Goetze T O, Paolucci V
Ketteler-Krankenhaus, Chirurgische Klinik, Offenbach, Deutschland.
Zentralbl Chir. 2014 Dec;139 Suppl 2:e43-8. doi: 10.1055/s-0030-1262698. Epub 2011 Mar 1.
Gallbladder cancer is suspected preoperatively in only 30 % of all patients, while the other 70 % of cases are discovered incidentally by the pathologist (incidental or occult gallbladder cancer or IGBC). If gallbladder cancer is suspected preoperatively, an open cholecystectomy must be performed. The increasing rate of cholecystectomies via laparoscopy has lad to the detection of more gallbladder cancers in an early stage. Extended resection with regional lymph node dissection for T2 carcinomas and for more advanced cancer has been suggested. If IGBC is detected postoperatively by the pathologist after simple cholecystectomy, radical re-resection in cases of T2 tumours and more advanced stages is recommended. However, it has been argued that T1b cancers may have spread regionally or systemically at presentation and, thus, it remains debatable whether T1b cancers should be treated by simple cholecystectomy or by radical resection. PATIENTS / MATERIAL AND METHOD: This investigation was based on the German Registry of "Incidental Gallbladder Cancer" of the German Society of Surgery. In the present study, we evaluated whether T1 carcinoma patients do profit from a radical re-resection and if the different techniques of liver resection have comparable results in T1 carcinomas.
We analysed 684 cases of IGBC including 124 patients with T1 cancer with a 5-year survival of 48 %. An extended re-resection increased the 5-year survival up to 68 % for T1-IGBC. The analysis shows no advantage for re-resection of T1a cancer. In contrast, the current analysis shows a statistically significant survival benefit for re-resection of T1b cancers from 34 % to 75 %. The Registry data show a trend of better survival for the patients treated with the wedge resection technique compared to other resection techniques.
For T1a cancer a simple cholecystectomy is sufficient. An immediate re-resection is highly recommended for patients with IGBC in T1b stage. The wedge resection technique combined with a locoregional lymphadenectomy of the hepatoduodenal ligament seems to be the strategy of choice for T1b cancer. An extended re-resection is necessary to determine the nodal status exactly, and to determine an exact definite staging for patients with T1b cancer.
在所有患者中，术前仅30%的患者被怀疑患有胆囊癌，而另外70%的病例是由病理学家偶然发现的（偶然或隐匿性胆囊癌或IGBC）。如果术前怀疑患有胆囊癌，则必须进行开腹胆囊切除术。腹腔镜胆囊切除术的增加率导致更多早期胆囊癌被发现。对于T2期癌和更晚期的癌症，有人建议进行扩大切除并清扫区域淋巴结。如果在单纯胆囊切除术后病理学家在术后发现IGBC，对于T2期肿瘤及更晚期病例，建议进行根治性再次切除。然而，有人认为T1b期癌症在确诊时可能已经发生区域或全身转移，因此，T1b期癌症应采用单纯胆囊切除术还是根治性切除术仍存在争议。
患者/材料与方法：本研究基于德国外科学会的“偶然胆囊癌”德国登记处的数据。在本研究中，我们评估了T1期癌患者是否能从根治性再次切除中获益，以及不同的肝切除技术在T1期癌中是否有可比的结果。
我们分析了684例IGBC病例，其中包括124例T1期癌患者，5年生存率为48%。对于T1期IGBC，扩大再次切除可将5年生存率提高至68%。分析显示，T1a期癌再次切除无优势。相比之下，目前的分析显示，T1b期癌再次切除的生存率从34%提高到75%，具有统计学意义。登记处数据显示，与其他切除技术相比，采用楔形切除技术治疗的患者生存趋势更好。
对于T1a期癌，单纯胆囊切除术就足够了。对于T1b期IGBC患者，强烈建议立即进行再次切除。楔形切除技术联合肝十二指肠韧带区域淋巴结清扫似乎是T1b期癌的首选策略。对于T1b期癌患者，需要进行扩大再次切除以准确确定淋巴结状态并确定确切的分期。
