Minimally Invasive HPB Surgery, Department of Surgical Oncology, Summit Medical Group, 1 Diamond Hill Rd., Bensley Pavilion, 4th Floor, Berkeley Heights, NJ 07922, USA.
Surg Endosc. 2013 Feb;27(2):406-14. doi: 10.1007/s00464-012-2489-8. Epub 2012 Aug 28.
Due to the perceived difficulty in dissecting gallbladder cancers and extrapancreatic cholangiocarcinomas off of the portal structures and in performing complex biliary reconstructions, very few centers have used minimally invasive techniques to remove these tumors. Furthermore, due to the relative rarity of these tumors when compared to hepatocellular carcinoma, only a few reports have focused on short- and long-term results.
We performed a review by combining the experience of three international centers with expertise in complex minimally invasive hepatobiliary surgery. Patients were entered into a database prospectively. All patients with gallbladder cancer and cholangiocarcinoma were analyzed; patients with distal cholangiocarcinomas who underwent laparoscopic pancreatoduodenectomies were excluded. Patients were divided according to if they had gallbladder cancer, hilar cholangiocarcinoma, or intrahepatic cholangiocarcinoma.
A total of 15 patients underwent laparoscopic resection for gallbladder cancer and 10 for preoperatively suspected gallbladder cancer, and 5 underwent laparoscopic completion procedures. An average of four lymph nodes (range = 1-11) were retrieved and all patients had an R0 resection. One patient (7 %) required conversion to an open procedure. No patients developed a biliary fistula, required percutaneous drainage, or had endoscopic stent placement. One patient had a recurrence at 3 months despite a negative final pathological margin, and a second patient had a distant recurrence at 20 months with a mean follow-up of 23 months. Nine patients underwent laparoscopic hepatectomy for intrahepatic cholangiocarcinoma. All anastomoses were completed laparoscopically. Biliary fistula was seen in two patients, one of which died after a transhepatic percutaneous biliary drain resulted in uncontrollable intra-abdominal hemorrhage despite reoperation. A third patient developed a pulmonary embolism. Thus, the morbidity and mortality rates were 33 and 11 %, respectively. One patient was converted to open and six patients (66 %) are alive with a median follow-up of 22 months. Five patients underwent minimally invasive resection for hilar cholangiocarcinoma; of these, two also required laparoscopic major hepatectomy. The mean estimated blood loss (EBL) was 240 mL (range = 0-400 mL) and the median length of stay (LOS) was 15 days (range = 11-21 days). All patients are alive with a median follow-up of 11 months (range = 3-18 months). None of the 29 patients developed port site recurrences.
Minimally invasive approaches to gallbladder cancer and intrahepatic and extrahepatic cholangiocarcinoma seem feasible and safe in the short term. Larger series with longer follow-up are needed to see if there are any long-term disadvantages or advantages to laparoscopic resection of extrapancreatic cholangiocarcinoma.
由于在门静脉结构上解剖胆囊癌和胰外胆管癌并进行复杂的胆道重建时难度较大，因此很少有中心采用微创技术来切除这些肿瘤。此外，由于与肝细胞癌相比，这些肿瘤相对少见，因此只有少数报道集中在短期和长期结果上。
我们通过结合三个在复杂微创肝胆外科方面具有专业知识的国际中心的经验进行了回顾。患者前瞻性地被纳入数据库。所有胆囊癌和胆管癌患者均进行了分析；排除了接受腹腔镜胰十二指肠切除术的远端胆管癌患者。患者根据是否患有胆囊癌、肝门部胆管癌或肝内胆管癌进行分组。
共有 15 例患者接受了腹腔镜胆囊切除术，10 例患者术前疑似胆囊癌，5 例患者接受了腹腔镜完成手术。平均取出 4 个淋巴结（范围=1-11），所有患者均行 R0 切除术。1 例（7%）患者需要转为开放手术。无患者发生胆瘘、需要经皮引流或内镜支架置入。1 例患者尽管最终病理切缘阴性，但仍在 3 个月时复发，另 1 例患者在 20 个月时出现远处复发，平均随访时间为 23 个月。9 例患者因肝内胆管癌行腹腔镜肝切除术。所有吻合均在腹腔镜下完成。2 例患者出现胆瘘，其中 1 例在经肝穿刺胆道引流后发生不可控制的腹腔内出血，尽管再次手术，但仍导致死亡。另 1 例患者发生肺栓塞。因此，发病率和死亡率分别为 33%和 11%。1 例患者转为开放手术，6 例（66%）患者存活，中位随访时间为 22 个月。5 例患者因肝门部胆管癌行微创切除术，其中 2 例还需要腹腔镜肝切除术。平均估计失血量（EBL）为 240 毫升（范围=0-400 毫升），中位住院时间（LOS）为 15 天（范围=11-21 天）。所有患者均存活，中位随访时间为 11 个月（范围=3-18 个月）。29 例患者均无切口部位复发。
在短期内，微创方法治疗胆囊癌和肝内外胆管癌似乎是可行和安全的。需要更大的系列和更长的随访时间，以观察腹腔镜胰外胆管癌切除术是否存在任何长期的劣势或优势。
