Based on the available evidence, we agree with the recommendations of Boulton and Adams, with one exception (Figure 3). We suggest that the indications for resection in asymptomatic patients with small polyps (less than 10 mm in diameter) be expanded to include those with other features that increase the risk of malignancy. In addition to older age (over 50 years) and the presence of gallstones, additional high risk features include the presence of solitary polyps or polyp growth. The safety of laparoscopic cholecystectomy, as well as the dismal prognosis of gallbladder carcinoma discovered late in its course (less than 5% five-year survival for stage III and IV tumours), favour this approach. The roles of novel imaging and diagnostic techniques such as EUS, enhanced CT scanning and fine needle aspiration need to be further defined before their incorporation into the standard management of these lesions.
Figure 3) Recommended strategy for the management of polypoid lesions of the gallbladder (PLG) in adults. *Consider use of other modalities such as endoscopic ultrasound to assess malignant potential; fThe frequency of ultrasounds after stability over two serial six-month examinations should be determined on a case by case basis depending on existing risk factors. GI Gastrointestinal.
The management of PLG once a decision has been made for resection is also of some debate. In a study by Kubota et al, seven of eight early-stage cancers (confined to the mucosa and muscularis propria) were less than 18 mm in diameter, whereas all advanced cancers exceeded this dimension. Thus, the authors recommended laparoscopic cholecystectomy for lesions less than 18 mm in diameter, but a second-look operation if the tumour is found to invade the subserosa or beyond on histology. Due to the higher potential of underlying malignancy, the authors recommended that all lesions greater than 18 mm in diameter be removed by extended open cholecystectomy (with partial liver resection), allowing for possible lymph node removal. Conversely, others have suggested open resection in all cases in which malignancy is suspected based on preoperative evaluation because laparoscopic cholecystectomy in those with unsuspected gallbladder cancer has been reported to lead to a poor prognosis from recurrences, both locally and at the port site. Unfortunately, trials comparing these surgical approaches are not available. Thus, the ideal surgical approach to PLG with a suspicion of malignancy is unsettled. Take advantage of this opportunity – buy alesse to enjoy lowest prices online.
The frequency of ultrasonographic monitoring of patients with unresected PLG is also unclear. Boulton and Adams suggested an interval of every three to six months, while others feel that decisions should be made on a case by case basis, adjusted by the risk factors of each individual patient. Several studies have followed low risk lesions for several years without significant adverse consequences or marked change in the size and risk profiles of the lesions. Rapid, marked growth of lesions, however, can be missed in intervals as short as four to 12 months.