Surgical treatment of gallbladder polypoid lesions

INTRODUCTION Polypoid lesions of the gallbladder can be divided into benign and malignant categories. Malignant polypoid lesions include carcinomas of the gallbladder, which is the fifth most common malignancy of the gastrointestinal tract and the most common malignancy of the biliary tract. Benign polypoid lesions of the gallbladder are divided into true tumors and pseudotumors. Pseudotumors account for most of polypoid lesions of the gallbladder, and include polyps, hyperplasia, and other miscellaneous lesions. Adenomas are the most common benign neoplasms of the gallbladder. Cholesterol polyps are the most common pseudotumors of the gallbladder. The polyps can be single or multiple, usually less than 10 mm in size. They have no predilection for any particular gallbladder site, and usually are attached to the gallbladder wall by a delicate, narrow pedicle. No malignant potential has been identified for this type of pseudotumor. Adenomas are the most common benign neoplasms of the gallbladder. They have no predilection site in the gallbladder, and may also be associated with gallstones or cholecystitis. The premalignant nature of adenomas remains controversial. Ultrasonography (US) has been demonstrated to be significantly better in detecting polypoid lesions of the gallbladder as compared with computed tomography and cholecystography. A mass fixed to the gallbladder wall of normal thickness, without shadowing, is seen in case of gallbladder polyp. Since gallbladder cancers usually present as polypoid lesions, differentiation between benign polypoid lesion and malignant lesion can be very difficult, even with high-resolution imaging techniques. PATIENTS AND METHODS Retrospectively we have analyzed 38 patients with ultrasonographicaly detected gallbladder polyps during the period from January 1995 to December 2000, who were treated at surgical department of Health Centre in Uzice and at Surgical clinic of Clinical Centre in Nis. We have analyzed patients demographical data as well as their symptoms and radiographic findings. If the patient was operated, patohistological findings were analyzed also. RESULTS In our study 38 examined patients had mean age of 53.2 years (standard deviation of 12.8 years; range 26-80 years). The male-female ratio was 1:1. Overall 36 patients had symptoms that could be related to gallbladder diseases. Among these patients, 32 had pain in the upper-right quadrant of the abdomen that could be defined as biliar colic, and two had symptoms of acute cholecystitis. Among remaining four patients, two were examined because of the pain in the lower part of the abdomen. One patient had high temperature of unknown origin and the gallbladder polyp was detected accidentally during the ultrasonographic examination of the abdomen. Second patient had jaundice of unknown origin with ultrasound showing no significant changes in biliary tract. Preoperative ultrasound findings were inconsistent. The size of the lesion was marked only in 18 out of 38 patients. Among 34 operated patients, just 11 of them had patohistologicaly verified polipoid lesion. Patohistological analyzes of extirpated gallbladders showed one normal gallbladder, seven cholesterol polyps, one polipoid cholecystitis, and two real gallbladder neoplasms. One patient had gallbladder adenoma while the other had adenocarcinoma. Malignancy rate was 2.94% (one in 34). All patients with neoplastic polyps had solitary lesion larger than 1 cm in diameter, while the patients with non-neoplastic lesions had multiple lesions smaller than 1 cm in diameter. All operated patients, with the exception of one, had pathologically verified abnormal gallbladders. This results showed the presence of chronic cholecystitis even in the absence of the polyps. DISCUSSION Generally, no treatment is required in young patients with very small gallbladder polyps who are completely free from any symptoms. A patient with dyspeptic symptoms but no painful episodes consistent with biliary colic should be managed conservatively. Cholecystectomy is also indicated in patients with large gallbladder polyps sized over 10 mm irrespective of symptomatology. In patients with gallbladder polypoid lesions smaller than 10 mm, cholecystectomy is indicated only if complicating factors are present, e.g., age over 50 years and coexistence of gallstones. If the gallbladder polyp is smaller than 10 mm and complicating factors are absent, the "watch-and-wait" strategy seems to be recommendable. CONCLUSION Although gallbladder polyps are rare, they represent a significant health problem because they may be a precursor to gallbladder cancer. On the basis of the available data, and the results that we have gained in our study we suggest that gallbladder should be extirpated in cases when: 1. symptomatic lesions are present regardless of size; 2. polyps larger than 10 mm are present because they represent a risk for gallbladder cancer; 3. polyps are showing rapid increase in size. Polyps less than 10 mm that are incidentally identified and not removed should be assessed by ultrasonography at least every six months. This is especially critical for sessile polyps, in which the possibility of a small cancerous polyp is greater than in pedunculated polyps. Also, asymptomatic lesions less than 10 mm in diameter should be removed if patient is older than 50 years or if he has concomitant gallbladder calculosis.