胆囊息肉样病变手术指征再思考——388例胆囊切除术回顾性研究

Rediscussion of surgical indications for gallbladder polypoid lesions:a retrospective study of 388 cases of cholecystectomy

目的探讨胆囊息肉样病变(PLG)手术指征。方法回顾性分析2008年1月至2018年12月在中山大学附属第三医院行胆囊切除术的388例PLG患者临床资料。患者均签署知情同意书,符合医学伦理学规定。其中男212例,女176例;年龄18~80岁,中位年龄41岁。采用ROC曲线确定良恶性病变的最佳预测界值,Logistic回归分析确定PLG恶变的危险因素,绘制Nomogram图预测良性病变发生概率。结果 ROC曲线显示,术前彩超提示直径12.0 mm为良性PLG诊断的最佳界值,14.5 mm为恶性PLG诊断的最佳界值。Logistic回归多因素分析显示,术前彩超提示直径<12 mm、数目多发、无血流、不合并胆囊结石是良性PLG的独立影响因素(OR=2.341,2.179,2.159,2.195;P<0.05);术前彩超提示直径≥12 mm和血胆固醇异常是恶性PLG的独立影响因素(OR=9.642,2.601;P<0.05)。绘制诊断良性PLG的临床因素Nomogram图,结果显示PLG直径权重最大,直径<12 mm良性病变可能性大。结论胆囊息肉直径≥12 mm 可能是胆囊息肉患者胆囊切除的最佳指征,其可以在保证恶变漏诊率较低的同时避免不必要的胆囊切除,为患者和社会节约医疗资源。

Objective To investigate the surgical indications for polypoid lesions of the gallbladder(PLG).Methods Clinical data of 388 patients with PLG undergoing cholecystectomy in the Third Affiliated Hospital of Sun Yat-sen University from January 2008 to December 2018 were retrospectively analyzed.The informed consents of all patients were obtained and the local ethical committee approval was received.Among them,212 patients were male and 176 female,aged from 18 to 80 years,with a median age of 41 years.The optimal threshold value for the diagnosis of benign or malignant lesions was determined by ROC curve.The risk factors for PLG malignancy were identified by Logistic regression analysis.Nomogram was delineated to predict the probability of benign lesions.Results The ROC curve showed that a diameter 12.0 mm was the optimal threshold value for the diagnosis of benign PLG and 14.5 mm for the diagnosis of malignant PLG.Logistic multivariate regression analysis revealed that,a diameter<12 mm,multiple lesions,no blood flow and no gallstones detected by preoperative color Doppler ultrasound were the independent influencing factors for benign PLG(OR=2.341,2.179,2.159,2.195;P<0.05).Preoperative color Doppler ultrasound indicated that a diameter≥12 mm and abnormal blood cholesterol were the independent influencing factors for malignant PLG(OR=9.642,2.601;P<0.05).The Nomogram of clinical factors for the diagnosis of benign PLG was delineated.The results showed that PLG diameter occupied the greatest weight,anda diameter<12 mm predicted the possibility of benign lesions.Conclusions The diameter≥12 mm may be the optimal surgical indication for cholecystectomy in patients with PLG,which can avoid unnecessary cholecystectomy while ensuring a low misdiagnosis rate of malignant PLG and minimize medical expenses for the patients and society.