腹腔镜胆囊手术中意外胆囊癌的诊治对策

安 鑫 薛冰川 张文龙

(山西医科大学第三医院普外科，太原 030053)

·经验交流·

腹腔镜胆囊手术中意外胆囊癌的诊治对策

安 鑫*薛冰川①张文龙

(山西医科大学第三医院普外科，太原 030053)

目的 探讨腹腔镜手术意外胆囊癌的临床特点及治疗方法。方法回顾性分析1997年9月～2015年9月我院4620例腹腔镜胆囊切除(laparoscopic cholecystectomy，LC)手术中意外胆囊癌12例的临床资料。1例术中冰冻病理诊断胆囊癌Nevin Ⅲ期，中转开腹行胆囊癌根治术；11例术后病理诊断胆囊癌，Nevin Ⅰ期1例和Ⅱ期1例未补充手术，Ⅲ期9例中5例拒绝手术，4例术后10～18 d(平均14 d)开腹行胆囊癌根治术。结果5例Nevin Ⅲ期LC后拒绝手术者失访。Ⅰ、Ⅱ期各1例LC术后随访63个月和6个月无复发，Ⅲ期行胆囊癌根治术5例中，2例分别术后8、10个月因腹腔广泛转移，死于恶病质，3例术后10、28、32个月胆囊癌肝转移死亡。结论腹腔镜胆囊手术时应高度警惕意外胆囊癌的发生，应及时行合适的补充治疗。

腹腔镜胆囊切除术； 意外胆囊癌

意外胆囊癌(unexpected gallbladder carcinoma，UGC)是术中或术后偶然发现的胆囊癌，发生率逐年升高，文献报道为0.2%～0.9%[1]。腹腔镜胆囊切除术(laparoscopic cholecystectomy，LC)是治疗胆囊良性疾病的金标准[2～5]，随着LC广泛开展，UGC越来越多，应及时行合适的补充治疗。1997年9月～2015年9月我院行4620例LC，发生UGC 12例(0.26%)，本文对其进行回顾性分析，探讨腹腔镜手术UGC的临床特点及治疗方法。

1 临床资料与方法

1.1 一般资料

本组12例，男3例，女9例。年龄42～69岁，平均58.8岁。10例有反复发作右上腹疼痛、向右肩部放射痛，病史8～22年，平均11年；2例自诉上腹部不适，自觉“胃疼”，病史分别为6、8年。均无体重减轻。均行超声检查，提示胆囊结石12例(结石大小1.2～3.5 cm)，伴胆囊息肉样病变2例(均为胆囊颈部腺瘤样息肉，大小0.5 cm和1.1 cm)，其中11例胆囊壁不均匀增厚(0.4～0.9 cm)。2例检查肿瘤标志物(CEA、CA19-9)，均未见异常。术前肝功能检查均在正常范围。

1.2 手术方法

均在全麻下行常规三孔LC，胆囊标本均置入标本袋内经剑突下切口取出。1例因与周围组织粘连不容易剥离，剖开胆囊可见胆囊底部与正常黏膜组织质地颜色不同，局部菜花样隆起改变，高度怀疑癌，行术中冰冻切片诊断为胆囊癌Nevin Ⅲ期，立即中转开腹胆囊连同肝楔形整块切除(距胆囊床2.0 cm)+肝十二指肠韧带淋巴结清扫。其余11例术中未怀疑恶性，术后石蜡切片诊断胆囊癌，1例NevinⅠ期、1例Nevin Ⅱ期未再行二次开腹手术，5例Nevin Ⅲ期患者因经济条件或年龄偏大拒绝二次手术，4例Nevin Ⅲ期术后10～18 d(平均14 d)开腹行胆囊癌根治术。

2 结果

石蜡切片病理，高分化腺癌3例，中分化腺癌4例，低分化腺癌4例，未分化癌1例。按Nevin分期，Ⅰ期(局限于黏膜层)1例，Ⅱ期(侵及肌层)1例，Ⅲ期(侵及胆囊壁全层)10例。

5例Nevin Ⅲ期LC后未手术患者失访。Nevin Ⅰ期、Ⅱ期各1例仅行LC，术后随访63个月和6个月，未见复发。Nevin Ⅲ期行胆囊癌根治术5例中，2例术后8、10个月因腹腔广泛转移死于恶病质，3例术后10、28、32个月胆囊癌肝转移死亡。

