8/2/2019 Sp870_Behrns

1/5

GALLBLADDER POLYPS: WHEN TO CUT, WHEN TO CUT BAIT

Kevin E. Behrns, M. D.

Hux Professor and Vice ChairChief of General Surgery

Department of SurgeryUniversity of FloridaGainesville, FL 32610

Type of Polyp

Gallbladder polyps are a common clinical findings occurring in 5% of patients who often

have cross-sectional imaging for non-specific abdominal symptoms. When encountering

patients with gallbladder polyps, it is important to note what type of polyp is described.While true polyps are adenomatous, gallbladder polyps are often non-epithelial

growths and, in fact, about 70% of polyps are cholesterol polyps that have no malignant

potential. Adenomas are uncommon and constitute approximately 8% of all gallbladderpolyps. Less common polypoid lesions include adenocarcinomas, inflammatory polyps,

gallstones masquerading as polyps and heterotopic tissue.

Risk Assessment

After considering the type of polyps, the risk of development of cancer should be

determined. Most demographic data suggest that men and women have an equalpropensity to develop adenomatous polyps, however, one study found that men had an

increased risk of polyp development. In addition, several studies have noted that patientswith primary sclerosing cholangitis (PSC) that have polyps are more likely to develop

adenocarcinoma. Finally, patients with advancing age may be predisposed to have cancer

because some data suggests that gallbladder polyps, like colonic polyps, have anadenoma-to-carcinoma sequence and, therefore, advancing age would permit malignant

transformation.

Morphology and size have long been deemed important features of gallbladder polyps. A

ten millimeter rule for gallbladder polyps is often cited as a reason for cholecystectomy

because polyps larger than 10 mm have an increased risk of cancer. Several caveatsshould be kept in mind when considering the size and morphology of gallbladder polyps.

First, polyps less than 5 mm rarely, if ever, harbor carcinoma. Conversely, polyps greater

than 15 mm may have cancer cells in up to 70% of specimens. Thus, those polyps that

are 5-15 mm must be carefully followed; with a risk of malignancy up to 22% in thesepatients. Finally, sessile polyps are more likely malignant than pedunculated polyps.

Additional Investigation

Gallbladder polyps are typically identified on ultrasonography, which has a sensitivity

and specificity of over 90%. Contrast enhanced CT may aid in the diagnosis with anoverall accuracy of 87% for cancer. FDG-PET adds little to the CT. Importantly,

8/2/2019 Sp870_Behrns

2/5

endoscopic ultrasound, which permits detailed evaluation of the gallbladder wall, hasexcellent diagnostic capabilities and should be used for indeterminate polyps of 5-15 mm.

Management

Clinical decision-making for gallbladder polyps is rather straightforward since theoptions include surveillance versus cholecystectomy. Cholecystectomy should beconsidered in patients with polyps greater than 15 mm and smaller polyps that are sessile

or found in patients with PSC. If the polyp is less than 15 mm and surveillance is the

management of choice then re-evaluation should occur every 3-6 months because some

studies suggest that polyps can increase in size 4-fold in 12 months. If the rate of growthis nil then surveillance can be stopped after 2 years.

If cholecystectomy is the treatment plan then one should consider the benefits of openversus laparoscopic cholecystectomy. Sentiment exists that laparoscopic

cholecystectomy should not be performed if there is evidence of cancer because

laparoscopic gallbladder cancer surgery is often complicated by port-site recurrence. Inone study, 16 patients with gallbladder polyps followed for 4 years had no recurrence. If

the specimen demonstrates cancer that invades the muscular wall then radical

cholecystectomy should be performed.

In addition, when selecting cholecystectomy over surveillance, it is important to know the

complications of cholecystectomy. In a large study of nearly 23,000 cholecystectomies,

the local complication rate was 7%. Systemic complications were observed in 2.3% ofpatients. Bile duct injury occurred in 0.3% of patients. Factors important in the outcome

include body mass index, male gender and surgeon experience.

Conclusion

When to cut? Patients with polyps greater than 15 mm should have their gallbladder

removed as should patients with PSC and sessile polyps.

