±¯½‚ „·‚...

download ±¯½‚ „·‚ §»·´Œ‡… ƒ„µ‰‚: §µ¹…³¹® ‘½„¹¼µ„€¹ƒ·

If you can't read please download the document

Embed Size (px)

description

Καρκίνος της Χοληδόχου Κύστεως: Χειρουργική Αντιμετώπιση - Δημήτρης Π. Κορκολής

Transcript of ±¯½‚ „·‚...

  • 1. : . ....

2. . . 22 : . . . . , trocars, < 6 - : R0 3. . . 33 , RCTs Level of Evidence??? T 4. . . 44 1950: wedge Glenn 1954: Glenns Park 1955: Takasaki 1980: en bloc Whipple Shirai 1982: Glenns 5. . . 55 50% 1 : 2 : 12 - 3 : Shirai Y, et al. Br J Surg 1992 Tsukada K, et al. Cancer 1997 6. . . 66 7. . . 77 8. . . 88 : pT1: 0-4% pT2: 20-62% pT3/T4: 60-81% : : 41.5% : 36.6% - : 20.0% - -: 20-25% ( ) Sikora SS, et al. J Surg Oncol 2006 9. . . 99 Western vs Japanese Results 0 5 : 81% 1 0% Bartlett DL, et al. Ann Surg 1996 0: 5 : 43% + 0% Benoist S, et al. Am J Surg 1998 3 N: N1 / 2 50%-60% N3 0% Kaneoka Y, et al. World J Surg 2003 5 1 : 30-31% Yamaguchi K, et al. Br J Surg 1997 10. . . 1010 status 12 Makuuchi M, et al. Arch Surg 2003 11. . . 1111 Portal Lymph Node Dissection (Western style) . Glenn . 12 GDA Dixon E, et al. Ann Surg 2005 Extended Portal Lymph Node Dissection (Japanese style) 12, , Shimada H, et al. Cancer 1997 ( ) 12 (Japanese style) Whipple (mortality 10-15%, morbidity 50%) Sasaki R, et al. Hepatogastroenterology 2002 12. . . 1212 Portal Lymph Node Dissection (Western style) 13. . . 1313 Extended Portal Lymph Node Dissection (Japanese style) 14. . . 1414 15. . . 1515 - IVb V . . GBC : . 54% . 28% . 28% 2 . 20% IVb V wedge resection Bartlett DL. Surgery of the Liver and Biliary Tract 2008 16. . . 1616 17. . . 1717 2mm 6mm 20mm , Hartmanns , / (12, , , ) Fong Y, et al. Ann Surg 1996 Nimura Y, et al. World J Surg 2003 18. . . 1818 19. . . 1919 20. . . 2020 - IVB - V 21. . . 2121 - IVB - V 22. . . 2222 - IVB - V 23. . . 2323 Type I: () Type II: Type III: Type IV: 12 Bile duct involvement 3-year survival: 6% Non-involvement 3-year survival: 64% 55% T3/T4 GBC Shimizu Y, et al. Surgery 2004 24. . . 2424 25. . . 2525 VIb V, , Roux-en-Y 26. . . 2626 : 1. 2. - Hartmanns pouch 3. 4. (25%) 5. 12 6. 7. 3 4 Taner CB, et al. J Gastrointest Surg 2007 Vollmer CM, et al. Ann Surg 2005 27. . . 2727 15% - 47% GBC: a. CT b. MRI c. PET 2/3 3 80% 4 LUS Lap Biopsy 55-65% >30% GBC Strasberg SM, et al. Ann Surg 2002 28. . . 2828 - - 3 , Jarnagin WR, et al. Seminars in Liver Disease 2004 Weber SM, et al. Ann Surg 2002 29. . . 2929 R0 , R0 : 1. - 2. 48 GBC : 5 : 13% R0 5 : 31% Ito H, et al. J Gastrointest Surg 2004 1990-1995: R0 7% 1995-2000: R0 CBD 35% Dixon E, et al. Ann Surg 2005 30. . . 3030 Duffy A, et al. Gallbladder Cancer (GBC): 10-Year Experience at Memorial Sloan-Kettering Cancer Centre (MSKCC) J Surg Oncol 2008 31. . . 3131 Surgery of the Liver, Biliary Tract and Pancreas L. H. Blumgart, 2006 32. . . 3232 Tis T1a : 5 : 85%-100% T1a: 2.5% A 25 1a GBC: : 13 pts : 12 pts 5 (p=0.9) 0/147 Wakai T, at al. Br J Surg 2001 : . . . . Suzuki S, et al. World J Surg 2004 33. . . 