Management of gallbladder polyps
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Eur Surg https://doi.org/10.1007/s10353-020-00659-8
Management of gallbladder polyps Dietmar Öfner
Received: 30 July 2020 / Accepted: 6 August 2020 © The Author(s) 2020
Summary A gallbladder polyp (GP) is defined as an elevation of the gallbladder mucosa that protrudes into the gallbladder lumen. Gallbladder polyps (GPs) have an estimated prevalence in adults of 0.3–12.3%. However, only 5% of polyps are considered “true” GPs that have malignant potential or are even already cancerous. The most important imaging method for diagnosis and follow-up of GPs is transabdominal ultrasound, but it fails to discriminate between true and pseudo polyps at a clinically relevant level. Although gallbladder cancer (GBC) arising from polyps is a rare event, malignancy is significantly more common among polyps from a size of 10 mm. In light of this, the consensus, which is reflected in current guidelines, is that surgery should be considered for polyps of 10 mm or greater. However, 10 mm is an arbitrary cutoff, and high-quality evidence to support this is lacking. Lowering the threshold for cholecystectomy when patients have additional risk factors for gallbladder malignancy may improve the cancer detection rate in polyps smaller than 10 mm. Nevertheless, the evidence behind this is also weak. This review shows the shortcomings in the available evidence and underlines the decision-making process regarding the surgical indication, surveillance, or both. Keywords Gallbladder polyps · Gallbladder cancer · “True” polyps · Pseudo polyps · Ultrasound
D. Öfner, MD, MSc () Department of Visceral, Transplant and Thoracic Surgery, Center of Operative Medicine, Medical University of Innsbruck, Anichstraße 35, 6020 Innsbruck, Austria [email protected]
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Introduction Gallbladder polyps (GPs) have an estimated prevalence of approximately 0.3–12.3% [1, 2], which varies widely in different regions of the world. They are rarely symptomatic [3, 4] and are mainly incidental findings. Until recently it was generally assumed that polyps in the gallbladder have the potential to grow and become cancerous over many decades [5]. However, a recent population-based study found out that the natural history of polyps is to grow over time, and polyps even more than 10 mm in size are rarely associated with gallbladder cancer (GBC; [6]). The majority of GPs are classified as pseudo or cholesterol polyps. They have no malignant potential and, therefore, do not require follow-up or intervention. Past studies assumed that “true” GPs occur in 5% of cases [1, 2, 7] and are subject to the adenoma–carcinoma sequence [8]. Although rare, malignancy is significantly more common among polyps of 10 mm or greater in size [2, 7]. It is therefore generally accepted that from this size up, GPs have to be removed surgically, preferably by laparoscopic cholecystectomy [2, 9, 10]. Nevertheless, it remains uncertain how many polyps in the gallbladder ultimately progress and become cancerous. The aforementioned recently published study involving more than 600,000 pati
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