[Natural course and treatment strategy of gallbladder polyp]

[Recent Updates on Diagnosis, Treatment, and Follow-up of Gallbladder Polyps]

A gallbladder (GB) polyp is an elevation of the GB mucosa that protrudes into the GB lumen. GB polyps have an estimated prevalence of 0.3-9.5% and can be divided into neoplastic (true) polyps and nonneoplastic polyps (pseudopolyps). Pseudopolyps are most commonly cholesterol polyps but also include focal adenomyomatosis and inflammatory polyps with no malignant potential. Neoplastic polyps, however, can be benign or malignant. Benign polyps are most commonly adenomas, while malignant polyps are usually adenocarcinoma. Transabdominal ultrasonography is the main radiological modality used for diagnosing and surveilling GB polyps. On the other hand, because it is difficult to diagnose GB polyps before surgery, alternative imaging modalities, such as endoscopic ultrasound, are being further evaluated. The current guidelines recommend cholecystectomy for GB polyps ≥ 10 mm in size as well as suboptimal sized GB polyps (6-9 mm) with other risk factors, including age >50, sessile, and symptoms. The quality of the evidence behind this practice is relatively low. Therefore, this review identifies the current gaps in the available evidence and guidelines and introduces methods that can help make decisions regarding patients who require a cholecystectomy or follow-up.

Diagnosis and Treatment of Gallbladder Polyps: Current Perspectives

INTRODUCTION

Gallbladder polyps (GBPs) are generally harmless, but the planning of diagnosis and treatment of the GBP is of clinical importance due to the high mortality risk of delays in the diagnosis of gallbladder carcinomas that show polypoid development.

MATERIALS AND METHODS

GBPs are usually incidentally detected during ultrasonographic (USG) examinations of the abdomen. The risk of carcinoma development from polypoid lesions in the literature is reported as 0-27%. There is no consensus about the management of the GBPs. Herein, we reviewed the contemporary data to update our knowledge about diagnosis and treatment of gallbladder polyps.

RESULTS

Polyps can be identified in five different groups, primarily as neoplastic and non-neoplastic. Cholesterol polyps account for 60% of all cases. The most common (25%) benign polypoid lesions after cholesterol polyps are adenomyomas.

CONCLUSION

Ultrasonography and endoscopic ultrasonography seems to be the most important tool in differential diagnosis and treatment. Ultrasonography should be repeated in every 3-12 months in cases that are thought to be risky. Nowadays, the most common treatment approach is to perform cholecystectomy in patients with polyps larger than 10 mm in diameter. Radical cholecystectomy and/or segmental liver resections should be planned in cases of malignancy.

HOW TO CITE THIS ARTICLE

Dilek ON, Karsu S, et al. Diagnosis and Treatment of Gallbladder Polyps: Current Perspectives. Euroasian J Hepatogastroenterol 2019;9(1):40-48.

The efficacy of real-time colour Doppler flow imaging on endoscopic ultrasonography for differential diagnosis between neoplastic and non-neoplastic gallbladder polyps

OBJECTIVES

We evaluated the usefulness of real-time colour Doppler flow (CDF) endoscopic ultrasonography (EUS) for differentiating neoplastic gallbladder (GB) polyps from non-neoplastic polyps.

METHODS

Between August 2014 and December 2016, a total of 233 patients with GB polyps who underwent real-time CDF-EUS were consecutively enrolled in this prospective study. CDF imaging was subjectively categorized for each patient as: strong CDF pattern, weak CDF pattern and no CDF pattern.

RESULTS

Of the 233 patients, 115 underwent surgical resection. Of these, there were 90 cases of non-neoplastic GB polyps and 23 cases of neoplastic GB polyps. In a multivariate analysis, a strong CDF pattern was the most significant predictive factor for neoplastic polyps; sensitivity, specificity, positive predictive value, negative predictive value and accuracy were 52.2 %, 79.4 %, 38.7 %, 86.9 % and 73.9 %, respectively. Solitary polyp and polyp size were associated with an increased risk of neoplasm.

CONCLUSIONS

The presence of a strong CDF pattern as well as solitary and larger polyps on EUS may be predictive of neoplastic GB polyps. As real-time CDF-EUS poses no danger to the patient and requires no additional equipment, it is likely to become a supplemental tool for the differential diagnosis of GB polyps.

KEY POINTS

• Differential diagnosis between neoplastic polyps and non-neoplastic polyps of GB is limited. • The use of real-time CDF-EUS was convenient, with high agreement between operators. • The real-time CDF-EUS is helpful in differential diagnosis of GB polyps.

Preoperative predictive factors for gallbladder cholesterol polyp diagnosed after laparoscopic cholecystectomy for polypoid lesions of gallbladder

BACKGROUNDS/AIMS

We investigated patients' clinical and radiological data to determine preoperative factors that predict cholesterol gallbladder (GB) polyps of large size, which can be helpful for decision on further diagnostic tools.

METHODS

In this study, we retrospectively analyzed 126 patients who underwent laparoscopic cholecystectomy for GB polyps >10 mm diagnosed preoperatively by abdominal ultrasonography between February 2002 and February 2016 in Department of Surgery, Sanggye Paik Hospital. Patients were divided into non-cholesterol polyps group and cholesterol polyps group, based on the postoperative pathologic diagnosis. Clinical and radiological data, such as gender, age, body weight, height, body mass index (BMI), laboratory findings, size, number and shape of the polypoid lesions, and presence of the concurrent GB stone were compared between the two groups.

