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基于风险分层比较胆囊疾病不同手术方式价值研究
刘红枝, 黄霆峰, 吴萌萌, 张丽娜, 陈振伟, 林科灿, 曾永毅
中国实用外科杂志 ›› 2025, Vol. 45 ›› Issue (11) : 1277-1282.
PDF(1615 KB)
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基于风险分层比较胆囊疾病不同手术方式价值研究
Value of different surgical strategies based on malignancy risk stratification in patients with gallbladder diseases
目的 探讨基于恶性风险分层的不同手术方式对胆囊疾病的价值。方法 回顾性分析2015年1月至2025年6月于福建医科大学孟超肝胆医院接受手术治疗的2888例胆囊疾病病人临床资料。根据手术方式分为：标准腹腔镜胆囊切除术组（胆囊切除组，n=1831）、腹腔镜胆囊切除联合术中冰冻组织病理学检查组（胆囊冰冻组，n=996）、中肝部分切除联合胆囊切除联合组织病理学检查（联合冰冻组，n=24）和胆囊癌根治术组（胆囊癌根治组，n=37）。比较各组病人临床特征、病理学检查结果、围手术期结局及长期生存情况。结果 胆囊切除组、胆囊冰冻组、联合冰冻组、胆囊癌根治组胆囊癌发生率分别为0.4%、1.4%、29.2%和81.1%；良性病变谱差异显著，联合冰冻组和胆囊癌根治组的良性病变主要为黄色肉芽肿性胆囊炎、胆囊良性肿瘤、胆囊炎等影像学鉴别诊断困难者。在鉴别诊断困难病例中，术中冰冻组织病理学检查诊断准确率显著高于术前影像学检查（97.3% vs. 75.5%，P<0.05）。各组胆囊癌病人在AJCC分期方面差异有统计学意义（P=0.011），胆囊切除组经术后病理诊断胆囊癌共7例，其中5例（71.4%）为0-Ⅱ期，胆囊癌根治组术前诊断胆囊癌而直接行根治术者仅16.7%为0-Ⅱ期。AJCC分期0-Ⅱ期术后1、3、5年生存率及无复发生存率优于Ⅲ-Ⅳ期病人，差异均有统计学意义（P<0.05）。但4组中位生存期及无复发生存期差异无统计学意义（P>0.05）。结论 胆囊疾病的外科治疗应基于恶性风险进行分层决策。对于影像学检查诊断困难或术中可疑的病例，术中冰冻组织病理学检查是区分良恶性、指导手术策略的关键工具。联合冰冻组织病理学检查兼顾有效性和安全性，可作为可疑胆囊癌病人的治疗策略。
Objective To evaluate the effectiveness of stratified surgical approaches for gallbladder diseases based on malignancy risk. Methods Retrospectively analyze the clinical data of 2888 patients who underwent surgery for gallbladder diseases at Mengchao Hepatobiliary Hospital of Fujian Medical University between January 2015 and June 2025. Patients were categorized into four groups: standard laparoscopic cholecystectomy (n=1831), laparoscopic cholecystectomy with intraoperative frozen section (IFS; n=996), middle hepatectomy plus cholecystectomy with IFS (n=24), and radical cholecystectomy (n=37). Clinical characteristics, pathology, perioperative outcomes, and long-term survival were compared. Results The incidence of gallbladder cancer (GBC) in the cholecystectomy group, the cholecystectomy with IFS group, the middle hepatectomy plus cholecystectomy with IFS group and the radical cholecystectomy group were 0.4%, 1.4%, 29.2%, and 81.1%, respectively. The spectrum of benign lesions exhibits significant differences. Benign lesions in the middle hepatectomy plus cholecystectomy with IFS group and the radical cholecystectomy group primarily included entities radiologically indistinguishable from malignancy, such as xanthogranulomatous cholecystitis and benign gallbladder tumors. In diagnostically challenging cases, IFS demonstrated higher accuracy than preoperative imaging (97.3% vs. 75.5%, P<0.05). AJCC staging distributions differed significantly among groups (P=0.011). In the cholecystectomy group, 7 incidental GBC cases were identified, 5 cases (71.4%) of which were Stage 0-Ⅱ, compared with only 16.7% in the radical cholecystectomy group. Patients with Stage 0-Ⅱ disease had superior 1, 3, and 5 year overall and disease-free survival compared with Stage Ⅲ-Ⅳ disease, with statistically significant differences (both P<0.05). However, median survival did not differ significantly among surgical approaches in GBC patients (P>0.05). Conclusion Surgical strategies for gallbladder diseases should be guided by malignancy risk stratification. In cases with indeterminate imaging or suspicious intraoperative findings, IFS is essential for distinguishing benign from malignant lesions and informing surgical escalation. Combining IFS offers a balanced approach, providing an effective and safe option for patients with suspected GBC.
