Management Strategy for Gallbladder Polypoid Lesions: Results of a 5-Year Single-Center Cohort Study

Abstract

Introduction: Controversy remains about the classification, differential diagnosis, and treatment strategy for gallbladder polypoid lesions (GPLs). This study sought to explore the individualized treatment strategy for GPLs. Methods: We retrospectively studied 642 consecutive patients with GPLs from January 2015 to May 2020. Univariate and multivariable analyses were performed to explore the potential risk factors for neoplastic polyps. The outcome of laparoscopic gallbladder-preserving polypectomy (GPP) was evaluated and compared with that of laparoscopic cholecystectomy (LC). Results: Of 642 enrolled patients, 572 underwent LC, and 70 underwent GPP. Pathologically, the majority of GPLs were cholesterol polyps (68.4%), followed by adenomyomatosis (19.9%), benign adenoma (7.3%), adenocarcinoma (3.6%), and rare pathological types (0.8%). Additionally, 66.3% (379/572) of the LC cases were classified as non-neoplastic, and 33.7% (193/572) neoplastic polyps. Multivariate analysis demonstrated that single polyps (OR 1.956, 95% CI 1.121–3.412; p=0.018), polyps located at the gallbladder fundus (OR 4.326, 95% CI 2.179–8.591; p<0.001), polyps not less than 14 mm (OR 2.833, 95% CI 1.614–4.973; p<0.001), and polyps with a broad base (OR 4.173, 95% CI 1.743–9.990; p=0.001) were independent risk factors for neoplastic polyps. The 5-year prospective results after GPP showed that the 1-year and 3-year polyp recurrence rates were 13.2% and 23.4%, respectively. Conclusion: The majority of GPLs are cholesterol or other benign lesions without malignant potential. LC is the main treatment procedure for GPLs with a high neoplastic risk. GPP is potentially feasible and could be an alternative management strategy for a group of GPLs patients who meet the selection criteria.

Advances in the management of gallbladder polyps: establishment of predictive models and the rise of gallbladder-preserving polypectomy procedures

“…After a 3-year follow-up period, three of the patients (3.84%) with gallbladder preservation were found to have recurring polyps, and two (2.56%) developed cholesterol crystal. As well, by analyzing the results of a five-year single-center cohort study, Tian et al suggest that Endolap polypectomy could be an alternative management strategy for a group of patients who meet the selection criteria [ 29 ].…”

Contemporary diagnosis and management of gallbladder polyps

“…Gallbladder (GB) polyps are present in 5%-10% of the general population with different geographical distributions, and they exhibit benign behaviours in most cases and are usually asymptomatic. Thus, they are diagnosed incidentally and consist of true neoplastic polyps (adenomas) and no neoplastic pseudopolyps, i.e., predominantly cholesterol polyps, which consist of up to 90% of cases, inflammatory polyps, hyperplastic polyps, and focal adenomyomatosis [1][2][3][4][5] as shown in Figure 1.…”

“…[11] The latter may occur in 5% of cases when the polyp size is equal to or more than 1 cm and up to 40% when it is 2 cm or more. [4,8,10,12] It is well known how imperative an early diagnosis of GB adenocarcinoma is to optimize any treatment chance [1] or cost effectiveness. [13] However, there is still disagreement regarding whether cholecystectomy is always necessary to achieve the above goal or whether it may be an overtreatment in some cases.…”

“…[14,15,17,18] Otherwise, polyps less than 1 cm in size in younger patients without genetic predisposition require ultrasound (US) follow-up. [4,10,11,19,20] However, others postulated limited benefits of US surveillance. [21] Additionally, the US is not recommended for polyp sizes less than 5 mm but without risk factors.…”

The New Perspectives Journal of Medicine

“…www.npjmjournal.com (75) (25) 。 另外，美国超声放射科医师协会建议对大小≥15mm的 息肉进行手术咨询，对于10-14mm的息肉，可以根据患者 因素或随访影像的增长证据来决定是否需要手术咨询 (66) 。 如果对息肉进行随访，最多3年足以识别绝大多数息肉相 关恶性肿瘤。 7. 手术基本原则 与开放式胆囊切除术相比，腹腔镜下胆囊切除术 (laparoscopic cholecystectomy, LC)具有术后并发症更 少、疼痛轻、失血量少、住院时间短、恢复快的优点， 现已成为胆囊良性疾病治疗的金标准 (67) 。胆囊标本取出 后应行全面检查(包括胆囊管)，同时根据术中病理学 检查结果决定后续处理方案 (65) 。针对胆固醇性GP、炎性 GP等良性病变，腹腔镜下保胆取息肉手术(laparoscopic gallbladder-preserving polypectomy, LGPP)可以保留胆囊 功能以及减少部分LC术后并发症，但是术后复发率较 高。Tian等前瞻性观察LGPP术后患者，结果显示1年和3 年息肉复发率分别为13.2%和23.4% (68) 。另外，并不推荐 对胆囊腺瘤性息肉行LGPP，因其无法去除息肉的蒂部以 避免息肉复发，而且，如果使含有肿瘤细胞的胆汁外溢至 腹腔，极易导致肿瘤腹腔种植转移 (69) 。LC治疗肿瘤性GP 是可行的，但如果外科医生认为术中胆囊穿孔的风险很 高，应转为剖腹手术，以避免潜在的腹腔内肿瘤播散 (70) 。 如果病理提示原位癌或侵及固有层(Tis期和T1a 期)，只要术中胆囊完整切除，无破溃，无胆汁溢出，且 胆囊置入标本袋内完整取出，单纯胆囊切除术已达根治目 的；如果侵及肌层或更多时(≥T1b期)需行根治性手术 (71,72) 。由于存在腹腔内播散和穿刺孔转移的风险，在LC后 再行GC根治术时，建议切除所有穿刺孔、肝脏Ⅳb段和Ⅴ 段，并进行完整的淋巴结切除术 (73,74)…”