How should polypoid lesions of the gallbladder be treated in the era of laparoscopic cholecystectomy?

Case report: Hypoechoic area as an ultrasound finding suggesting subserosal invasion in polypoid carcinoma of the gall bladder

Ultrasound studies have demonstrated the gall bladder wall to consist of two or more (usually three) layers. Gall bladder tumours with neither a thinned nor split outermost hyperechoic layer are confined to the mucosa or muscle layer, or have only invaded the shallow subserosa. Differentiation of these two types of tumour has posed difficulties. We report a case of polypoid gall bladder carcinoma invading the shallow subserosa with a thickened outermost hyperechoic layer but a hypoechoic area in the deeper part of the tumour. Ultrasound and pathological correlation in this case demonstrated that the hypoechoic area represented an adenocarcinoma invading the subserosa accompanied by abundant fibrosis.

Surveillance of pre-malignant disease of the pancreatico-biliary system

Technical advancements in ultrasonography, contrast-enhanced computed tomography and magnetic resonance imaging, as well as the wider availability of these ultramodern imaging techniques, have resulted in the early detection and a better classification of various asymptomatic and symptomatic pancreatico-biliary lesions. Pre-malignant biliary and pancreatic lesions are rare disorders, and no clear data are available to define their malignant potential. Because of the lack of controlled epidemiological data, the time span for malignant transformation and its frequency cannot be defined in the majority of these lesions. Adenomyomatosis of the gallbladder and gallbladder polyps larger than 10 mm should be treated by cholecystectomy even in asymptomatic patients because of an increased risk of malignant transformation. Chronic cholangitis, primary sclerosing cholangitis and choledochal cysts are also pre-malignant conditions. The timing of surgery, once it is advised for a pre-malignant condition that is still benign, should, however, be individualized to the particular patient situation. In patients with chronic pancreatitis, surgery may be indicated for disease-related complications. In as much as chronic pancreatitis predisposes to a higher risk of pancreatic cancer, any suspicion of malignancy should warrant a surgical exploration. Intraductal papillary tumours and mucin-producing pancreatic tumours are other pre-malignant pancreatic lesions whose malignant potential cannot be precisely determined pre-operatively. They should be resected in situations where there is a high degree of suspicion even without a clear objective diagnosis. In conclusion, pre-malignant hepato-biliary and pancreatic lesions of uncertain pathology should undergo early resection in view of treatment limitations and the dismal prognosis of established cancers. While hepato-biliary and pancreatic surgery is nowadays performed in specialized centres, with a low post-operative morbidity and mortality, it is equally important to understand that observation alone with regular computed tomography or magnetic resonance imaging control can no longer be recommended in the management of these lesions.

Differential diagnosis of polypoid lesions of the gallbladder by endoscopic ultrasonography

BACKGROUND

Transabdominal ultrasonography (US) has made the detection of gallbladder polyps easier, but the differential diagnosis of polyps less than 20 mm remains difficult. Therefore, we evaluated the usefulness of endoscopic ultrasonography (EUS) for the differential diagnosis of gallbladder polyps.

METHODS

Among patients with gallbladder polyps less than 20 mm, we reviewed 89 patients who underwent US and EUS before surgery and assessed the results of differential diagnoses by them.

RESULTS

In all, 86.5% of these polyps were precisely diagnosed by EUS. However, only 51.7% were diagnosed by US. Sensitivity, specificity, and positive and negative predictive values of EUS at the diagnosis of carcinoma were 91.7%, 87.7%, 75.9%, and 96.6%, respectively. Those of US were 54.2%, 53.8%, 54.2%, and 94.6%, respectively.

CONCLUSIONS

EUS may markedly improve the accuracy of the differential diagnosis of gallbladder polyps. Therefore, EUS is thought to play an important role in determining the treatment strategy for gallbladder polyps.

