胆囊癌的危险险因素因素 胆囊息肉(胆囊息肉(1cm)20n n乙型肝炎病毒患者有乙肝病史的比例在意外胆囊癌为21.74%(5/23),在术前确诊的胆囊癌为30.30%(10/33),均高于普通人群。n n血吸虫感染患者有血吸虫疫水接触史的比例在意外胆囊癌为39.13%(9/23),在术前确诊的胆囊癌为24.24%(8/33),均高于普通人群。四四 意外胆囊癌的危险因素 邹声泉,中华普通外科杂志,邹声泉,中华普通外科杂志,邹声泉,中华普通外科杂志,邹声泉,中华普通外科杂志,20192019乙型肝炎病毒四乙型肝炎病毒四 意外胆囊癌的危意外胆囊癌的危险险因素因素 邹邹声泉,中声泉,中华华普通外科普通外科杂杂21五五意外胆囊癌诊断术前诊断同济医院23例UGC术前诊断分析:n n肝癌2n n结石14n n腺瘤3n n结石合并腺瘤4 邹声泉,中华普通外科杂志,邹声泉,中华普通外科杂志,邹声泉,中华普通外科杂志,邹声泉,中华普通外科杂志,2019201920192019五五 意外胆囊癌意外胆囊癌诊诊断断术术前前诊诊断断 同同济济医院医院23例例UGC术术前前诊诊22五五意外胆囊癌诊断术前检查意外胆囊癌意外胆囊癌意外胆囊癌意外胆囊癌(23(23(23(23例例例例)术前确诊胆囊癌术前确诊胆囊癌术前确诊胆囊癌术前确诊胆囊癌(33(33(33(33例例例例)n nB B超超16161414 n nCT 1CT 12 2 n n MRI 0 MRI 01 1 n n B B超超+CT 3+CT 31212 n n B B超超+MRI 2+MRI 23 3 n n B B超超+CT+MRI 1+CT+MRI 11 1 邹声泉,中华普通外科杂志邹声泉,中华普通外科杂志邹声泉,中华普通外科杂志邹声泉,中华普通外科杂志,2019201920192019五五 意外胆囊癌意外胆囊癌诊诊断断术术前前检查检查23对对1818例术后例术后发现发现UGCUGC患者,其中患者,其中1313例例再行再行CTCT和和/或或MRCPMRCP检查,检查,9 9例例为阳性,其影像学表现为:为阳性,其影像学表现为:n n胆囊窝周缘肝脏高密度增强影n n第一肝门部侵犯伴胆囊三角淋巴结肿大n n局部肝叶转移灶n n胰头及肝十二指肠韧带内淋巴结肿大n n胆总管局部狭窄伴肝内胆管扩张 田华田华田华田华.中华外科杂志中华外科杂志中华外科杂志中华外科杂志,2019,43(13,2019,43(13,2019,43(13,2019,43(13):):):):936-8.936-8.936-8.936-8.五五意外胆囊癌诊断术后检查 对对18例例术术后后发现发现UGC患者,其中患者,其中13例再行例再行CT和和/或或M24五五意外胆囊癌诊断早期诊断n n术中超声术中超声 Intraoperative ultrasonography(IOUS)Intraoperative ultrasonography(IOUS)n n超声引导的细针穿刺针吸细胞学超声引导的细针穿刺针吸细胞学 US-guided fine needle aspiration biopsy(FNAB)US-guided fine needle aspiration biopsy(FNAB)OR fine-needle aspiration cytology(FNAC)OR fine-needle aspiration cytology(FNAC)n n内镜超声内镜超声 Endoscopic ultrasound(EUS)Endoscopic ultrasound(EUS)n n内镜超声引导的细针穿刺针吸细胞学内镜超声引导的细针穿刺针吸细胞学 EUS-guided fine-needle aspiration(FNA)EUS-guided fine-needle aspiration(FNA)n n胆汁细胞学胆汁细胞学 Bile cytology Bile cytology 五五 意外胆囊癌意外胆囊癌诊诊断断早期早期诊诊断断术术中超声中超声25五五意外胆囊癌诊断早期诊断n n内镜下经乳头插管进入胆囊 Endoscopic transpapillary catheterization into the gallbladder(ETCG)一例患者行一例患者行一例患者行一例患者行ETCGETCGETCGETCG抽取胆囊中的胆汁,细胞学未发现异常,抽取胆囊中的胆汁,细胞学未发现异常,抽取胆囊中的胆汁,细胞学未发现异常,抽取胆囊中的胆汁,细胞学未发现异常,但是但是但是但是human telomerase reverse transcriptase(hTERT)human telomerase reverse transcriptase(hTERT)human telomerase reverse transcriptase(hTERT)human telomerase reverse transcriptase(hTERT)mRNAmRNAmRNAmRNA呈阳性呈阳性呈阳性呈阳性Uchida NUchida N,Tsutsui KTsutsui K,Kobara HKobara H。A case of gallbladder A case of gallbladder carcinoma diagnosed preoperatively by the detection of carcinoma diagnosed preoperatively by the detection of human telomerase reverse transcriptase mRNA in human telomerase reverse transcriptase mRNA in endoscopically obtained gallbladder bile.ENDOSCOPY.2019 endoscopically obtained gallbladder bile.ENDOSCOPY.2019 Feb;35(2):185-8.Feb;35(2):185-8.