RESULTS

Of the 126 cases, 73 had cholesterol polyps (57.9%) and 53 cases were non-cholesterol polyps (42.1%). The younger age (<48.5 years), size of polyp <13.25 mm and multiple polyps were independent predictive variables for cholesterol polyps, with odd ratios (OR) of 2.352 (p=0.045), 5.429 (p<0.001) and 0.472 (p<0.001), respectively.

CONCLUSIONS

Age, size and polyp number were used to predict cholesterol GB polyp among polypoid lesions of the gallbladder >10 mm. For cases in which these factors are not applicable, it is strongly recommended to evaluate further diagnostic tools, such as computed tomography, endoscopic ultrasonography and tumor markers.

Fate of dyspeptic or colonic symptoms after laparoscopic cholecystectomy

BACKGROUND/AIMS

Gallbladder diseases can give rise to dyspeptic or colonic symptoms in addition to biliary pain. Although most biliary pain shows improvement after cholecystectomy, the fates of dyspeptic or colonic symptoms still remain controversial. This study as-sessed whether nonspecific gastrointestinal symptoms improved after laparoscopic cholecystectomy (LC) and identified the char-acteristics of patients who experienced continuing or exacerbated symptoms following surgery.

METHODS

Sixty-five patients who underwent LC for uncomplicated gallbladder stones or gallbladder polyps were enrolled. The patients were surveyed on their dyspeptic or colonic symptoms before surgery and again at 3 and 6 months after surgery. Patients' mental sanity was also assessed using a psychological symptom score with the Symptom Checklist-90-Revised questionnaire.

RESULTS

Forty-four (67.7%) patients showed one or more dyspeptic or colonic symptoms before surgery. Among these, 31 (47.7%) and 36 (55.4%) patients showed improvement at 3 and 6 months after surgery, respectively. However, 18.5% of patients showed continuing or exacerbated symptoms at 6 months after surgery. These patients did not differ with respect to gallstone or gall-bladder polyps, but differed in frequency of gastritis. These patients reported lower postoperative satisfaction. Patients with ab-dominal symptoms showed higher psychological symptom scores than others. However, poor mental sanity was not related to the symptom exacerbation.

CONCLUSIONS

Elective LC improves dyspeptic or colonic symptoms. Approximately 19% of patients reported continuing or exacerbated symp-toms following LC. Detailed history-taking regarding gastritis before surgery can be helpful in predicting patients' outcome after LC.

Analysis of gallbladder polypoid lesion size as an indication of the risk of gallbladder cancer

BACKGROUNDS/AIMS

Recent advances in ultrasonography have contributed to the early detection of gallbladder cancer. We attempted to predict the progression of the disease by comparing the sizes of polypoid lesions, and we suggest that the size of the lesion would be a useful guideline to determine an appropriate primary surgical approach for polypoid lesions of the gallbladder.

METHODS

We have retrospectively analyzed 253 patients that, during the operation period from January 2009 to December 2011, had had ultrasonographically detected gallbladder polypoid lesions, and who underwent cholecystectomy at Ulsan university hospital. We have analyzed the demographic data of the patients, the preoperative size of polypoid lesions, and pathologic findings.

RESULTS

Of a total of 253 patients, 235 patients had benign lesions, and 18 patients had malignant lesions. Among the malignant polyp patients, 11 had pT1 cancer, 6 had pT2 cancer, and 1 had pT3 cancer. The average size of polypoid lesions was 9.1±3.1 mm and that of malignant lesions was 28.2±16.4 mm. The receiver operating characteristic (ROC) curve of the benign and malignant groups shows that 14.5 mm is the optimal point of prediction of the malignancy. Of a total of 18 patients of GB cancer, 11 had pT1 and the average size of their polypoid lesions was 20.5±5.8 mm 7 had pT2 with a size of 39.1±20.7 mm. ROC curve analysis of the pT1 and pT2 groups shows that 27 mm would be the optimal point to predict T2 and above cancer.

CONCLUSIONS

In the case of an early cancer, curative treatment can be achieved through a simple and minimally invasive laparoscopic cholecystectomy. We attempted to predict early cancer occurrence among polypoid lesions of the gallbladder using the simplest standard, size. Although there are some limitations, size can be a simple and easy way to evaluate polypoid lesions of the gallbladder.

Diagnosis and management of gallbladder polyps

Gallbladder cancer is a rather uncommon disease, when it gives symptoms it has usually reached an incurable stage. Therefore, every attempt must be made to find the asymptomatic stages and look for premalignant gallbladder polyps. Even if gallbladder cancer is a rare disease, gallbladder polyps are common, only a few polyps develop to cancer. This makes gallbladder polyps another problem: which are the polyps that must be surgically removed, which shall be followed-up, or for how long? The author used the keyword “gallbladder polypsn” in PubMed and reviewed the scientific literatures published from January 2000 to December 2011. The present review article has summarized almost all respects of gallbladder polyp, including the risk factors, clinical diagnosis and management, and comments made from the author, in which clinical treatments are recommended. It is author's purpose that the 11-year-knowledge about gallbladder polyps summarized from all worlds’ literatures is enough to know how clinicians will handle the next patient with gallbladder polyp.