A new strategy to predict the neoplastic polyps of the gallbladder based on a scoring system using EUS

BACKGROUND

A new method to predict neoplastic polyps of the gallbladder using a scoring system based on five endoscopic ultrasonography (EUS) variables is presented.

METHODS

EUS data from patients with gallbladder polyps who were to undergo cholecystectomy were used for the construction of an EUS scoring system in polyps between 5 and 15 mm in diameter (reference group). The EUS scoring system developed from those patients was applied to other patients (validation group).

RESULTS

In the reference group, size was the most significant predictor of neoplastic polyp. All polyps 5 mm or less in diameter were non-neoplastic and 94% of polyps of greater than 15 mm were neoplastic in the reference group. For polyps between 5 and 15 mm in diameter, the area under the receiver-operating characteristic curves (ROC) plots for the endoscopic scoring system was significantly greater than that under the ROC plots for polyp size alone (p < 0.01). In the validation group, the risk of neoplastic polyp was significantly higher for polyps with a score of 6 or greater compared with those with a score of less than 6 (p < 0.01).

CONCLUSIONS

Our data show that a score based on five EUS variables identifies those patients at risk of neoplasia when polyps are between 5 and 15 mm in diameter. (Gastrointest Endosc 2000;52:372-9).

Isolated Small Gallbladder Polyps: An Indication for Cholecystectomy in Symptomatic Patients

To evaluate patients with gallbladder polyps and to compare them with patients with chronic acalculous cholecystitis, 301 patients with chronic acalculous disease of the gallbladder, of which 45 had polyp disease of the gallbladder, were reviewed out of 7181 cholecystectomies performed from June 1985 through June 1995. Of the 45 patients, 30 (Group A) were diagnosed preoperatively by ultrasound and 15 (Group B) postoperatively on pathologic examination. In each group, the most common polyp was cholesterol type (19/45) with multiple lesions in 10 of these 19 patients. Chronic cholecystitis was present elsewhere in the gallbladder in 40 per cent of Group A and 80 per cent of Group B patients ( P = 0.02). Forty-three patients had polyps less than 5 mm in diameter, one a 1.5-cm gallbladder cholesterol polyp, and one a 1.3-cm tubulovillous polyp with a focus of carcinoma in situ. During this same period, 17 patients had primary malignancy of the gallbladder, none of which were found in polypoid lesions. In Group A patients there were significantly fewer preoperative tests than in typical acalculous patients [2.3 versus 3.8 ( P < 0.03)], including upper endoscopy ( P < 0.02) and hepatobiliary scintigraphy ( P < 0.00001). Of the patients with polyps, 42 of 45 (93.3%) had resolution of symptoms postoperatively with a mean follow-up of 178.9 ± 505.0 days (range 1–2438 days). Most patients with biliary tract symptoms and a small (<5-mm) gallbladder polyp underwent fewer preoperative diagnostic tests than patients with chronic acalculous cholecystitis. This abbreviated preoperative workup appears warranted in view of the high incidence of symptom resolution.

Laparoscopic cholecystectomy in the treatment of patients with gall bladder cancer

BACKGROUND

Surgical procedures based on the depth of the primary tumor invasion (pT category) have been proposed in the treatment of gallbladder cancer (GBC). Trocar site metastases have been reported in patients who underwent laparoscopic cholecystectomy (LC) for preoperatively undiagnosed GBC.

STUDY DESIGN

The aim of this study was to clarify the role of LC as a surgical strategy for GBC. From 1986 to 1998, 56 patients with GBC underwent surgical resection. Survival rates were compared retrospectively according to pT category and use of LC.

