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Joint Hospital Surgical Grand Round 21 Dec 2002 Management of Gallbladder Polyps Dr David IP Shing Fai Department of Surgery United Christian Hospital. What is a Polypoid Lesion of Gallbladder? PLG. Any elevated lesions of the mucosal surface of the gallbladder wall
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Joint Hospital Surgical Grand Round 21 Dec 2002 Management of Gallbladder Polyps Dr David IP Shing Fai Department of Surgery United Christian Hospital
What is a Polypoid Lesion of Gallbladder?PLG • Any elevated lesions of the mucosal surface of the gallbladder wall • Definition of PLG by USG: • similar echogenicity to GB wall • project into lumen • fixed • lack displacement • lack acoustic shadow • may or may not have a pedicle
Prevalence of PLG • USA • 3-7% in healthy subjects • Denmark • male: 4.6% • female: 4.3% • Japan • male: 6.28% • female: 9.5% • Chinese • 6.9%
Classification of polypoid lesions of gallbladder Christensen and Ishak (1970) • Benign • True tumors • adenoma • Mesodermal: lipoma, leiomyoma, haemangioma • Pseudotumors • Hyperplasia: adenomyomatosis • Polyp: inflammatory, cholesterol • Malignant • adenocarcinoma
Common types of PLG • Cholesterol polyp (40-70%) • Inflammatory polyp • Adenomyomatous hyperplasia • Adenoma • Carcinoma
USG diagnosis of PLG • Senitivity 90.1% (Yang et al, 1992) • Specificity 93.9% (Yang et al, 1992 ) • False -ve: • thickened GB wall may obscure small polyps • presence of GS mask detection of polyp • False +ve: Other lesions that may mimic GB polyps • Small GS impacted in GB wall • Thick bile (sludge ball) • Mucosal folds
Natural history of PLG 1. Moriguchi et al 1996 • 109 patients with PLG • FU with USG x 5yrs • 4 patients received cholecystectomy • 2 patients died of other causes • 1 patient developed CA gallbladder, but location different form previous polyp • rest of patients: size of lesion did not change in 88.3% • Conclusion • Most polypoid lesions of gallbladder detected by USG are benign
Natural history of PLG 2. Csendes A et al 2001 • 111 patients with PLG <10mm • Clinical and USG FU for 71 months (mean) • Result: • none of the patients developed biliary symptom, gallstone or carcinoma of gallbladder • 50% similar size • 23.5% shrank or disappeared • 26.5% in number or size
Indications for cholecystectomy • Possibility of Malignancy/ Malignant change of these lesions • Symptoms
Indications for cholecystectomy Possibility of malignancy • Small polypoid carcinomas can be curatively resected, best prognosis • Early detection and differentiation of neoplastic lesion from non-neoplastic one is important
Features of neoplastic PLG on US • Solitary lesion • Diameter >10mm • Sessile appearance • Low echogenicity • Rapid growth
Indications for cholecystectomy • USG alone cannot definitely distinguish adenocarcinoma from non-neoplastic lesions
Indications for cholecystectomy Possibility of malignancy • Size of polyp >10mm • prevalence of malignancy 37-88% • Johnson CD et al 1997 • Kubota K et al 1994 • Majeed AW et al 1995 • Shinkai H et al 1998 • Chijiwa K 1994 • cholesterol polyp: • 73% <10mm • 28% >10mm • Adenocarcinoma • 9% <10mm • 18% 11-15mm • 46% 16-20mm
Indications for cholecystectomy Possibility of malignancy • Coexist gallstone • 85% in malignant PLG, 59% in benign PLG • Tinsley AR et al 1975 • Smok G et al 1986 • Bivins BA et al 1975 • Albores-Saavedra J et al 1980 • Edelman DS et al 1993
Indications for cholecystectomy Possibility of malignancy • Solitary PLG • Sessile lesion • Ishikawa O et al 1989 • Polyp rapid in size • Hachisuka K et al 1986 • Chijiwa K et al 1994 • Koga A et al 1988 • Old age: >50
Features of non-neoplastic PLG on EUSEndoscopic Ultrasonography • Demonstrates the fine structure • Cholesterol polyps (95%) • Echogenic spot • Aggregation of echogenic spots • Adenomyomatosis • Multiple microcysts • Comet tail artefact • Other lesions are diagnosed as neoplastic
Indications for cholecystectomy • EUS (endoscopic ultrasound) highly accurate for differentially diagnosing polypoid gallbladder lesions (97%) • Sugiyama et al 2000 • Azuma et al 2001
Indications for cholecystectomy Kimura K et al 2001 • 46 consecutive patients with pedunculated polypoid lesions of the gallbladder >10mm diagnosed as non-neoplasms at the initial EUS enrolled in study • FU EUS • Results: • No changes in lesions observed in 43/46 • Remaining 3 with spontaneous self-detachment of the lesions • Conclusion: • EUS is useful for determining treatment indications for PLG • Even the lesions are large, contributes to avoiding unnecessary surgery
EUS • Recommended when USG cannot rule out neoplastic lesion • Save cholecystectomy
Indications for cholecystectomy • ? Symptoms • abdominal pain, episodic vomiting, bloating, fatty food intolerance, dyspepsia • polyp loosen and may obstruct or prolapse into cystic duct
Symptomatic PLG • Jones-Monahan et al, 2000 • Retrospective review of 45 patients with PLG receiving cholecystectomy • 93.3% had resolution of symptoms postoperatively with a mean FU 179+/-505 days • Terzi et al, 2000 • All asymptomatic patients had benign PLG while all patients with malignant PLG are symptomatic
Symptomatic PLG • Retrospective review only • Symptoms usually non-specific • Justify for cholecystectomy? • Major surgery with complications
Conclusion • Neoplastic lesion detected on USG/ EUS • Cholecystectomy is warranted • Non-neoplastic PLG on USG/ EUS • Not require cholecystectomy • Not require regular follow • Natural history • Majority of these lesion will remain unchanged • Symptomatic non-neoplastic PLG • Do not recommend cholecystectomy • Further prospective study
Indications for cholecystectomy • Adenoma carry a risk of developing into adenocarcinoma • Adenoma-carcinoma sequence • Both adenoma and carcinoma require cholecystectomy • Distinguishing between these two lesions is not essential to management