五五 意外胆囊癌意外胆囊癌诊诊断断早期早期诊诊断内断内镜镜下下经经乳乳头头插管插管进进入胆囊入胆囊Uch26五五意外胆囊癌诊断早期诊断n n氟化脱氧葡萄糖正电子发射型计算机断层Fluorodeoxyglucose positron emission tomography(FDG-PET)胆囊癌敏感度胆囊癌敏感度胆囊癌敏感度胆囊癌敏感度 78%78%(11/1411/1411/1411/14)胆管癌敏感度胆管癌敏感度胆管癌敏感度胆管癌敏感度 85%85%(结节型)(结节型)(结节型)(结节型)18%18%(浸润型)(浸润型)(浸润型)(浸润型)Anderson CDAnderson CDAnderson CDAnderson CD,Rice MHRice MHRice MHRice MH,Pinson CWPinson CWPinson CWPinson CW.Fluorodeoxyglucose PET.Fluorodeoxyglucose PET.Fluorodeoxyglucose PET.Fluorodeoxyglucose PET imaging in the evaluation of gallbladder carcinoma and imaging in the evaluation of gallbladder carcinoma and imaging in the evaluation of gallbladder carcinoma and imaging in the evaluation of gallbladder carcinoma and cholangiocarcinoma.J Gastrointest Surg.2019 Jan;8(1):90-7.cholangiocarcinoma.J Gastrointest Surg.2019 Jan;8(1):90-7.cholangiocarcinoma.J Gastrointest Surg.2019 Jan;8(1):90-7.cholangiocarcinoma.J Gastrointest Surg.2019 Jan;8(1):90-7.五五 意外胆囊癌意外胆囊癌诊诊断断早期早期诊诊断氟化脱氧葡萄糖正断氟化脱氧葡萄糖正电电子子发发射型射型计计算算27六六LC切口种植问题生长速度 二例意外胆囊癌 LC术后21天 脐部切口种植 Wade TP,Comitalo JB,Andrus CH,et al.Wade TP,Comitalo JB,Andrus CH,et al.Wade TP,Comitalo JB,Andrus CH,et al.Wade TP,Comitalo JB,Andrus CH,et al.Laparoscopic cancerLaparoscopic cancerLaparoscopic cancerLaparoscopic cancer surgery.Lessons from gallbladder cancer.Surg surgery.Lessons from gallbladder cancer.Surg surgery.Lessons from gallbladder cancer.Surg surgery.Lessons from gallbladder cancer.Surg Endosc,1994,8(6):698-701.Endosc,1994,8(6):698-701.Endosc,1994,8(6):698-701.Endosc,1994,8(6):698-701.六六 LC切口种植切口种植问题问题生生长长速度速度 二例意二例意28六六LC切口种植问题种植率Paolucci组织德国、瑞士、澳大利亚外科学会对409例LC后肿瘤种植率的调查:n切口转移17.1%(70/409)取物袋取物袋 11.5%11.5%(8/708/70)n仅腹膜播散1.8%(6/339)Paolucci V.Paolucci V.Paolucci V.Paolucci V.Zentralbl Chir,2019,128(4):309-12.Zentralbl Chir,2019,128(4):309-12.Zentralbl Chir,2019,128(4):309-12.Zentralbl Chir,2019,128(4):309-12.六六 LC切口种植切口种植问题问题种植率种植率 Paolucci组织组织德德29六六LC切口种植问题原因n nCO2气腹n n胆囊穿孔n n肿瘤生物学特性n n操作引起肿瘤细胞脱落 Schaeff B,Paolucci V,Thomopoulos J.Schaeff B,Paolucci V,Thomopoulos J.Schaeff B,Paolucci V,Thomopoulos J.Schaeff B,Paolucci V,Thomopoulos J.Port sitePort sitePort sitePort site recurrences after laparoscopic surgery.A recurrences after laparoscopic surgery.A recurrences after laparoscopic surgery.A recurrences after laparoscopic surgery.A review.Dig Surg,2019,15:124-34.review.Dig Surg,2019,15:124-34.review.Dig Surg,2019,15:124-34.review.Dig Surg,2019,15:124-34.n n胆汁漏出n n局部损伤n n操作者个人技术 六六 LC切口种植切口种植问题问题原因原因CO2气腹胆汁漏出气腹胆汁漏出30六六LC切口种植问题预防n n减少上述因素n n再次手术时将切口组织切除n n必要时可行切口放疗n n保护伤口,使用取物袋n n定期随访观察六六 LC切口种植切口种植问题问题预预防减少上述因素防减少上述因素31六六LC切口种植问题与预后的关系n研究认为,LC切口种植者预后差:9 9例患者中有例患者中有4 4例出现切口种植例出现切口种植 转移者中位存活转移者中位存活时间为时间为4.54.5月月 Braghetto I,Bastias J,Csendes A,et al.Braghetto I,Bastias J,Csendes A,et al.Braghetto I,Bastias J,Csendes A,et al.Braghetto I,Bastias J,Csendes A,et al.Gallbladder carcinomaGallbladder carcinomaGallbladder carcinomaGallbladder carcinoma during laparoscopic cholecystectomy:is it associated during laparoscopic cholecystectomy:is it associated during laparoscopic cholecystectomy:is it associated during laparoscopic cholecystectomy:is it associated with bad prognosis?Int Surg,2019,84(4):344-9.with bad prognosis?Int Surg,2019,84(4):344-9.with bad prognosis?Int Surg,2019,84(4):344-9.with bad prognosis?Int Surg,2019,84(4):344-9.