RESULTS

Five-year survival was 91% for pT1 (n = 13), 64% for pT2 (n = 25), 34% for pT3 (n = 14), and 0% for pT4 tumors (n = 4; p<0.0001). LC was performed on 11 patients (4 with pT1, 5 with pT2, and 2 with pT3 tumors). Of the seven patients with pT2 or pT3 tumors, three underwent a second radical operation, three had an open radical operation to which the procedure was converted from LC, and one underwent no additional procedures. For pT1 tumors, one patient died of trocar site metastasis from bile spillage after LC. For pT2 or pT3 tumors, 5-year survival was 63% for radical surgery (n = 35) and 0% for cholecystectomy alone (n = 4; p<0.05). For pT2 or pT3 tumors treated by radical surgery, 5-year survival was 75% for laparoscopic approach (n = 6) and 60% for open surgery (n = 29; not significant).

CONCLUSIONS

LC may help to establish the diagnosis and to determine the surgical strategy for undiagnosed GBC. It is important to prevent spillage or implantation of malignant cells during LC. For pT2 or pT3 tumors diagnosed laparoscopically, a second or converted open radical surgery is necessary.

Polypoid lesions of the gallbladder: report of 100 cases with special reference to operative indications

BACKGROUND

The nature of polypoid lesions of the gallbladder is difficult to define before operation, and surgical indications still remain controversial. The aim of this study was to identify characteristics of each type of polypoid lesion of the gallbladder and indications for surgery.

METHODS

Clinical data were retrospectively correlated with the histopathologic characteristics of polypoid lesions in 100 patients who had cholecystectomy.

RESULTS

There were 74 benign polypoid lesions, including 39 cholesterol polyps, 20 adenomas, and 15 with adenomyomatous hyperplasia and 26 malignant polypoid lesions. Twenty-seven percent of patients with benign polyps and 73 percent of patients with malignant polyps were over 60 years of age. Polypoid lesions of the gallbladder were diagnosed by preoperative ultrasonography in only 36 patients (36%). All types of polypoid lesions of the gallbladder, whether benign or malignant, were frequently solitary, and gallstones coexisted in the majority of patients with all polypoid lesions of the gallbladder except cholesterol polyps. The lesions were > 10 mm in 88% of the malignant polyps and in only 15% of the benign polyps.

CONCLUSIONS

The risk factors for malignancy were the age of the patient ( >60 years), the coexistence of gallstones, and the size of the polypoid lesions (>10 mm in diameter). In asymptomatic patients, cholecystectomy can be justified if there are risk factors for malignancy.

Primary gallbladder cancer: recognition of risk factors and the role of prophylactic cholecystectomy

The objective of this article is to review the available literature on the epidemiology, predisposing factors, and conditions associated with primary gallbladder cancer, and to discuss the role of prophylactic cholecystectomy in high-risk patient populations. Gallbladder cancer is a highly malignant tumor with a poor 5-yr-survival rate. It is a tumor of the elderly and has striking genetic, racial, and geographic characteristics, with an extremely high prevalence in Native Americans and Chileans. Cholelithiasis is a well-established risk factor for gallbladder cancer and the risk seems to correlate with stone size. Polyps that are >1 cm, single, sessile, and echopenic are associated with a higher risk of malignancy. Anomalous junction of pancreaticobiliary ducts (AJPBD), especially without choledochal cyst, and porcelain gallbladder are additional factors that predispose to gallbladder cancer. Lesser associations include chronic bacterial infections of the gallbladder, typhoid carrier state, certain occupational and environmental carcinogens, hormonal changes in women, and certain social, dietary, and familial factors. It is important to identify high-risk groups for gallbladder cancer because of the dismal nature of this tumor. In patients with porcelain gallbladder and anomalous junction of the pancreatic and biliary ducts, cholecystectomy is recommended provided that the patient is a good operative candidate. Patients with large solitary polyps or gallstones require close ultrasonic follow-up. With the advent of endoscopic ultrasound it is expected that early changes of malignancy in polyps will be reliably detected, and more patients will potentially be cured with a simple cholecystectomy. Through a MEDLINE/PAPERCHASE search we identified and reviewed articles regarding gallbladder cancer published in English-language journals between 1966 and 1999, using the key words biliary tract and gallbladder diseases, cancer, neoplasms, surgery, cholelithiasis, gallstones, cholecystitis, gallbladder polyps, risk factors, chemical industry, occupational diseases, typhoid, porcelain gallbladder, bacteremia, and precancerous conditions. We also used the bibliography of relevant articles to increase our search. A total of 122 publications were selected using the mentioned data source.

