Kinoshita H, Nakayama T, Imayama H, Okuda K
Department of Surgery, Kurume University School of Medicine, Fukuoka, Japan.
Nihon Geka Gakkai Zasshi. 1998 Oct;99(10):700-5.
Diagnosis of extension by intraoperative ultrasonography (IOUS) and treatment based on the degree of histological extension in carcinoma of the gallbladder are discussed. IOUS is a useful technique for the diagnosis of the depth of wall invasion and direct invasion of the liver. The authors diagnose the depth of wall invasion based on the layer structure, unequal width, and discontinuity of the layer echogram. By this technique, mucosal cancer (m cancer) or cancer extending to the proper muscle layer (mp cancer) can be differentiated from cancer with submucosal invasion (ss cancer), and also ss cancer from cancer exposing the serosa (se) or cancer infiltrating to the serosa (si). However, differentiation between m cancer and mp cancer is not possible by IOUS or by other diagnostic techniques. In terms of histological extension, lymph node metastasis or vascular and nerve invasion is not found in m cancer, but in some cases of mp cancer vascular invasion is present. As a radical operative procedure for early m and mp cancer, full-thickness cholecystectomy or partial resection of the liver bed and dissection of lymph nodes 8, 12, and 13 should be conducted. As lymph node metastasis and vascular and nerve invasion are frequent in ss or more advanced cancer, complete lymph node dissection should be performed. Cholecystectomy, partial resection of the liver bed, bile duct resection, and dissection of lymph nodes 8, 12, and 13 is the preferred radical operative procedure for ss cancer. In the cases with in metastasis to lymph nodes 8 and 13, pancreatoduodenectomy is combined. The basic operative procedure for se and si cancer has not been established, but is should be radical and safe. Considering the poor prognosis and frequency of lethal postoperative complications, at present we should not only expand the resected area but select a reasonable and well-balanced operative procedure depending on the degree of cancer extension.
讨论了通过术中超声检查（IOUS）诊断胆囊癌的扩展情况以及根据组织学扩展程度进行治疗。IOUS是诊断胆囊壁侵犯深度和肝脏直接侵犯的有用技术。作者根据层结构、宽度不均和层回声图的连续性来诊断壁侵犯深度。通过该技术，可将黏膜癌（m癌）或扩展至固有肌层的癌（mp癌）与侵犯黏膜下层的癌（ss癌）区分开来，也可将ss癌与浆膜暴露癌（se）或浸润至浆膜的癌（si）区分开来。然而，IOUS或其他诊断技术无法区分m癌和mp癌。在组织学扩展方面，m癌未发现淋巴结转移或血管及神经侵犯，但在某些mp癌病例中存在血管侵犯。作为早期m癌和mp癌的根治性手术，应进行全层胆囊切除术或肝床部分切除术以及第8、12和13组淋巴结清扫。由于ss癌或更晚期癌症中淋巴结转移以及血管和神经侵犯较为常见，应进行完整的淋巴结清扫。胆囊切除术、肝床部分切除术、胆管切除术以及第8、12和13组淋巴结清扫是ss癌首选的根治性手术。对于第8和13组淋巴结转移的病例，联合胰十二指肠切除术。se癌和si癌的基本手术方法尚未确立，但应既根治又安全。考虑到预后较差和术后致命并发症的发生率，目前我们不仅应扩大切除范围，还应根据癌症扩展程度选择合理且平衡的手术方法。
