Shimizu Hiroaki, Kimura Fumio, Yoshidome Hiroyuki, Ohtsuka Masayuki, Kato Atsushi, Yoshitomi Hideaki, Nozawa Satoshi, Furukawa Katunori, Mitsuhashi Noboru, Takeuchi Dan, Suda Kosuke, Yoshioka Isaku, Miyazaki Masaru
Department of General Surgery, Graduate School of Medicine, Chiba University, Inohana, Chuo-ku, Chiba, 260-0856, Japan.
J Hepatobiliary Pancreat Surg. 2007;14(4):358-65. doi: 10.1007/s00534-006-1188-z. Epub 2007 Jul 30.
BACKGROUND/PURPOSE: The role of aggressive surgery for stage IV gallbladder carcinoma remains controversial. Survival and prognostic factors were analyzed in patients with stage IV disease, based on the Japanese Society of Biliary Surgery (JSBS) classification, to identify the group of patients who could benefit from radical surgery.
A retrospective analysis was done of 79 patients with JSBS stage IV gallbladder carcinoma who had undergone surgical resection with curative intent at our institution. The standard procedures were anatomical S4a + S5 subsegmentectomy (n = 29) with extrahepatic bile duct resection and extended lymphadectomy, but when right Glisson's sheath and/or the hepatic hilum were involved, right extended hepatectomy (n = 34) or right trisegmentectomy (n = 3) was selected. To achieve a tumor-free margin combined pancreaticoduodenectomy was performed in 12 patients, and major vascular resection in 17 patients.
In the patients with stage IV gallbladder carcinoma, the curative resection rate was 65.8% and the hospital mortality rate was 11.4%. The postoperative 5-year survival rate following curative resection was 13.7%. Univariate analysis indicated that curability, hepatoduodenal ligament invasion, nodal involvement, and vascular resection were significant prognostic factors. Neither hepatic invasion nor liver metastasis was a significant factor.
Aggressive surgical resection should be considered even in stage IV patients when hepatoduodenal ligament invasion and nodal involvement are absent or limited. Acceptable survival may be expected among such patients only when curative resection is achieved.
背景/目的：积极手术治疗IV期胆囊癌的作用仍存在争议。基于日本胆道外科学会（JSBS）分类，对IV期疾病患者的生存情况和预后因素进行分析，以确定能从根治性手术中获益的患者群体。
对我院79例接受了根治性手术切除的JSBS IV期胆囊癌患者进行回顾性分析。标准手术方式为解剖性S4a + S5亚段切除术（n = 29），并行肝外胆管切除和扩大淋巴结清扫术，但当右侧肝门Glisson鞘和/或肝门受累时，选择右半肝扩大切除术（n = 34）或右三叶切除术（n = 3）。为达到切缘无肿瘤，12例患者行联合胰十二指肠切除术，17例患者行主要血管切除术。
IV期胆囊癌患者的根治性切除率为65.8%，医院死亡率为11.4%。根治性切除术后的5年生存率为13.7%。单因素分析表明，可切除性、肝十二指肠韧带侵犯、淋巴结受累和血管切除是显著的预后因素。肝侵犯和肝转移均不是显著因素。
即使是IV期患者，当不存在或仅有局限性肝十二指肠韧带侵犯和淋巴结受累时，也应考虑积极的手术切除。只有实现根治性切除，这类患者才可能获得可接受的生存率。