Surgical management of polypoid lesions of the gallbladder

BACKGROUND

With improvements in ultrasonography more polypoid lesions of the gallbladder (PLGs) are being detected. The management of these is controversial.

METHODS

The demographic, radiological and pathological data of 38 patients with ultrasonographically detected PLGs were reviewed. A Medline search for such lesions was performed and a review of the literature is presented.

RESULTS

Thirty-four patients underwent cholecystectomy and four were advised against or declined operation. Of the 34 who had cholecystectomy, 11 had macroscopic and histopathologically proven PLGs. Of these, seven had cholesterol polyps, two had adenomas, one had a carcinoid tumour and one had an adenocarcinoma of the gallbladder. One patient had a histopathologically normal gallbladder. The remainder had chronic cholecystitis with or without gallstones. All of the patients with neoplastic lesions of the gallbladder had solitary polyps greater than 1.0 cm in diameter.

CONCLUSION

A protocol for the management of ultrasonographically detected PLGs is proposed. In this protocol it is suggested that patients with a PLG should undergo surgery if they are symptomatic, or if the PLG is 1.0 cm or more in diameter.

Diagnosis of the depth of invasion of gallbladder carcinoma by EUS

BACKGROUND

The prognosis of gallbladder carcinoma is dismal and relates to the depth of invasion as expressed by the T factor in TNM staging. We evaluated the utility of endoscopic ultrasound (EUS) in the diagnosis of the depth of invasion of gallbladder cancer.

METHODS

Thirty-nine patients who underwent both EUS and surgery were included in this study. The EUS images were classified according to the relation between tumor echo pattern and gallbladder-wall structure, and the resulting types were compared with depth of invasion as determined histologically. Based on the results, a set of diagnostic criteria is proposed.

RESULTS

The EUS images were classified into four categories. Type A is a pedunculated mass with a fine-nodular surface and intact neighboring wall. Type B is a broad-based mass with an irregular surface and intact outer hyperechoic layer of the adjacent wall. In type C, the outer hyperechoic layer is irregular due to a mass echo, whereas, in type D, the outer hyperechoic layer is disrupted by a mass echo. Each of the four categories of EUS images correlated well with the histologic depth of invasion.

CONCLUSION

EUS is useful in the T staging of gallbladder cancer.

Laparoscopic cholecystectomy and unsuspected gallbladder carcinoma

Gallbladder cancer is a relatively uncommon malignancy in the United States. Its presentation is similar to that of lithic disease of the gallbladder. Laparoscopic cholecystectomy has become the method of choice for removing the gallbladder in most benign conditions. Occasionally, unsuspected gallbladder carcinoma is encountered in association with laparoscopic cholecystectomy. Overall, gallbladder cancer portends a poor prognosis. However, in select cases, a favorable outcome can be expected and the less favorable predicted expected outcome can be improved. Management of patients with gallbladder cancer in different situations is discussed: gallbladder cancer noted postoperatively on final pathology, gallbladder cancer noted after removal of the gallbladder and opening of the specimen at the time of surgery, difficulty encountered at the time of dissection and resultant suspicion of gallbladder cancer, and diagnosis of extensive disease at initial placement of the laparoscope. The technique of extended cholecystectomy is outlined.

Differential diagnosis of small polypoid lesions of the gallbladder: the value of endoscopic ultrasonography

OBJECTIVE

To evaluate the accuracy of endoscopic ultrasonography (EUS) in making a differential diagnosis of small (< or =20 mm) polypoid lesions of the gallbladder.

SUMMARY BACKGROUND DATA

Differential diagnosis of these lesions is often difficult using conventional imaging modalities.

