RSS-Feed abonnieren
DOI: 10.1055/s-2000-10072
J.A.Barth Verlag in Medizinverlage Heidelberg GmbH & Co.KG
Das postoperativ nachgewiesene Gallenblasenkarzinom
Nachbeobachtung oder Nachoperation?Publikationsverlauf
Publikationsdatum:
31. Dezember 2000 (online)
![](https://www.thieme-connect.de/media/zblchir/200012/lookinside/thumbnails/10.1055-s-2000-10072-1.jpg)
Postoperative diagnosis of gallbladder carcinoma. Observation or reoperation?
Summary
Background: The prognosis of gallbladder carcinoma is generally poor. The 5-year survival rate amounts to less than 5 % in most series due to the high proportion of advanced stages at the time of diagnosis. Early stages are commonly found only with histological work-up after cholecystectomy (CCE). In these cases the question arises whether or not reoperation for completion resection would be indicated.Patients/Methods: A retrospective analysis examined all patients of the Clinic of Surgery (Charité) in Berlin with gallbladder carcinoma operated on between January 1981 and August 1993. A literature search was carried out using the MEDLINE retrieval system for the key words “gallbladder carcinoma”, “surgical therapy”, and “reoperation” limited to the period after 1970.Results: The retrospective results of the own clinic and the analysis of the literature review demonstrate significantly higher survival rates after reoperation compared to CCE alone and observation for all cases of gallbladder carcinoma with stages T1b or higher stages. The extended radical CCE can be performed with low morbidity. With preceding laparoscopic CCE the trocar sites have to be completely excised.Discussion: To avoid the situation of postoperative diagnosis of gallbladder carcinoma, the surgeon should intraoperatively during CCE perform a careful macroscopic control of the gallbladder. Suspect findings should be followed intraoperatively by histological examination. Nevertheless, local spread of GBCa and distribution of lymphatic metastases can certainly not be assessed completely after simple CCE. Based on the published results and because of low morbidity reoperation is indicated for most cases of GBCa when diagnosed postoperatively.
Zusammenfassung
Problemstellung: Die allgemein schlechte Prognose des Gallenblasenkarzinoms (GBCa) mit nur 5 % 5-Jahres-Überlebensrate ist durch die hohe Zahl fortgeschrittener Befunde bei Diagnosestellung bedingt. Frühstadien des GBCa werden häufig erst postoperativ nach einer Cholezystektomie (CCE) entdeckt. In diesen Fällen entsteht das Problem der Indikation zu einer Nachresektion.Patienten/Methoden: Es erfolgte eine retrospektive Analyse des chirurgischen Krankengutes mit der Diagnose GBCa im Zeitraum 1981-1993 an der Chirurgischen Klinik der Charité Berlin. Außerdem wurde eine Literaturrecherche unter Benutzung des MEDLINE-Systems bezüglich der Stichworte „gallbladder carcinoma”, „surgical therapy”, „reoperation” und „observation” im Zeitraum nach 1970 vorgenommen.Ergebnisse: Die Ergebnisse der eigenen Retrospektive und der Analyse der aktuellen Literatur zeigen gegenüber der einfachen CCE mit Nachbeobachtung eine signifikant höhere Überlebensrate für die Nachresektion bei Vorliegen eines Stadiums ≥ T1b (T1b oder T2). Diese Operation ist mit geringer Morbidität durchführbar. Nach vorausgegangener laparoskopischer CCE müssen insbesondere auch die Trokarinsertionen exzidiert werden.Diskussion: Um das Dilemma der Fragestellung zu verringern, sollte eine subtile intraoperative makroskopische Kontrolle der GB durch den Operateur erfolgen. Bei suspekten Befunden ist eine intraoperative histologische Untersuchung obligat. Die lokale Ausbreitung des GBCa sowie der Lymphknoten-Status können nach einfacher CCE dennoch selten sicher eingeschätzt werden. Eine Abgrenzung der Stadien T1a und T1b ist oft nicht möglich. Aufgrund der publizierten Ergebnisse und der niedrigen Morbidität ist die Nachresektion in den meisten Fällen eines postoperativ diagnostizierten GBCa indiziert.
