Buhr J, Hürtgen M, Heinrichs C M, Graf M, Padberg W M
Klinik für Allgemein- und Thoraxchirurgie, Universität Giessen.
Dtsch Med Wochenschr. 1996 Jan 19;121(3):57-61; discussion 61-2. doi: 10.1055/s-2008-1042972.
A 66-year-old woman was known to have had cholecystolithiasis for at least 4 years. Laparoscopic cholecystectomy was performed at another hospital where histological examination surprisingly revealed middle-grade differentiated carcinoma of the gall-bladder (pT2, G2). A nodular metastasis of the gall-bladder carcinoma was noted on the abdominal wall 3 months later and excised. Lymph-vessel carcinomatosis was already present. The patient again noticed a tumour in the right mid-abdomen and a further tumour was palpated in the epigastrium 5 months after the operation.
Laboratory and tumour-marker (CEA, CA 19-9) tests were unremarkable, while sonography and computed tomography were highly suspicious for abdominal wall metastases in the epigastrium and right mid-abdomen.
Both metastases were excised. Laparotomy revealed tumour recurrence in the old gall-bladder bed, as well as extensive peritoneal carcinoma. Two months after the operation she developed jaundice, caused by tumour compression of the choledochal duct. An expanding stent was inserted into the stenosed section of the duct. The patient died 13 months after the first operation from the underlying malignancy with multiple liver metastases and malignant ascites.
Indications for minimally invasive surgery in malignant tumour should be narrowly defined. Because tumour seeding is possible after laparoscopic cholecystectomy with incidentally found carcinoma extensive re-excision should be performed.
一名66岁女性已知患有胆囊结石至少4年。在另一家医院进行了腹腔镜胆囊切除术，组织学检查意外发现为中分化胆囊癌（pT2，G2）。3个月后在腹壁发现胆囊癌结节性转移并切除，此时已有淋巴管癌转移。术后5个月，患者再次注意到右上腹有一肿瘤，在上腹部又可触及另一肿瘤。
实验室检查及肿瘤标志物（癌胚抗原、糖类抗原19-9）检测无异常，而超声检查和计算机断层扫描高度怀疑上腹部和右上腹腹壁有转移。
两处转移灶均被切除。剖腹手术发现原胆囊床有肿瘤复发，以及广泛的腹膜癌。术后两个月，患者因肿瘤压迫胆总管出现黄疸，在狭窄段置入了扩张支架。患者在首次手术后13个月死于潜在恶性肿瘤，伴有多发肝转移和恶性腹水。
恶性肿瘤微创手术的适应证应严格界定。由于腹腔镜胆囊切除术中偶然发现癌肿后可能发生肿瘤种植，应进行广泛的再次切除。