METHODS

The findings of EUS and transabdominal ultrasonography were retrospectively analyzed in 65 surgical cases of small polypoid lesions (cholesterol polyp in 40, adenomyomatosis in 9, adenoma in 4, and adenocarcinoma in 12).

RESULTS

Polypoid lesions exceeding 10 mm suggested malignancy. EUS showed a tiny echogenic spot or an aggregation of echogenic spots with or without echopenic areas in 95% of patients with cholesterol polyps. EUS showed multiple microcysts or comet tail artifact in all adenomyomatosis cases. Adenomas and adenocarcinomas were not associated with the echogenic spots, microcysts, or artifacts. Among adenomas and adenocarcinomas, all sessile lesions were adenocarcinomas. EUS differentiated among polypoid lesions more precisely than ultrasonography (97% vs. 71%).

CONCLUSIONS

A tiny echogenic spot or an aggregation of echogenic spots and multiple microcysts or comet tail artifact is pathognomonic for cholesterol polyp and adenomyomatosis, respectively. Polypoid lesions without these findings indicate adenoma or adenocarcinoma on EUS. Routine use of EUS is recommended for differential diagnosis of polypoid gallbladder lesions when ultrasonography shows no signs indicative of either cholesterol polyp or adenomyomatosis.

Laparoscopic biliary surgery

Treatment of gallstones by laparoscopic cholecystectomy has become standard therapy over the past decade and has received wide patient acceptance. Problems are infrequent but those such as biliary injury may be serious and continue to be a cause of concern. Biliary injury is more likely when surgery is performed in the presence of acute inflammation. Laparoscopic bile duct exploration is becoming standardized and the results are good. The role of other laparoscopic biliary procedures such as biliary bypass is still uncertain.

The National Cancer Data Base report on carcinoma of the gallbladder, 1989-1995

BACKGROUND

Reports utilizing data from the Commission on Cancer's National Cancer Data Base (NCDB) have previously contained evaluations of time trends for stage of disease at diagnosis, treatment, and survival for multiple tumor sites. Data collected from 1989, 1990, 1994, and 1995 for carcinoma of the gallbladder are presented herein.

METHODS

The data presented in this review were collected from hospital cancer registries from across the U.S. Seven calls for data yielded a total of 5,850,000 cases for the years 1985-1995, including 2574 gallbladder carcinoma cases from 1989-1990 and 2914 cases from 1994-1995 from hospital cancer registries across the U.S. These data represent approximately 8.8% and 8.4% of the estimated cases of liver and biliary track cancers diagnosed in the U.S. during the two respective time periods.

RESULTS

There were no changes in patient demographics between 1989-1990 and 1994-1995. Most gallbladder carcinoma patients were white women. The documentation of tumor stage improved noticeably between the two study periods. There was no increased frequency in the occurrence of early stage tumors between the two reporting times, an era that saw the development and widespread application of laparoscopic cholecystectomy. Treatment differed according to stage of disease. Surgery alone, particularly nonradical surgery, was performed more frequently in the initial treatment of gallbladder carcinoma. A large percentage of gallbladder carcinoma patients received no definitive therapeutic intervention because of the advanced stage of disease at presentation and the lack of effective treatments for these cancers. Multimodality treatment was utilized more often for young patients. Survival was closely related to tumor stage, with 60% 5-year survival for Stage 0 patients, 39% for Stage I patients, and 15% for Stage II patients, but only 5% for Stage III patients and 1% for Stage IV patients. Patient outcome was not demonstrably affected by more aggressive therapy, nor was an adverse effect in results seen in early stage cancers between 1989-1990 and 1994-1995.

CONCLUSIONS

The NCDB data are valuable in the evaluation of trends in malignant diseases, treatments, and patient survival. No substantial differences were apparent in the diagnosis, treatment, and survival of patients during this 7-year study period. The data do not support any adverse effect on outcome results with the introduction of laparoscopic cholecystectomy in the U.S.

