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中华肝脏外科手术学电子杂志 doi: 10.3877/cma.j.issn.2095-3232.2024994

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规范化胆囊良性疾病诊治流程减少胆囊癌误诊误治
周迪1, 全志伟2,()   
  1. 1. 200072 上海,同济大学附属第十人民医院(上海市第十人民医院)肝胆胰外科
    2. 200092 上海交通大学医学院附属新华医院普通外科
  • 收稿日期:2024-06-15
  • 通信作者: 全志伟

Standardization on diagnosis and treatment process of benign gallbladder diseases to reduce misdiagnosis and inappropriate treatment

Di Zhou1, Zhiwei Quan2,()   

  1. 1. Department of Hepatobiliary and Pancreatic Surgery, Tenth People's Hospital of Tongji University (Shanghai Tenth People's Hospital), Shanghai 200072, China
    2. Department of General Surgery, Xinhua Hospital Affiliated to Shanghai Jiao Tong University School of Medicine, Shanghai 200092, China
  • Received:2024-06-15
  • Corresponding author: Zhiwei Quan
引用本文:

周迪, 全志伟. 规范化胆囊良性疾病诊治流程减少胆囊癌误诊误治[J]. 中华肝脏外科手术学电子杂志, doi: 10.3877/cma.j.issn.2095-3232.2024994.

Di Zhou, Zhiwei Quan. Standardization on diagnosis and treatment process of benign gallbladder diseases to reduce misdiagnosis and inappropriate treatment[J]. Chinese Journal of Hepatic Surgery(Electronic Edition), doi: 10.3877/cma.j.issn.2095-3232.2024994.

胆囊良性疾病是我国地域分布最广、患者群最多的良性疾病之一。病理学上,胆囊良性疾病主要分为胆囊腔内病变以及弥漫性或局限性胆囊壁增厚两大类型。除胆固醇息肉外,大多数胆囊良性疾病都有恶变的可能。术前进行科学评估,术中选择合适的手术入路,术后正确处理胆囊标本,建立规范化的胆囊良性疾病诊治流程可有效减少胆囊癌误诊误治。

Benign gallbladder disease is one of the most widely distributed diseases in China with the largest number of patients. Benign gallbladder diseases can be pathologically divided into intra-gallbladder lesions and diffuse or localized thickening of gallbladder wall. Except for cholesterol polyps, most benign gallbladder diseases have the risk of malignant transformation. Scientific preoperative evaluation, intraoperative selection of appropriate surgical approaches, proper postoperative management of gallbladder samples and establishment of standardized diagnosis and treatment process for benign gallbladder diseases can effectively reduce misdiagnosis and inappropriate treatment of gallbladder cancer.