3 讨论

3.1 UGC的早期诊断

结合本组12例UGC及相关报道[6，7]分析，LC术前若出现以下情况应引起足够重视：年龄>60岁，胆囊结石直径>3 cm、症状反复发作病程>5年，胆囊腺瘤样息肉直径>1 cm，胆囊壁增厚或萎缩性胆囊。必要时可以做胆囊区薄层CT扫描。本组12例UGC中3例结石>3 cm，12例病程均超过5年，2例胆囊腺瘤样息肉，11例胆囊壁不均匀增厚。

LC术中应注意观察胆囊情况，切除的胆囊标本要剖视，如发现有异常，有条件时尽量做术中冰冻快速病理检查。本组仅1例有菜花样突起的胆囊做术中快速病理检查；与肝床、大网膜粘连1例，胆囊壁不均匀增厚且有黏液状物5例，萎缩性胆囊3例，未见明显异常2例，均未做术中病理。

3.2 UGC的处理

应该正确掌握UGC二次手术的指征、手术时机和采取合理的手术方式。本组12例UGC均为Nevin Ⅲ期及以下患者，故我们认为，LC发现的UGC较多为早期病例(Nevin Ⅲ期及以下)，病灶仅侵犯黏膜和肌层。一般认为，Nevin Ⅰ、Ⅱ期因肿瘤组织仅发生在胆囊黏膜内或肌层，未穿破胆囊浆膜，只要将胆囊完整切除取出，无胆汁外漏，切缘无癌组织残留，行单纯LC即可，术后定期随访复查[8]。Nevin Ⅲ期需再次手术根治切除。换句话说，UGC二次手术的指征是病变侵及肌层以外达浆膜层，能手术切除和清扫的Nevin Ⅲ期患者。我院行胆囊癌根治性手术包括切除胆囊附近2 cm肝脏+肝十二指肠韧带淋巴结清扫。本组5例Nevin Ⅲ期行开腹胆囊癌根治术。UGC多属于早期，行胆囊癌扩大根治术能否改善预后依据不足，所以不主张盲目扩大UGC的根治范围。

总之，在LC中发现UGC应谨慎处理，目前对于UGC的诊治尚未明确，应该提高对UGC的认识，术中常规剖视胆囊标本，可疑胆囊癌行术中快速病理检查，及早做出诊断，Nevin Ⅲ期应行胆囊癌根治性手术。

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(修回日期：2016-05-23)

(责任编辑：王惠群)

Diagnosis and Treatment of Unexpected Gallbladder Carcinoma During Laparoscopic Cholecystectomy

AnXin*,XueBingchuan,ZhangWenlong*.

*DepartmentofGeneralSurgery,ThirdHospitalofShanxiMedicalUniversity,Taiyuan030053,China

AnXin,E-mail:anppke@163.com

Objective To explore clinical characteristics and treatment for unexpected gallbladder carcinoma during laparoscopic surgery. Methods A retrospective analysis was made on clinical data of 12 cases of unexpected gallbladder carcinoma out of 4620 cases of laparoscopic cholecystectomy (LC) in our hospital from September 1997 to September 2015. Intraoperative frozen pathological diagnosis showed gallbladder cancer Nevin stage Ⅲ in 1 case,and a conversion to open surgery of gallbladder cancer was conducted. The remaining 11 cases of gallbladder carcinoma were diagnosed by pathology after surgery. One case of Nevin stage Ⅰ and 1 case of stage Ⅱ were not surgically treated. Of the other 9 cases of Nevin stage Ⅲ,there were 5 patients who refused surgery and 4 patients received open radical resection of gallbladder cancer at 10-18 d (mean,14 d) postoperatively. Results The 5 cases of Nevin stage Ⅲ who refused open radical surgery were lost to follow-up. Two cases of stage Ⅰ and Ⅱ were followed up for 63 months and 6 months after LC without recurrence. Of the 5 cases of stage Ⅲ undergoing open radical surgery,2 cases dead at 8 and 10 months postoperatively because of abdominal extensive metastasis and cachexia,and 3 cases dead at 10,28,and 32 months postoperatively because of gallbladder carcinoma liver transfer. Conclusions The occurrence of unexpected gallbladder cancer should be taken into consideration during laparoscopic cholecystectomy. Timely and appropriate complementary therapy should be given.

Laparoscopic cholecystectomy; Unexpected gallbladder cancer

*通讯作者，E-mail：anppke@163.com

①现工作单位：北京北亚骨科医院综合外科，北京 102445

B

1009-6604(2016)09-0858-02

10.3969/j.issn.1009-6604.2016.09.024

2015-12-05)