Surgical indications for small polypoid lesions of the gallbladder

BACKGROUND

To determine which polyps of the gallbladder should be operated upon, we investigated the size and number of polyps in resected gallbladders, and studied changes in gallbladder polyps using ultrasonography (US).

METHODS

We studied 74 resected gallbladders with small polypoid lesions less than 20 mm in diameter, and 60 patients with gallbladder polyps by US. The polyps in resected gallbladders were classified into four groups histologically, and clinical features, maximum diameter, and number of lesions were compared among the groups. In the followed-up cases with gallbladder polyps, the size and number of polyps were examined by US, and changes during the observation period were studied.

RESULTS

The mean diameter of adenoma was 6.00 +/- 3.39 mm (mean +/- SD) and that of cancer 10.8 +/- 4.16 mm; 97% of cholesterol polyps were less than 10 mm in diameter (3.66 +/- 2.68 mm). Neoplastic polyps tended to be single (adenoma, n = 1.40 +/- 0.89; cancer, n = 1.16 +/- 0.40), whereas half of the cholesterol polyps were multiple (n = 3.09 +/- 3.31). However, when there were fewer than 3 lesions, the incidence of neoplasm was 37% among polyps 5 to 10 mm in diameter. A low incidence (6%) of neoplasm was also observed among polyps less than 5 mm in diameter.

CONCLUSIONS

These data indicate that an aggressive surgical approach for small gallbladder polyps is warranted when there are fewer than 3 polyps, regardless of their size.

Recurrent melanoma of the leg and polypoid lesions of the gallbladder--a management dilemma

Isolated limb perfusion (ILP) is a well-tolerated method of regional chemotherapy for melanoma, with response rates ranging from 40-80%, used to treat recurrences or metastases confined to the limb from which the original tumour was excised. We present the case of a 75-year-old woman with a third recurrence of melanoma of the left leg, referred for ILP, in whom staging investigations revealed two probable malignant polypoid lesions of the gallbladder (PLG). These were thought likely to represent metastatic melanoma. In view of the diagnostic difficulty, she underwent laparoscopic cholecystectomy together with left superficial femoral ILP. Multiple papillary adenomatosis, with dysplasia ranging from mild to severe, and with areas of invasive adenocarcinoma, were found on gallbladder histology. No previous case of this combination of tumours has been reported. This case provides evidence of an adenoma-carcinoma sequence, and to our knowledge no previous case has been reported with both carcinoma and the full range of dysplasia from mild to severe within the same gallbladder. The use of minimally invasive surgery allowed the ILP to be performed at the same operation. The pathology, natural history and place of laparoscopic surgery in the management of PLG is discussed.

Reliability of frozen section diagnosis of gallbladder tumor for detecting carcinoma and depth of its invasion

BACKGROUND

An accurate frozen section diagnosis is important when deciding the surgical strategy against a gallbladder tumor intraoperatively. Little has been reported on the accuracy of frozen section diagnosis of the gallbladder.

PATIENTS AND METHODS

In a total of 86 consecutive patients with gallbladder tumor, the accuracy of the frozen section diagnosis was examined. There were 32 patients with polypoid lesions and 54 with nonpolypoid tumors.

RESULTS

The frozen tissue diagnosis and final diagnosis were identical in 82 of the 86 cases, that is, benign in 65 and malignant in 17. The other four cases had different diagnoses, that is, conversion from benign to malignant in two and from malignant to benign in two. The overall accuracy of frozen diagnosis was 95.3% (97.0% for benign and 94.7% for malignant). In 32 polypoid lesions, the accuracy of frozen section diagnosis was 91% (93% for benign; 89% for malignant). In 54 nonpolypoid lesions, the accuracy of diagnosis was 98% (100% for benign; 93% for malignant). The diagnosis of depth of invasion was identical only in 7 (70%) of the 10 carcinoma cases examined, while it was diverse in the remaining 3, that is, conversion from adenocarcinoma invading the subserosa to that limiting to the mucosa in one, from carcinoma within the mucosa to that infiltrating the muscle coat in one, and from carcinoma affecting the muscle layer to that invading the subserosa in the other. Alterations of frozen section diagnosis about being benign or malignant and about the depth of invasion were encountered in seven patients, five of whom had a polypoid tumor.