When to cut bait? Those polyps ranging between 5-15 mm should be closely followed or,

alternatively, the gallbladders removed. Patients with gallbladder polyps less than 5 mm

should have surveillance and not undergo operation.

8/2/2019 Sp870_Behrns

3/5

1

GALLBLADDER POLYPS:

WHEN TO CUT, WHEN TO

CUT BAIT

Kevin E. Behrns, M. D.

Hux Professor and Vice Chairman

Chief of General & GI Surgery

University of Florida

Gainesville, FL

GALLBLADDER POLYPS

Learning Objectives

To discuss the types of gallbladder polyps

To identify factors that influence managementof gallbladder polyps

Is this cancer?

To describe imaging studies that assist in thediagnosis of gallbladder

To discuss the advantages and disadvantagesof surveillance vs. cholecystectomy

GALLBLADDER POLYPS

Case Presentation

61 y. o. man with left

flank bulge and

asymptomatic filling

defect of GB

2.2 cm mass

CT c/w single adherent

gallstone

CA 19-9 normal

Lap chole August 2007

GALLBLADDER POLYPS

Clinical Question

IS THIS A TRUE

GALLBLADDER POLYP?

GALLBLADDER POLYPS

Types of Polyps

Prevalence 4%-9.5%

Cholesterol polyps-70%

Adenomas- 8%

Adenocarcinoma-5.6%

Inflammatorypolyps- 13%

Gallstones

Gastric heterotopia

Hepatobiliary Pancreat Dis Int 2004;3:591

GALLBLADDER POLYPS

Clinical Question

IF THIS IS A POLYP, WHAT

FACTORS INFLUENCE

MANAGEMENT?

8/2/2019 Sp870_Behrns

4/5

2

GALLBLADDER POLYPS

Risk Assessment

Demographics Males

11.3% vs. 7.2%

Controversial

Indian

Primary sclerosingcholangitis

Hep B sAg+ 11.4% vs. 9.1%

Advancing age Adenoma-to-carcinoma

sequence

Morphology Size- 10 mm rule

Rapid growth

61 patients followed with USfor 48 months 29% had increased size or number

of polyps

48% of benign lesions exceed10 mm

Polyps less than 5 mm almostnever malignant

Polyps > 15 mm have increasedrisk of harboring malignancy Up to 46-70% malignant

Polyps 5-15 mm have 14%-22% of malignancy

Sessile polyps harbormalignancy in 33% versus 13%in pedunclulated polypsregardless of size

Ann Surg 2001;234:657

Gastrointest Endosc 200;52:372

Eur J Surg Oncol 2008

J Gastroentrol & Hepatol 2007

GALLBLADDER POLYPS

Morphologic Factors- Size

29567Sugiyama1995

39672Kubota1995

380172Yang1992

78340Koga1988

%ACA

>10 mm

%ACA

8/2/2019 Sp870_Behrns

5/5

3

GALLBLADDER POLYPS

Operative Techniques

Should a laparoscopic cholecystectomy be performed?

16 patients with gallbladder adenoma Follow-up 4 years

No recurrence

6 patients with malignant polyps Follow-up 2-8 years

2 required radical cholecystectomy

1 recurrence with PT2

Importance of full thickness resection without perforation

Polyps > 18 mm should be removed by open cholecystectomy

Surg Laparosc Endosc Percutan Tech 2001;11:242

GALLBLADDER POLYPS

Cholecystectomy Risk

SALTS Study Group-22,953 cholecystectomies Mortality 0.3%

Complications- 7% intraoperative

4% postoperative local

2.3% systemic

0.3 % bile duct injury

Factor associated withcomplications Male gender, BMI, ASA,

emergency operation,surgeon experience

JACS 2006;203;723

Critical View of Safety of Triangle of Calot

GALLBLADDER POLYPS

Summary- Size

Polyps 15 mm

Cholecystectomy

Polyps 5-15 mm

Surveillance Growth rate

Morphology

Demographics

Histology of Case Presentation

GALLBLADDER POLYPS

Conclusions

WHEN TO CUT

Polyp >15 mm

Sessile polyp

Increasing in sizebetween 5-15 mm

Patient with PSC

Patient preference

WHEN TO CUT BAIT

Polyp