六六 LC切口种植切口种植问题问题与与预预后的关系研究后的关系研究认为认为,LC切口种植者切口种植者32六六LC切口种植问题与预后的关系nPaolucci认为,LC与OC相比,随访27月,切口种植率相近:LC 7%(10/142)OC 5.1%(4/79)Paolucci V,Neckell M,Gotze T.Paolucci V,Neckell M,Gotze T.Paolucci V,Neckell M,Gotze T.Paolucci V,Neckell M,Gotze T.Unsuspected gallbladder carcinoma-the Unsuspected gallbladder carcinoma-the Unsuspected gallbladder carcinoma-the Unsuspected gallbladder carcinoma-the CAE-S/CAMIC registry.Zentralbl Chir,2019,128(4):309-12.CAE-S/CAMIC registry.Zentralbl Chir,2019,128(4):309-12.CAE-S/CAMIC registry.Zentralbl Chir,2019,128(4):309-12.CAE-S/CAMIC registry.Zentralbl Chir,2019,128(4):309-12.六六 LC切口种植切口种植问题问题与与预预后的关系后的关系Paolucci认为认为,L33七七手术方式与预后的关系SchauerSchauer对对127127例患者的回顾分析:例患者的回顾分析:n n根治性切除根治性切除(35.5%35.5%)五年生存率五年生存率20%20%n n非根治性切除非根治性切除(64.5%64.5%)中位时间中位时间3.23.2月月均在均在2424月内死亡月内死亡 Schauer RJ,Meyer G,Baretton G,et al.Schauer RJ,Meyer G,Baretton G,et al.Schauer RJ,Meyer G,Baretton G,et al.Schauer RJ,Meyer G,Baretton G,et al.Prognostic factors Prognostic factors Prognostic factors Prognostic factors and and and and long-term results after surgery for gallbladder carcinoma:long-term results after surgery for gallbladder carcinoma:long-term results after surgery for gallbladder carcinoma:long-term results after surgery for gallbladder carcinoma:a retrospective study of 127 patients.Langenbecks Arch a retrospective study of 127 patients.Langenbecks Arch a retrospective study of 127 patients.Langenbecks Arch a retrospective study of 127 patients.Langenbecks Arch Surg,2019,386(2):110-7.Surg,2019,386(2):110-7.Surg,2019,386(2):110-7.Surg,2019,386(2):110-7.七七 手手术术方式方式与与预预后的关系后的关系Schauer对对127例患者的回例患者的回34意外胆囊癌组意外胆囊癌组意外胆囊癌组意外胆囊癌组 术前确诊胆囊癌组术前确诊胆囊癌组术前确诊胆囊癌组术前确诊胆囊癌组 (18181818例)例)例)例)(43434343例)例)例)例)n n切除率切除率72.2%39.5%72.2%39.5%n n五年生存率五年生存率56.7%56.7%24.3%24.3%田华田华田华田华.中华外科杂志中华外科杂志中华外科杂志中华外科杂志,2019,43(132019,43(132019,43(132019,43(13):):):):836-8836-8836-8836-8.七七 手术方式根治性手术疗效对比 35n n对高危人群进行普查,进行卫生宣教n n术前B超检查提示为结石和/或息肉并伴有前述危险因素时,应行CT/MRCP检查n n对其它相关疾病的检查结果为阴性者,应高度警惕此病,并详细检查n n胆汁细胞学检查八八重视胆囊癌的早期诊断 对对高危人群高危人群进进行普行普查查,进进行行卫卫生宣教八生宣教八 重重视视胆囊癌的早期胆囊癌的早期诊诊断断 36n n术中对可疑病例应积极采取措施确诊n n提高诊断胆囊癌的影像学技术n n对其生物学特性进行深入研究,开发具有特异性的标记物八八 重视胆囊癌的早期诊断 术术中中对对可疑病例可疑病例应积应积极采取措施确极采取措施确诊诊八八 重重视视胆囊癌的早期胆囊癌的早期诊诊断断 37谢 谢!谢谢 谢谢!38关于意外胆囊癌的几个问题课件关于意外胆囊癌的几个问题课件39
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