CONCLUSIONS

The intraoperative frozen tissue diagnosis is fairly reliable as to whether lesions are malignant or benign; however, accuracy is low in patients with polypoid lesions of the gallbladder. Also, frozen section diagnosis does not reliably measure the depth of invasion of gallbladder carcinoma.

Reliability of frozen section diagnosis of gallbladder tumor for detecting carcinoma and depth of its invasion

BACKGROUND

An accurate frozen section diagnosis is important when deciding the surgical strategy against a gallbladder tumor intraoperatively. Little has been reported on the accuracy of frozen section diagnosis of the gallbladder.

PATIENTS AND METHODS

In a total of 86 consecutive patients with gallbladder tumor, the accuracy of the frozen section diagnosis was examined. There were 32 patients with polypoid lesions and 54 with nonpolypoid tumors.

RESULTS

The frozen tissue diagnosis and final diagnosis were identical in 82 of the 86 cases, that is, benign in 65 and malignant in 17. The other four cases had different diagnoses, that is, conversion from benign to malignant in two and from malignant to benign in two. The overall accuracy of frozen diagnosis was 95.3% (97.0% for benign and 94.7% for malignant). In 32 polypoid lesions, the accuracy of frozen section diagnosis was 91% (93% for benign; 89% for malignant). In 54 nonpolypoid lesions, the accuracy of diagnosis was 98% (100% for benign; 93% for malignant). The diagnosis of depth of invasion was identical only in 7 (70%) of the 10 carcinoma cases examined, while it was diverse in the remaining 3, that is, conversion from adenocarcinoma invading the subserosa to that limiting to the mucosa in one, from carcinoma within the mucosa to that infiltrating the muscle coat in one, and from carcinoma affecting the muscle layer to that invading the subserosa in the other. Alterations of frozen section diagnosis about being benign or malignant and about the depth of invasion were encountered in seven patients, five of whom had a polypoid tumor.

CONCLUSIONS

The intraoperative frozen tissue diagnosis is fairly reliable as to whether lesions are malignant or benign; however, accuracy is low in patients with polypoid lesions of the gallbladder. Also, frozen section diagnosis does not reliably measure the depth of invasion of gallbladder carcinoma.

Changing indications for laparoscopic cholecystectomy. Stones without symptoms and symptoms without stones

In less than a decade, laparoscopic methods have dramatically improved the safety and convenience of cholecystectomy. As a result, the number of cholecystectomies performed nationwide has increased significantly. Whether this increase is a reflection of any major change in operative indications is unclear; the actual answer may vary from community to community. Silent gallstones continue to represent a sometimes contentious therapeutic dilemma. Because their natural history is unlikely to have changed, the management guidelines previously established for open cholecystectomy continue to have relevance today. Thus, it can be agreed that the majority of patients with silent gallstones do not require a cholecystectomy. The changing risk-benefit ratio suggests that some liberalization of these guidelines may now be in order. Already a number of transplantation surgeons have begun to recommend pretransplant cholecystectomy for asymptomatic patients who are found to have gallstones during screening. Available evidence also appears to support the use of pre-emptive laparoscopic cholecystectomy for other indications such as in selected women of childbearing age, young children, and patients with very large gallstones. The problem of silent gallstones in diabetics continues to be more enigmatic, but some complicated diabetics are probably best managed with operation. Other patient groups who are at high risk of having adverse outcomes from expectant management will be more precisely identified by future research efforts. Laparoscopic cholecystectomy should also be helpful in patients with various forms of acalculous biliary disease. However, special caution is advisable in approaching chronic acalculous cholecystitis until more specific and reproducible diagnostic methods are further validated.