表1 各常见胆囊良性疾病中合并IGBC的发生率[1]
表2 胆囊良性疾病的超声检查诊断项目及其影像学表现[4]
项目 超声表现
胆囊 大小 长径、短径的测量;超声Murphy征1
  胆汁 正常表现:无回声或透声良好
    炎性或脓性胆汁1:集点状/斑点状/絮状回声/团块状/乳头状/长条状沉积物回声
    产气菌感染1:出现气体回声,可伴有彗星尾征
胆囊壁 厚度* 正常:2~3 mm;异常:>4 mm为增厚
  回声 均匀的单层清晰回声/不规则多层低回声1/出现Doppler信号1/胆囊壁透声层1/壁内条纹状透声层1
  连续性 均匀性增厚,胆囊壁各层结构清晰完整/不均匀增厚、连续性破坏/胆囊壁缺损2
腔内病变 结石 回声特点、大小、数目、部位(是否颈部、壶腹部嵌顿)
  胆固醇息肉 向腔内突出的乳头状或桑葚状结节/强回声或中等回声/多数不超过1.0 cm/多带蒂/不随体位改变而移动
  胆囊腺肌症 对称性壁增厚、壁内囊性间隙(Aschoff窦)、壁内回声灶、各种反射伪影(彗星尾、V形、环形下降、闪烁伪影)
  瓷化胆囊 半月形高回声结构伴后方声影/双凸曲线样回声伴声影/不规则团块状回声伴声影
  黄色肉芽肿胆囊炎 胆囊壁内低回声结节或低回声带/非局灶性增厚/壁轮廓光滑/壁结节/黏膜连续性完整
  IgG4相关硬化性胆囊炎 胆囊壁各层均显著增厚
  腺瘤 中等强度回声/后方不伴声影/不随体位变化/可能有血流信号
  可疑癌变 低回声层增厚/壁不规则、增厚、不规则和破裂/最外层高回声层局灶性增厚,内壁和(或)外壁不连续
胆囊管-肝总管汇合部 有无结石嵌顿/肿瘤
胆囊周边区域 渗出或穿孔:液性回声/气体回声
肝内外胆管 是否扩张/有无高回声/结石影
表3 胆囊壁不均匀增厚的慢性胆囊炎和胆囊癌的影像学鉴别要点[4,16,17]
图1 胆囊壁的解剖层次示意图注:1为肝脏Laénnec膜,2为胆囊板,3为胆囊浆膜下层的内层,4为胆囊浆膜下层的外层,5为胆囊浆膜层,6为胆囊动脉深支,7为胆囊动脉浅支,*示胆囊淋巴结
[1]
石原慎, 城口明彦, 宫川秀二, 他. 進展度に応じた胆囊癌の治療戦略 胆道癌全国登録データより見た胆囊癌の動向[J]. 胆と膵, 2015, 1(36):15-18.
[2]
Kellil T, Chaouch MA, Aloui E, et al. Incidence and preoperative predictor factors of gallbladder cancer before laparoscopic cholecystectomy: a systematic review[J]. J Gastrointest Cancer, 2021, 52(1):68-72.
[3]
Lam CM, Yuen AW, Wai AC, et al. Gallbladder cancer presenting with acute cholecystitis: a population-based study[J]. Surg Endosc, 2005, 19(5):697-701.
[4]
Miyoshi H, Inui K, Katano Y, et al. B-mode ultrasonographic diagnosis in gallbladder wall thickening[J]. J Med Ultrason, 2021, 48(2):175-186.
[5]
Gallahan WC, Conway JD. Diagnosis and management of gallbladder polyps[J]. Gastroenterol Clin North Am, 2010, 39(2):359-367, x.
[6]
Fujiwara K, Abe A, Masatsugu T, et al. Effect of gallbladder polyp size on the prediction and detection of gallbladder cancer[J]. Surg Endosc, 2021, 35(9):5179-5185.
[7]
Kim JH, Lee JY, Baek JH, et al. High-resolution sonography for distinguishing neoplastic gallbladder polyps and staging gallbladder cancer[J]. AJR Am J Roentgenol, 2015, 204(2):W150-159.
[8]
Choi TW, Kim JH, Park SJ, et al. Risk stratification of gallbladder polyps larger than 10 mm using high-resolution ultrasonography and texture analysis[J]. Eur Radiol, 2018, 28(1):196-205.
[9]
Xie XH, Xu HX, Xie XY, et al. Differential diagnosis between benign and malignant gallbladder diseases with real-time contrast-enhanced ultrasound[J]. Eur Radiol, 2010, 20(1):239-248.
[10]
Kanthan R, Senger JL, Ahmed S, et al. Gallbladder cancer in the 21st century[J]. J Oncol, 2015, 2015:967472.
[11]
Kim SW, Kim HC, Yang DM, et al. Gallbladder carcinoma: causes of misdiagnosis at CT[J]. Clin Radiol, 2016, 71(1):e96-109.
[12]
Yu MH, Kim YJ, Park HS, et al. Benign gallbladder diseases: imaging techniques and tips for differentiating with malignant gallbladder diseases[J]. World J Gastroenterol, 2020, 26(22):2967-2986.
[13]
Runner GJ, Corwin MT, Siewert B, et al. Gallbladder wall thickening[J]. AJR Am J Roentgenol, 2014, 202(1):W1-12.
[14]
Levy AD, Murakata LA, Abbott RM, et al. From the archives of the AFIP. Benign tumors and tumorlike lesions of the gallbladder and extrahepatic bile ducts: radiologic-pathologic correlation. Armed Forces Institute of Pathology[J]. Radiographics, 2002, 22(2):387-413.
[15]
Ghersin E, Soudack M, Gaitini D. Twinkling artifact in gallbladder adenomyomatosis[J]. J Ultrasound Med, 2003, 22(2):229-231.
[16]
Kim SJ, Lee JM, Lee JY, et al. Analysis of enhancement pattern of flat gallbladder wall thickening on MDCT to differentiate gallbladder cancer from cholecystitis[J]. AJR Am J Roentgenol, 2008, 191(3):765-771.
[17]
Catalano OA, Sahani DV, Kalva SP, et al. MR imaging of the gallbladder: a pictorial essay[J]. Radiographics, 2008, 28(1):135-155.
[18]
Chun KA, Ha HK, Yu ES, et al. Xanthogranulomatous cholecystitis: CT features with emphasis on differentiation from gallbladder carcinoma[J]. Radiology, 1997, 203(1):93-97.
[19]
Zhao F, Lu PX, Yan SX, et al. CT and MR features of xanthogranulomatous cholecystitis: an analysis of consecutive49 cases[J]. Eur J Radiol, 2013, 82(9):1391-1397.
[20]
Clemente G, Nuzzo G, de Rose AM, et al. Unexpected gallbladder cancer after laparoscopic cholecystectomy for acute cholecystitis: a worrisome picture[J]. J Gastrointest Surg, 2012, 16(8):1462-1468.
[21]
Lee JS, Kim JH, Kim YJ, et al. Diagnostic accuracy of transabdominal high-resolution US for staging gallbladder cancer and differential diagnosis of neoplastic polyps compared with EUS[J]. Eur Radiol, 2017, 27(7):3097-3103.
[22]
Morine Y, Shimada M, Imura S, et al. Detection of lymph nodes metastasis in biliary carcinomas: morphological criteria by MDCT and the clinical impact of DWI-MRI[J]. Hepatogastroenterology, 2015, 62(140):777-781.
[23]
陈晶云, 丁国平, 梁霄, 等. 腹腔镜胆囊癌根治术的临床疗效分析[J]. 中华普通外科杂志, 2022, 37(05): 339-343.
[24]
吴昕, 谢天歌, 李秉璐, 等. 腹腔镜手术治疗胆囊癌的安全性和效果分析[J]. 中华外科杂志, 2023, 61(4):330-335.
[25]
周迪, 全志伟. "意外胆囊癌"更名与重视胆囊良性疾病的规范化诊治[J]. 肝胆胰外科杂志, 2020, 32(11):641-645.
[26]
全志伟, 周迪. 胆囊疾病规范化诊断与治疗流程及其技术细节[J]. 中华消化外科杂志, 2021, 20(8):846-849.
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