Department of General Surgery, Cleveland Clinic, Cleveland, OH, USA.
Department of Internal Medicine, Cleveland Clinic, Cleveland, OH, USA.
J Gastrointest Surg. 2021 Sep;25(9):2344-2352. doi: 10.1007/s11605-021-04942-1. Epub 2021 Feb 9.
Gallbladder adenocarcinoma has a poor prognosis as it is often diagnosed incidentally, and patients have a high risk for residual and occult metastatic disease. Expert guidelines recommend definitive surgery for ≥T1b tumors; however, surgical management is inconsistent. This study evaluates the factors that affect the completion of radical resection with portal lymphadenectomy and its impact on survival.
A retrospective review of patients who underwent surgery for gallbladder cancer from 2008 to 2017 at an academic institution was performed. Patients were analyzed based on whether they underwent definitive surgical resection. Patient factors and clinical decision-making were analyzed; overall survival was compared using Kaplan-Meier analysis.
Seventy-five patients with ≥T1b tumors were identified, of who 32 (42.7%) underwent definitive resection. Fifty-four (72%) patients had gallbladder cancer identified as an incidental diagnosis following laparoscopic cholecystectomy. Among patients who did not undergo definitive resection, the underlying factors were varied. Only 24 (55.8%) patients in the non-definitive resection group were seen by surgical oncology. Among patients who underwent re-operation for definitive resection, 12 (38.7%) were upstaged on final pathology. Of the 43 patients who did not undergo definitive resection, 4 (9.3%) had metastatic disease identified during attempted re-resection. Patients who underwent definitive resection had a significantly longer median overall survival compared to those who did not (4.3 v. 1.9 years, p = 0.02).
Patients undergoing definitive resection have a significantly improved survival, including as part of a re-operative strategy. Universal referral to a surgical specialist is a modifiable factor resulting in increased definitive resection rates.
胆囊腺癌预后较差，因为它通常是偶然诊断出来的，而且患者有残余和隐匿性转移疾病的高风险。专家指南建议对≥T1b 肿瘤进行确定性手术；然而，手术管理并不一致。本研究评估了影响根治性切除伴门脉淋巴结清扫术完成的因素及其对生存的影响。
对 2008 年至 2017 年在一所学术机构接受胆囊癌手术的患者进行了回顾性分析。根据患者是否接受确定性手术进行了分析。分析了患者的因素和临床决策；使用 Kaplan-Meier 分析比较总生存率。
确定了 75 名≥T1b 肿瘤患者，其中 32 名（42.7%）接受了确定性手术。54 名（72%）患者在腹腔镜胆囊切除术后意外发现胆囊癌。在未行确定性切除术的患者中，潜在因素各不相同。只有 24 名（55.8%）非确定性切除术患者接受了外科肿瘤学治疗。在接受确定性再手术的患者中，12 名（38.7%）患者的最终病理分期升高。在未行确定性切除术的 43 名患者中，4 名（9.3%）在试图再次切除时发现转移性疾病。行确定性切除术的患者中位总生存期明显长于未行确定性切除术的患者（4.3 比 1.9 年，p = 0.02）。
行确定性切除术的患者的生存显著改善，包括作为再次手术策略的一部分。普遍转介给外科专家是一个可改变的因素，可提高确定性切除术的比例。
