1. Joint Hospital Surgical Grand Round 21 Dec 2002 Management of Gallbladder Polyps Dr David IP Shing Fai Department of Surgery United Christian Hospital

2. 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

3. 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%

4. Classification of polypoid lesions of gallbladder Christensen and Ishak (1970) 1.Benign –True tumors adenoma Mesodermal: lipoma, leiomyoma, haemangioma –Pseudotumors Hyperplasia: adenomyomatosis Polyp: inflammatory, cholesterol 2.Malignant –adenocarcinoma

5. Common types of PLG Cholesterol polyp (40-70%) Inflammatory polyp Adenomyomatous hyperplasia Adenoma Carcinoma

6. 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

7. 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

8. 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

9. Indications for cholecystectomy 1.Possibility of Malignancy/ Malignant change of these lesions 2.Symptoms

10. 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

11. Features of neoplastic PLG on US Solitary lesion Diameter >10mm Sessile appearance Low echogenicity Rapid growth

12. USG alone cannot definitely distinguish adenocarcinoma from non-neoplastic lesions Indications for cholecystectomy

13. 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

14. 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

15. 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

16. Features of non-neoplastic PLG on EUS Endoscopic 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

17. Cholesterol polyp

18. Adenomyomatosis

19. Carcinoma

20. EUS (endoscopic ultrasound) highly accurate for differentially diagnosing polypoid gallbladder lesions (97%) –Sugiyama et al 2000 –Azuma et al 2001 Indications for cholecystectomy

21. 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 Indications for cholecystectomy

22. EUS Recommended when USG cannot rule out neoplastic lesion Save cholecystectomy

23. Indications for cholecystectomy ? Symptoms –abdominal pain, episodic vomiting, bloating, fatty food intolerance, dyspepsia –polyp loosen and may obstruct or prolapse into cystic duct

24. 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

25. Symptomatic PLG Retrospective review only Symptoms usually non-specific –Justify for cholecystectomy? –Major surgery with complications Method of cholecystectomy Bile leakageBile duct injury Open0 – 0.5%0.1- 0.5% Laparoscopic1.3 – 2.7%0.5 – 2%

26. 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

27. Thank you

28. 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 Indications for cholecystectomy