胆囊良性疾病 / 胆囊癌 / 术中组织病理学检查 / 胆囊根治术 / 预后
benign gallbladder diseases / gallbladder cancer / intraoperative frozen biopsy / radical resection / prognosis
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Gallbladder cancer (GBC) is a highly lethal and often overlooked malignancy increasingly affecting young adults. This study quantified the global proportion of GBC cases attributable to 10 key modifiable risk factors, employing Monte Carlo simulations and estimates from field‐wide systematic review and meta‐analysis. Approximately three‐quarters of global GBC cases are attributable to key modifiable factors (74.6%; 95% uncertainty interval, 63.7–83.7), with a slightly higher share observed in females. Central obesity (29.7%; 8.7–49.5), gallstones (27.9%; 16.8–40.7), and physical inactivity (20.5%; 7.4–34.1) were identified as the leading contributors. Most GBC cases are preventable, with a large share linked to metabolic health conditions.
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中华医学会外科学分会胆道外科学组, 中国医师协会外科医师分会胆道外科专业委员会. 胆囊癌诊断和治疗指南(2019版)[J]. 中华外科杂志, 2020, 58(4):243-251. DOI:10.3760/cma.j.cn112139-20200106-00014.
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This study aimed to determine the incidence and the prognosis of incidental carcinoma of the gallbladder (IGBC) after cholecystectomy through a meta-analysis. This meta-analysis included 51 studies and 436,636 patients with cholecystectomy. The incidence rate of IGBC after cholecystectomy was 0.6% (95% confidence interval (CI) 0.5–0.8%). The incidence rate of recent studies was not significantly different from those of past studies. The mean age and female ratio of the IGBC subgroup were not significantly different from those of the overall patient group. The estimated rates of IGBC were 13.0%, 34.1%, 39.7%, 22.7%, and 12.5% in the pTis, pT1, pT2, pT3, and pT4 stages, respectively. Patients with IGBC had a favorable overall survival rate compared to patients with non-IGBC (hazard ratio (HR) 0.574, 95% CI 0.445–0.739). However, there was no significant difference of disease-free survival between the IGBC and non-IGBC subgroups (HR 0.931, 95% CI 0.618–1.402). IGBC was found in 0.6% of patients with cholecystectomy. The prognosis of patients with IGBC was favorable compared to those with non-IGBC. In the pathologic examination after cholecystectomy for benign diseases, a sufficient examination for histology should be guaranteed to detect IGBC.
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Gallbladder cancer is the most common malignancy of the biliary tract. When diagnosed in an advanced stage it has a very poor prognosis. Therefore, early diagnosis and thorough assessment of a suspicious gallbladder polyp is essential to improve survival rate. The aim of this systematic review is to assess the role of fine needle aspiration cytology (FNAC) in the management of gallbladder cancer. For that purpose, a systematic review was carried out in the MEDLINE, EMBASE, Cochrane, Scopus and Google Scholar databases between 1 July 2004 and 22 April 2021. Six studies with 283 patients in total were included. Pooled sensitivity and specificity of FNAC were 0.85 and 0.94, respectively, while the area under the calculated summary receiver operating characteristic (SROC curve (AUC) was 0.98. No complications were reported. Based on the high diagnostic performance of FNAC in the assessment of gallbladder masses, we suggest that every suspicious mass should be evaluated further with FNAC to facilitate the most appropriate management.
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The frequency of gallbladder cancer in Europe is less than 1% of all gallstone operations. With the introduction of laparoscopic surgery and the higher acceptance of this technique, patients with gallstones have gallbladder removal much earlier in their gallstone history. So the percentage of gallbladder carcinomas will decrease in the future. We report on our surgical procedures in patients with suspicious gallbladders having laparoscopic gallbladder removal, and how to proceed after the diagnosis of gallbladder carcinoma. From June 1990 to December 2001, we have performed 7,130 cholecystectomies in a single department. 47 of these patients (0.66%) were identified as having carcinoma. There were 40 females and 7 males, with a mean age of 70.6 years. In 17 cases (36%) there was a preoperative suspicion of malignancy. Most commonly, in 30 cases (64%), malignancy was suspected intraoperatively or diagnosed postoperatively after pathological examination of the resected gallbladder. We recommend removal with a bag for all gallbladders with a suspected wall or scleroatrophic calcified gallbladder area. In stage Tis or T1 laparoscopy + cholecystectomy is sufficient. For T2 and T3 we perform reoperation with liver bed resection and lymphadenectomy.