Key words
Gallbladder carcinoma - postoperative diagnosis - reoperation - observation
Schlüsselwörter
Gallenblasenkarzinom - postoperative Diagnose - Nachoperation - Nachbeobachtung
Literatur
- 1 American Joint Committee on Cancer .Manual for staging of cancer. 3rd edn. Philadelphia: Lippincott 93-98
- 2 de Aretxabala X A, Roa I S, Burgos L A, Araya J C, Villaseca M A, Silva J A. Curative resection in potentially resectable tumors of the gallbladder. Eur J Surg. 1997; 163 419-426
- 3 Arnaud J P, Casa C, Georgeac C, Serra-Maudet V, Jacob J P, Ronceray J, Bergamaschi R. Primary carcinoma of the gallbladder - review of 143 cases. Hepato-Gastroenterology. 1995; 42 811-815
- 4 Bartlett D L, Fong Y, Fortner F G, Brennan M F, Blumgart L H. Long term results after resection for gallbladder cancer. Ann Surg. 1996; 224 639-646
- 5 Benoist S, Panis Y, Fragniez P L. Long-term results after curative resection for carcinoma of the gallbladder. Am J Surg. 1998; 175 118-122
- 6 Cijiiwa K, Sumiyoshi K, Nakayama F. Impact of recent advances in hepatobiliary imaging techniques on the preoperative diagnosis of carcinoma of the gallbladder. World J Surg. 1991; 15 322-327
- 7 Cubertafond P, Gainant A, Cucciaro G. Surgical treatment of 724 carcinoma of the gallbladder. Ann Surg. 1994; 3 275-280
- 8 Donohue J H, Nagorney D M, Grant C S, Tsushima K, Ilstrup D M, Adson M A. Carcinoma of the gallbladder. Does radical resection improve outcome?. Arch Surg. 1990; 115 237-241
- 9 Drouard F, Delamarre J, Capron J. Cutaneous seeding of gallbladder cancer after laparoscopic cholecystectomy. N Engl J Med. 1991; 325 1316
- 10 Fong Y, Heffernan N, Blumgart L H. Gallbladder carcinoma discovered during laparoscopic cholecystectomy. Cancer. 1998; 83 423-427
- 11 Gagner M, Rossi R L. Radical operations for carcinoma of the gallbladder: present status in North America. World J Surg. 1991; 15 344-347
- 12 Henson D E, Albores-Saavedra J, Corle D. Carcinoma of the gallbladder. Histologic types, stage of disease, grade, and survival rates. Cancer. 1992; 70 1493-1497
- 13 Jacobi C A, Ordemann J, Böhm B, Zieren H U, Sabat R, Müller J M. Inhibition of peritoneal tumor cell growth and implantation in laparoscopic surgery in a rat model. Am J Surg. 1997; 174 359-363
- 14 Kemeny M M. Is there a role for radical surgery in advanced gallbladder carcinoma?. HPB Surg. 1997; 10 335-338
- 15 Köckerling F, Scheele J, Gall F P. Die chirurgische Therapie des Gallenblasenkarzinoms. Chirurg. 1988; 59 236-243
- 16 Lomis K D, Vitola J V, Delbeke D, Snodgrass S L, Chapman W C, Wright J K, Pinson C W. Recurrent gallbladder carcinoma at laparoscopy port sites diagnosed by positron emission tomography: Implications for primary and radical secon operations. Am Surg. 1997; 63 341-345
- 17 Matsumoto Y, Fujii H, Aoyama H, Yamamoto M, Sugahara K, Suda K. Surgical treatment of primary carcinoma of the gallbladder based on the histologic analysis of 48 surgical specimens. Am J Surg. 1992; 163 239-245
