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Finding 'em? Following 'em? Fixing 'em?: Comment on “Risk and Cost-Effectiveness of Surveillance Followed by Cholecystectomy for Gallbladder Polyps”

Finding 'em? Following 'em? Fixing 'em?: Comment on “Risk and Cost-Effectiveness of Surveillance... By their own admission, the article by Cairns et al1 will not change current clinical practice but it starkly focuses the issues surrounding the management of gallbladder polyps. More than half of ultrasonographically detected polypoid gallbladder masses are not adenomatous polyps but benign lesions such as cholesterol deposits or gallstones with no malignant potential. Even among adenomatous polyps, the rate of malignant change is unclear. This uncertainty is reflected in referral patterns where nearly 50% of all polyps in their series were neither discussed at a multidisciplinary meeting, referred for hepatobiliary specialist review, or even followed up. Only 7% of polyps that were followed up increased in size. Only 4% of resected polyps were potentially malignant or cancerous. However, set against this very benign picture is the specter of carcinoma of the gallbladder, which, when treatable, requires major hepatic surgery and for which there are no particularly effective adjuvant therapies. This provides an impetus to monitor or treat all gallbladder polyps. The treatment options currently available to the surgeon are ongoing surveillance or laparoscopic cholecystectomy. As Cairns et al point out, surveillance is only cost-effective when there is a high prevalence of adenomatous lesions within the polyp population—something with current imaging techniques we cannot yet be sure of. This highlights the need for a means of assessing metabolic function in polypoid gallbladder lesions that would help in defining nonmetabolically active calculi and mineral deposits. In addition, serial ultrasonography also has a significant financial and emotional cost to patients and relies on compliance and patient recall procedures. With this level of uncertainty in diagnosis and persisting concerns over the natural history of polyps, many patients and their surgeons will opt for a safely performed laparoscopic cholecystectomy to define the diagnosis and conclusively treat the problem rather than a prolonged period of surveillance. Back to top Article Information Correspondence: Dr Koea, North Shore Hospital, Department of Surgery, Private Bag 93503, Takapuna, Auckland 0620, New Zealand (jonathan.koea@waitematadhb.govt.nz). Published Online: August 20, 2012. doi:10.1001 /archsurg.2012.1959 Financial Disclosure: None reported. References 1. Cairns V, Neal CP, Dennison AR, Garcea G. Risk and cost-effectiveness of surveillance followed by cholecystectomy for gallbladder polyps [published online August 20, 2012]. Arch Surg. 2012;147(12):1078-1083Google ScholarCrossref http://www.deepdyve.com/assets/images/DeepDyve-Logo-lg.png Archives of Surgery American Medical Association

Finding 'em? Following 'em? Fixing 'em?: Comment on “Risk and Cost-Effectiveness of Surveillance Followed by Cholecystectomy for Gallbladder Polyps”

Archives of Surgery , Volume 147 (12) – Dec 1, 2012

Finding 'em? Following 'em? Fixing 'em?: Comment on “Risk and Cost-Effectiveness of Surveillance Followed by Cholecystectomy for Gallbladder Polyps”

Abstract

By their own admission, the article by Cairns et al1 will not change current clinical practice but it starkly focuses the issues surrounding the management of gallbladder polyps. More than half of ultrasonographically detected polypoid gallbladder masses are not adenomatous polyps but benign lesions such as cholesterol deposits or gallstones with no malignant potential. Even among adenomatous polyps, the rate of malignant change is unclear. This uncertainty is reflected in referral patterns...
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References (2)

Publisher
American Medical Association
Copyright
Copyright © 2012 American Medical Association. All Rights Reserved.
ISSN
0004-0010
eISSN
1538-3644
DOI
10.1001/archsurg.2012.1959
Publisher site
See Article on Publisher Site

Abstract

By their own admission, the article by Cairns et al1 will not change current clinical practice but it starkly focuses the issues surrounding the management of gallbladder polyps. More than half of ultrasonographically detected polypoid gallbladder masses are not adenomatous polyps but benign lesions such as cholesterol deposits or gallstones with no malignant potential. Even among adenomatous polyps, the rate of malignant change is unclear. This uncertainty is reflected in referral patterns where nearly 50% of all polyps in their series were neither discussed at a multidisciplinary meeting, referred for hepatobiliary specialist review, or even followed up. Only 7% of polyps that were followed up increased in size. Only 4% of resected polyps were potentially malignant or cancerous. However, set against this very benign picture is the specter of carcinoma of the gallbladder, which, when treatable, requires major hepatic surgery and for which there are no particularly effective adjuvant therapies. This provides an impetus to monitor or treat all gallbladder polyps. The treatment options currently available to the surgeon are ongoing surveillance or laparoscopic cholecystectomy. As Cairns et al point out, surveillance is only cost-effective when there is a high prevalence of adenomatous lesions within the polyp population—something with current imaging techniques we cannot yet be sure of. This highlights the need for a means of assessing metabolic function in polypoid gallbladder lesions that would help in defining nonmetabolically active calculi and mineral deposits. In addition, serial ultrasonography also has a significant financial and emotional cost to patients and relies on compliance and patient recall procedures. With this level of uncertainty in diagnosis and persisting concerns over the natural history of polyps, many patients and their surgeons will opt for a safely performed laparoscopic cholecystectomy to define the diagnosis and conclusively treat the problem rather than a prolonged period of surveillance. Back to top Article Information Correspondence: Dr Koea, North Shore Hospital, Department of Surgery, Private Bag 93503, Takapuna, Auckland 0620, New Zealand (jonathan.koea@waitematadhb.govt.nz). Published Online: August 20, 2012. doi:10.1001 /archsurg.2012.1959 Financial Disclosure: None reported. References 1. Cairns V, Neal CP, Dennison AR, Garcea G. Risk and cost-effectiveness of surveillance followed by cholecystectomy for gallbladder polyps [published online August 20, 2012]. Arch Surg. 2012;147(12):1078-1083Google ScholarCrossref

Journal

Archives of SurgeryAmerican Medical Association

Published: Dec 1, 2012

Keywords: cholecystectomy,cost effectiveness,polyp of gallbladder,surveillance, medical

There are no references for this article.