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Background/Objectives: Gallbladder cancer (GBC) is a lethal malignancy curable only by surgical resection in early stages (Tis, T1, T2). Significant controversy exists regarding the optimal extent of surgery. This review summarizes recent trends and evidence on surgical strategies for Tis, T1, and T2 GBC to guide practice and research. Methods: This narrative review synthesizes recent literature on surgical management of Tis, T1a, T1b, and T2 GBC based on American Joint Committee on Cancer (AJCC) 8th edition staging. It examines simple vs. extended cholecystectomy (simple cholecystectomy (SC) vs. extended/radical cholecystectomy (EC/RC)), the role of lymphadenectomy (LND) and hepatectomy, and minimally invasive surgery (MIS). Results: Simple cholecystectomy is curative for Tis/T1a GBC. For T1b, regional LND is essential for staging/potential benefit, especially examining ≥5–6 nodes. Tumor size is critical; SC alone may suffice for T1b < 1 cm (low lymph node metastasis (LNM) risk), while EC/RC with LND is indicated for ≥1 cm (higher LNM risk). Routine hepatectomy for T1b lacks survival support. For T2 GBC, mandatory regional LND (≥6 nodes) is required for both T2a and T2b substages due to high LNM rates; T2b has higher LNM than T2a. Routine hepatectomy for T2 is debated; evidence suggests no routine benefit for T2a beyond LND, with conflicting findings for T2b. R0 resection is paramount. MIS is feasible for early stages in experienced hands. Conclusions: Management of early GBC is moving towards risk stratification. SC is standard for Tis/T1a. Adequate regional LND is crucial for T1b (especially ≥1 cm) and mandatory for T2 GBC. Routine hepatectomy, particularly for T2b, remains controversial. Tailored surgery prioritizes R0 resection and comprehensive LND, necessitating further standardized research.
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Surgery remains the preferred treatment option for early-stage gallbladder cancer (GBC). According to the anatomical position of the primary tumor, accurate preoperative stage and strict control of surgical indications, appropriate surgical strategies are selected to achieve the optimal surgical effect. However, most patients have already been at the locally advanced stage or the tumor has metastasized at the initial diagnosis. The postoperative recurrence rate and 5-year survival rate remain unsatisfactory even after radical resection for gallbladder cancer. Hence, there is an urgent need for more treatment options, such as neoadjuvant therapy, postoperative adjuvant therapy and first-line and second-line treatments of local progression and metastasis, in the whole-course treatment management of gallbladder cancer patients. In recent years, the application of molecular targeted drugs and immunotherapy has brought greater hope and broader prospects for the treatment of gallbladder cancer, but their effects in improving the prognosis of patients still lack sufficient evidence-based medicine evidence, so many problems should be addressed by further research. Based on the latest progress in gallbladder cancer research, this review systematically analyzes the treatment trends of gallbladder cancer.
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The NCCN Guidelines for Biliary Tract Cancers (BTCs) provide recommendations for the evaluation and comprehensive care of patients with gallbladder cancer, intrahepatic cholangiocarcinoma, and extrahepatic cholangiocarcinoma. The multidisciplinary panel of experts is convened at least once annually to review requests from internal and external entities as well as to evaluate new data on current and emerging therapies. This manuscript focuses on the adjuvant chemotherapy and chemoradiation treatment options for BTCs as well as the systemic treatment recommendations for patients with advanced BTCs.
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Early gallbladder cancer (EGC), defined as T1 and T2 disease, is frequently curable when completely excised without bile spillage. The objective of the present study was to determine what effect initial laparoscopic cholecystectomy has on outcome in patients with EGC. Of 89 patients referred to our institution with gallbladder cancer over an 11-year period, 26 had undergone initial laparoscopic cholecystectomy. Sixteen of the 26 patients had T1 or T2 disease and are the subjects of this report. These patients were reviewed retrospectively to assess preoperative diagnosis, intraoperative bile spillage, and outcome (recurrence and survival). In addition, the Western literature was reviewed to determine the impact of initial laparoscopic cholecystectomy on recurrence and survival of patients with EGC. Six patients had a preoperative ultrasound consistent with a mass in the gallbladder wall. Seven (44%) had documented bile spillage during the laparoscopic cholecystectomy. T stage based on the laparoscopic cholecystectomy was T1 (n = 1) and T2 (n = 15). Twelve patients underwent reexploration of whom seven underwent further radical excision (gallbladder liver bed resection and extensive lymphadenectomy). After a mean follow-up of 20.1 months (range 4 to 39 months), 69% of patients have had a recurrence or died. Three patients had a port-site recurrence. Five (71%) of seven patients with bile spillage at laparoscopic cholecystectomy have had a recurrence or died of disease. A review of the Western literature on EGC initially removed by laparoscopic cholecystectomy (including the present series) yielded 21 patients with T1 and 42 patients with T2 disease. One-year Kaplan-Meier survival (T1 = 89%, T2 = 71%) and 3-year Kaplan-Meier survival (T1 = 47%, T2 = 40%) of these patients is worse than prior reports for open cholecystectomy. An initial laparoscopic cholecystectomy with its potential for bile spillage can convert potentially curable EGC to incurable disease. Patients with preoperative findings suspicious for gallbladder cancer should undergo open exploration with intent to perform a radical cancer operation as a primary procedure if the diagnosis is confirmed intraoperatively.