- 18 Miyazaki M, Itoh H, Ambiru S, Shimizu H, Togawa A, Gohchi E, Nakajima N, Suwa T. Radical surgery for advanced gallbladder carcinoma. Br J Surg. 1996; 83 478-481
- 19 Nevin J E, Moran T J, Kay S, King R. Carcinoma of the gallbladder: staging, treatment, and prognosis. Cancer. 1976; 37 141-148
- 20 North J H, Pack M S, Hong C, Rivera D E. Prognostic factors for adenocarcinoma of the gallbladder: An analysis of 162 cases. Am Surg. 1998; 64 437-440
- 21 Ogura Y, Mizumoto R, Isaji S, Kusuda T, Matsuda S, Tabata M. Radical operations for carcinoma of the gallbladder: present status in Japan. World J Surg. 1991; 15 337-343
- 22 Onoyama H, Yamamoto M, Tseng A, Ajiki T, Saitoh Y. Extended cholecystectomy for carcinoma of the gallbladder. World J Surg. 1995; 19 758-763
- 23 Piehler J M, Crichlow R W. Primary carcinoma of the gallbladder. Surg Gynecol Obstet. 1978; 147 929-942
- 24 Rückert J C, Rückert R I, Gellert K, Hecker K, Müller J M. Surgery for carcinoma of the gallbladder. Hepato-Gastroenterology. 1996; 43 527-533
- 25 Shimada H, Endo I, Togo S, Nakano A, Izumi T, Nakagawara G. The role of lymph node dissection in the treatment of gallbladder carcinoma. Cancer. 1997; 79 892-899
- 26 Shirai Y, Yoshida K, Tsukada K, Muto T. Inapparent carcinoma of the gallbladder. An appraisal of a radical second operation after simple cholecystectomy. Ann Surg. 1992; 215 326-331
- 27 Taylor H W, Huang J K C. “Routine” pathological examination of the gallbladder is a futile exercise. Br J Surg. 1998; 85 208
- 28 Todoroki T, Kawamoto T, Takahashi H, Takada Y, Koike N, Otsuka M, Fukao K. Treatment of gallbladder cancer by radical resection. Br J Surg. 1999; 86 622-627
- 29 Tsukada K, Kurosaki I, Uchida K, Shirai Y, Oohashi Y, Yokoyama N, Watanabe H, Hatakeyama K. Lymph node spread from carcinoma of the gallbladder. Cancer. 1997; 80 661-667
- 30 Wanebo H J, Vezeridis M P. Carcinoma of the gallbladder. J Surg Oncol. 1993; Suppl 3 134-139
- 31 Yamaguchi K, Tsuneyoshi M. Subclinical gallbladder carcinoma. Am J Surg. 1992; 163 382-386
- 32 Yamaguchi K, Cijiiwa Kk, Ichimiya H, Sada M, Kawakami K, Nishikata F, Konomi K, Tanaka M. Gallbladder carcinoma in the era of laparoscopic cholecystectomy. Arch Surg. 1996; 131 981-984
- 33 Yamaguchi K, Chijiiwa K, Saiki S, Nishihara K, Takashima M, Kawakami K, Tanaka MM. Retrospective analysis of 70 operations for gallbladder carcinoma. Br J Surg. 1997; 84 200-204
- 34 Z'graggen K, Birrer S, Maurer C A, Wehrli H, Klaiber C, Baer H U. Incidence of port site recurrence after laparoscopic cholecystectomy for Preoperatively unsuspected gallbladder carcinoma. Surgery. 1998; 124 831-838
Dr. J. C. Rückert
Klinik für Allgemein-, Gefäß-, Thorax- und ViszeralchirurgieUniversitätsklinikum Charitéder Humboldt-Universität BerlinCampus Mitte
Schumannstraße 20/21
D-10117 Berlin
Telefon: Tel.: 0 30/28 02-50 70
Fax: Fax: 0 30/28 02-47 79
eMail: e-mail: jens-c.rueckert@charite.de