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Joint Hospital Surgical Grand Round 21 Dec 2002 Management of Gallbladder Polyps PowerPoint Presentation
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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
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
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
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
Common types of PLG
  • Cholesterol polyp (40-70%)
  • Inflammatory polyp
  • Adenomyomatous hyperplasia
  • Adenoma
  • Carcinoma
usg diagnosis of plg
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
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 plg1
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
Indications for cholecystectomy
  • Possibility of Malignancy/ Malignant change of these lesions
  • Symptoms
indications for cholecystectomy1
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
Features of neoplastic PLG on US
  • Solitary lesion
  • Diameter >10mm
  • Sessile appearance
  • Low echogenicity
  • Rapid growth
indications for cholecystectomy2
Indications for cholecystectomy
  • USG alone cannot definitely distinguish adenocarcinoma from non-neoplastic lesions
indications for cholecystectomy3
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 cholecystectomy4
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 cholecystectomy5
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 eus endoscopic ultrasonography
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 cholecystectomy6
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 cholecystectomy7
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
slide22
EUS
  • Recommended when USG cannot rule out neoplastic lesion
  • Save cholecystectomy
indications for cholecystectomy8
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
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 plg1
Symptomatic PLG
  • Retrospective review only
  • Symptoms usually non-specific
    • Justify for cholecystectomy?
    • Major surgery with complications
conclusion
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 cholecystectomy9
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