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Current meta-analysis was performed to systematically evaluate the potential prognostic factors for overall survival among resected cases with gallbladder carcinoma.
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Gallbladder cancer is a rare but potentially fatal disease. It is often asymptomatic in early stages and is frequently found incidentally or during the workup for benign biliary disease. We present two patients who each had suspicious gallbladder imaging findings and highlight their differences on radiologic and pathologic examination.
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Xanthogranulomatous cholecystitis (XGC) is an extremely rare entity. Due to XGC’s clinical and radiological resemblance to gallbladder carcinoma (GBC), intraoperative frozen section during cholecystectomy is often performed to exclude the diagnosis of GBC. Our study is aiming to find a noninvasive indicator of XGC. To our knowledge, this is the largest XGC cohort ever studied.
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段克才, 董志涛, 方鲲鹏, 等. 黄色肉芽肿性胆囊炎临床诊治策略研究(附110例回顾性分析)[J]. 中国实用外科杂志, 2024, 44(12):1407-1411. DOI: 10.19538/j.cjps.issn1005-2208.2024.12.18.
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The management of radiologically suspected gallbladder cancers (GBC) that lack definitive radiological features usually involves performing a first-stage routine laparoscopic cholecystectomy, followed by an open second-stage liver resection (segments IVB and V) and hilar lymphadenectomy (extended cholecystectomy) if subsequent formal histology confirms a malignancy. Performing a cholecystectomy with an intraoperative frozen section to guide the need for conversion to an extended cholecystectomy as a single-stage procedure has multiple benefits compared to a two-stage approach. However, the safety and efficacy of this approach have not yet been evaluated in a tertiary setting.A retrospective cohort study was performed using a database of all consecutive patients with suspected GBC who had been referred to our tertiary unit. Following routine cholecystectomy, depending on the operative findings, the gallbladder specimen was removed and sent for frozen-section analysis. If malignancy was confirmed, the depth of tumour invasion was evaluated, followed by simultaneous extended cholecystectomy, when appropriate. The sensitivity and specificity of frozen section analysis for the diagnosis of GBC were measured using formal histopathology as a reference standard.A total of 37 consecutive cholecystectomies were performed. In nine cases, GBC was confirmed by intraoperative frozen section analysis, three of which had standard cholecystectomy only as their frozen section showed adenocarcinoma to be T1a or below (n=2) or were undetermined (n=1). In the remaining six cases, malignant invasion beyond the muscularis propria (T1b or above) was confirmed; thus, a synchronous extended cholecystectomy was performed. The sensitivity (95% CI 66.4%-100%) and specificity (95% CI 87.7%-100%) for identifying GBC using frozen section analysis were both 100%. The net cost of the single-stage pathway in comparison to the two-stage pathway resulted in overall savings of £3894.Intraoperative frozen section analysis is a reliable tool for guiding the use of a safe, single-stage approach for the management of GBC in radiologically equivocal cases. In addition to its lower costs compared to a conventional two-stage procedure, intraoperative analysis also affords the benefit of a single hospital admission and single administration of general anaesthesia, thus greatly enhancing the patient's experience and relieving the burden on waiting lists.Copyright © 2024 The Author(s). Published by Wolters Kluwer Health, Inc.
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Up to 60% of incidentally detected gallbladder cancers (GBCs) have a primary stage of pathologic T2 stage (pT2), defined by invasion of the peri‐adventitial tissue by the tumour, a plane breached during a simple cholecystectomy. This study assesses the impact of incidental detection of pT2 GBCs on survival outcomes.