3333 StudyStudy YearYear No. ofNo. of casescases ProcedureProcedure 3-Y survival3-Y survival (%)(%) 5-Y survival5-Y survival (%)(%) OuchiOuchi 19871987 1414 Not specifiedNot specified 7878 71.471.4 YamaguchiYamaguchi 19881988 1111 Not specifiedNot specified 100100 NRNR DonohueDonohue 19901990 66 83% simple83% simple cholecystectomycholecystectomy 100100 100100 GallGall 19911991 77 SimpleSimple cholecystectomycholecystectomy 8686 8686 OguraOgura 19911991 366366 Not specifiedNot specified 8787 7878 YamaguchiYamaguchi 19921992 66 SimpleSimple cholecystectomycholecystectomy 100100 100100 ShiraiShirai 19921992 5656 SimpleSimple cholecystectomycholecystectomy 100100 100100 3838 ExtendedExtended cholecystectomycholecystectomy 100100 100100 MatsumotoMatsumoto 19921992 44 ExtendedExtended cholecystectomycholecystectomy 100100 100100 OertliOertli 19931993 66 SimpleSimple cholecystectomycholecystectomy 100100 100100 De AretxabalaDe Aretxabala 19971997 3232 69% simple69% simple cholecystectomycholecystectomy 9494 9494 Survival after resection of Stage I carcinoma of gallbladder 34. . . 3434 T1b H 11 pts T1b: - Shirai Y, et al. Eur J Surg 1992 25 pts T1b: 10 87% Wakai T, at al. Br J Surg 2001 35. . . 3535 T1b 1b: 15%-28% : 13%-15.6% De Aretxabala XA et al. Cancer 1992 30% - 60% 1b 10% Ouchi K, et al. Surgery 1987 Matsumoto Y, et al. Am J Surg 1992 5 < 65% 1b Wagholikar GD, et al. J Am Coll Surg 2002 n bloc wedge resection >2cm 12 Dixon E, et al. Ann Surg 2005 36. . . 3636 Portal Lymph Node Dissection (Western style) Glenns 37. . . 3737 T2 : OC LC 2 40-50%: 30-50%: Tsukada K, et al. Ccancer 1997 : 5 : 40% : 90% Shirai Y, et al. Ann Surg 1992 38. . . 3838 StudyStudy YearYear No. ofNo. of casescases ProcedureProcedure 3-Y survival (%)3-Y survival (%) 5-Y survival (%)5-Y survival (%) ShiraiShirai 19921992 3535 Simple cholecystectomySimple cholecystectomy 5757 40.540.5 1010 extendedextended cholecystectomycholecystectomy 9090 9090 YamaguchiYamaguchi 19921992 2525 Simple cholecystectomySimple cholecystectomy 3636 3636 MatasumotoMatasumoto 19921992 99 extendedextended cholecystectomycholecystectomy 100100 100100 OerttliOerttli 19931993 1313 simple cholecystectomysimple cholecystectomy 2929 2424 BartlettBartlett 19961996 88 extendedextended cholecystectomycholecystectomy 100100 8888 PaquetPaquet 19981998 55 extendedextended cholecystectomycholecystectomy 100100 8080 De AretxabalaDe Aretxabala 19971997 1818 Simple cholecystectomySimple cholecystectomy NRNR 2020 2020 extendedextended cholecystectomycholecystectomy NRNR 7070 FongFong 20002000 3737 extendedextended cholecystectomycholecystectomy 6868 5959 Survival after Resection of Stage II (T2) Gallbladder Cancers 39. . . 3939 T2 To : 2.5 Muratore A, et al. J Surg Oncol 2003 1 OC LC Toyonaga T, et al. World J Surg 2003 2 Suzuki S, et al. World J Surg 2004 LC port sites 1cm. K 17% 6 (2-2.5) Lundberg O, et al. J Hepatobiliary Pancreat Surg 2001 40. . . 4040 T2 n bloc IVb V , -, 12 , , , Donohue GH, et al. J Gastrointest Surg 2007 41. . . 4141 Extended Cholecystectomy (Japanese style) Modified Glenns Operation 42. . . 4242 3 4 Y : >70% : >60% : >40% R0 : 20mm: : 35% GBC / Misra S, et al. Lancet Oncol 2003 46. . . 4646 3 4 GBC : IVb-V GBC -Hartmanns: GBC Calot: en bloc Roux en-Y Taj Mahal (S4b+S5+S1) GBC : + Whipple, , ports Donohue GH, et al. J Gastrointest Surg 2007 47. . . 4747 HepaticoPancreaticoduodenectomy with Portal VeinHepaticoPancreaticoduodenectomy with Portal Vein Reconstruction for Carcinoma of the GallbladderReconstruction for Carcinoma of the Gallbladder 48. . . 4848 3 4 : III IV M 1686 GBCs in Japan: % % 12.8 2.9 21.9 2.3 48.3 18 12 54 15.3 Ogura Y, et al. World J Surg 1991 Onoyama H, et al. World J Surg 1995 Hemming AW, et al. J Gastrointest Surg 2007 49. . . 4949 EE 50. . . 5050 EE 51. . . 5151 EE 52. . . 5252 53. . . 5353 54. . . 5454 55. . . 5555 56. . . 5656 57. . . 5757 58. . . 5858 R0 is T1a 1b -T2 12 T3 T4