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徐畅, 胡明泰, 谢智华, 等. 腹腔镜胆囊切除术后“意外”胆囊癌行开放根治性切除术疗效分析[J]. 中国实用外科杂志, 2023, 43(4):405-410. DOI: 10.19538/j.cjps.issn1005-2208.2023.04.08.
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Incidental gallbladder cancer is a rare event, and its prognosis is largely affected by the tumour stage and treatment. The aim of this study was to analyse the management, treatment and survival of patients with incidental gallbladder cancer in a national cohort over a decade.Patients were identified through the Swedish Registry of Gallstone Surgery (GallRiks). Data were cross-linked to the national registry for liver surgery (SweLiv) and the Cancer Registry. Medical records were collected if registry data were missing. Survival was measured as disease-specific survival. The study was divided into two intervals (2007-2011 and 2012-2016) to evaluate changes over time.In total, 249 patients were identified with incidental gallbladder cancer, of whom 92 (36·9 per cent) underwent re-resection with curative intent. For patients with pT2 and pT3 disease, median disease-specific survival improved after re-resection (12·4 versus 44·1 months for pT2, and 9·7 versus 23·0 months for pT3). Residual disease was present in 53 per cent of patients with pT2 tumours who underwent re-resection; these patients had a median disease-specific survival of 32·2 months, whereas the median was not reached in patients without residual disease. Median survival increased by 11 months for all patients between the early and late periods (P = 0·030).Re-resection of pT2 and pT3 incidental gallbladder cancer was associated with improved survival, but survival was impaired when residual disease was present. A higher re-resection rate and more R0 resections in the later time period may have been associated with improved survival.© 2019 BJS Society Ltd. Published by John Wiley & Sons Ltd.
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王坚, 杨传鑫. 降低意外胆囊癌发生率的再认识[J]. 中国实用外科杂志, 2023, 43(11): 1248-1250. DOI:10.19538/j.cjps.issn1005-2208.2023.11.11.
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李起, 张小弟, 张东, 等. 意外胆囊癌新辅助化疗10例疗效分析[J]. 中国实用外科杂志, 2023, 43(8):906-910. DOI: 10.19538/j.cjps.issn1005-2208.2023.08.15.
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The optimal surgical management of patients with incidental gallbladder cancer (IGBC) and their long‐term survival remains unclear.
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| [30] |
The Japanese Society of Hepato-Biliary-Pancreatic Surgery launched the clinical practice guidelines for the management of biliary tract cancers (cholangiocarcinoma, gallbladder cancer, and ampullary cancer) in 2007, then published the 2nd version in 2014.In this 3rd version, clinical questions (CQs) were proposed on six topics. The recommendation, grade for recommendation, and statement for each CQ were discussed and finalized by an evidence-based approach. Recommendations were graded as Grade 1 (strong) or Grade 2 (weak) according to the concepts of the Grading of Recommendations Assessment, Development, and Evaluation (GRADE) system.The 31 CQs covered the six topics: (a) prophylactic treatment, (b) diagnosis, (c) biliary drainage, (d) surgical treatment, (e) chemotherapy, and (f) radiation therapy. In the 31 CQs, 14 recommendations were rated strong and 14 recommendations weak. The remaining three CQs had no recommendation. Each CQ includes a statement of how the recommendations were graded.This latest guideline provides recommendations for important clinical aspects based on evidence. Future collaboration with the cancer registry will be key for assessing the guidelines and establishing new evidence.© 2020 Japanese Society of Hepato-Biliary-Pancreatic Surgery.
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Gallbladder cancer (GBC) frequently mimics gallbladder benign lesions (GBBLs) in radiological images, leading to preoperative misdiagnoses. To address this challenge, we initiated a prospective, multicenter clinical trial (ChicCTR2100049249) and proposed a multimodal, non-invasive diagnostic model to distinguish GBC from GBBLs. A total of 301 patients diagnosed with gallbladder-occupying lesions (GBOLs) from 11 medical centers across 7 provinces in China were enrolled and divided into a discovery cohort and an independent external validation cohort. An artificial intelligence (AI)-based integrated model, GBCseeker, is created using cell-free DNA (cfDNA) genetic signatures, radiomic features, and clinical information. It achieves high accuracy in distinguishing GBC from GBBL patients (93.33% in the discovery cohort and 87.76% in the external validation cohort), reduces surgeons' diagnostic errors by 56.24%, and reclassifies GBOL patients into three categories to guide surgical options. Overall, our study establishes a tool for the preoperative diagnosis of GBC, facilitating surgical decision-making.Copyright © 2025 Elsevier Inc. All rights reserved.
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