Minimally invasive treatment of gallbladder polyps
0 
Abstract
Gallbladder cancer is a lethal disease when diagnosed at later stages, and gallbladder polyps may have malignant potential or harbor cancer, especially as the polyp increases in size. Therefore, cholecystectomy has been recommended by guidelines for gallbladder polyps ≥ 10 mm, or smaller polyps with risk factors. In this article, we review minimally invasive approaches to the management of gallbladder polyps. The predominant method of cholecystectomy has been laparoscopic, which has advantages in faster recovery compared to open cholecystectomy. More recently, many surgeons have converted their minimally invasive techniques to robotic approaches. In addition, combined laparoscopic-endoscopic or purely endoscopic approaches have been reported. The ultimate goal of gallbladder polyp management using minimally invasive approaches is to minimize morbidity, given the low incidence of cancer within polyps, while preventing polyps with malignant potential from converting to cancer, or curing cancerous polyps.
Keywords
INTRODUCTION
Gallbladder polyps are estimated to have a prevalence of about 5%-15% of the population[1-4] and are most commonly discovered incidentally on abdominal ultrasound (US). In addition to abdominal US, computed tomography (CT) scan or magnetic resonance imaging (MRI) scan can be used to diagnose gallbladder polyps, but given the accuracy and lower cost of abdominal US, ultrasonography remains the preferred imaging modality. Gallbladder polyps can be classified as either pseudopolyps, which include cholesterol polyps, focal adenomyosis, hyperplastic polyps, and inflammatory polyps, or true polyps, which include adenomatous polyps or malignant polyps[5]. Pseudopolyps make up the majority of gallbladder polyps[6] and are considered to be benign. While adenomas are also benign, there is some evidence that they can potentially transform into malignant[7-9]. The natural history of gallbladder polyps has been investigated in several long-term US follow-up studies. Studies with 8-11 years of follow-up for small gallbladder polyps less than 6 mm showed that up to about one-third of patients no longer have visible polyps on the long-term follow-up US[4,10,11]. However, another long-term follow-up of 20 years of gallbladder polyps demonstrated that even for small polyps less than 6 mm, growth of 2 mm or greater is not uncommon[12].
The treatment of gallbladder polyps with potentially a high risk of transforming into or containing adenocarcinoma is important, given the markedly improved survival of gallbladder cancer when detected in earlier stages compared to T3 or later lesions. Factors associated with increased risk of malignancy include older age, sessile polyp, single or unifocal polyp, larger size, a growth rate greater than 3 mm per year, Asian or Indian ethnicity, hyperlipidemia, and symptoms[6,13-17]. For example, Asian patients have been reported to have a rate of malignant gallbladder polyps of 14%, vs. 6% for European patients[18]. An additional identified risk factor for malignancy in gallbladder polyps is primary sclerosing cholangitis, with these patients demonstrating a greater than 50% rate of malignancy in gallbladder masses ranging from size 0.5 cm to over 3.0 cm[19,20]. However, these studies were small (less than 20 patients each) and retrospective in nature. There is mixed evidence as to whether gallstones are a risk factor for gallbladder cancer in patients with gallbladder polyps[17,21]. One study used a scoring system consisting of the presence of age greater than 50, symptoms, polyp size greater than 12.5 mm, single polyp, gallstones, and gallbladder wall thickness and demonstrated that when less than 4 of these factors were present, the rate of neoplastic polyp was less than 1%, while if 4 or more were present, the rate of neoplastic polyp was 63%[22]. A recent meta-analysis exhibited a low risk of gallbladder cancer in polyps less than 10 mm in size, showing that in studies with at least moderate quality, 4.6 cancers per 10,000 patients were detected in polyps less than 10 mm[23]. The risk of gallbladder cancer in polyps less than 6 mm appears to be extremely small and essentially zero[18]. However, the management of intermediate-sized gallbladder polyps is somewhat controversial, as even polyps less than 10 mm may be true or neoplastic polyps[14] and other studies have shown a small but nonzero risk of malignancy in polyps less than 10 mm[18,24], while conversely other studies including the largest cohort study of over 35,000 patients with gallbladder polyps over 20 years have seen none or exceptionally rare gallbladder cancer cases in polyps less than 10 mm[12,25].
MANAGEMENT OF GALLBLADDER POLYPS
Several different societies have published guidelines for the management of gallbladder polyps. The most recent guidelines from the Society of Radiologists in Ultrasound (SRU) focus on characteristics of the polyp and recommend cholecystectomy for polyps ≥ 15 mm or ≥ 7 mm if focal wall thickening is also present, and US surveillance for polyps 10-14 mm and polyps 7-9 mm the polyp is sessile or pedunculated with a thick stalk. No follow-up is needed for pedunculated polyps that are less than 10 mm in size and also have a thin stalk. The European guidelines recommend cholecystectomy for polyps that are symptomatic or ≥ 10 mm. These guidelines stratify patients with risk factors including age ≥ 60 years, primary sclerosing cholangitis, Asian ethnicity, and sessile lesion including focal gallbladder wall thickening ≥ 4 mm. For patients with small polyps and no risk factors, no follow-up is needed. For patients with small polyps and risk factors, surveillance is recommended. Finally, for patients with 7-9 mm polyps without risk factors, surveillance is recommended, but if a risk factor is present, then cholecystectomy is recommended. The Canadian Association of Radiologists (CAR) follows the American College of Radiology (ACR) white page recommendations with no follow for small polyps, US surveillance for polyps 7-9 mm, and cholecystectomy for polyps ≥ 10 mm.
The guidelines, each described in Table 1, together can be synthesized to stratify patients based on symptoms, size of polyp, and risk factors for malignancy. We recommend first treating those who are symptomatic with cholecystectomy. Next, in asymptomatic patients, the size and presence of risk factors (age, Asian ethnicity, primary sclerosing cholangitis, and characteristics of the polyp, including sessile polyps or polyps with focal wall thickening) should be considered. Small polyps in patients without risk factors may not need further follow-up, while intermediate-size or small polyps with risk factors should undergo surveillance for growth with cholecystectomy if the size increases to greater than 1 cm. Lastly, intermediate-size polyps with risk factors or large polyps greater than 1 cm in size are generally recommended to be resected. A treatment algorithm based on these guidelines is shown in Figure 1.
Society guidelines and recommendations regarding the management of incidentally discovered gallbladder polyps
| Society | Year published | Size | ||
| ≤ 6 mm | 7-9 mm | ≥ 10 mm | ||
| SRU[26] | 2022 | Pedunculated or sessile: no follow-up Focal wall thickening ≥ 4 mm: US at 6, 12, 24, 36 mo vs. surgery | Pedunculated, thin stalk: no follow-up Pedunculated, thick stalk or sessile: US at 12 mo, stop if decrease ≥ 4 mm Focal wall thickening ≥ 4 mm: surgery | 10-14 mm, pedunculated or sessile: US at 6, 12, 24, 36 mo vs. surgery ≥ 15 mm: surgery Focal wall thickening ≥ 4mm: surgery |
| ESGAR, EAES, EFISDS, ESGE[27,28] | 2017 with 2022 update | Symptoms present: surgery No risk factors*: no follow-up Risk factor* present: US at 6, 12, 24 mo; stop if no growth | Symptoms present: surgery No risk factors*: US at 6, 12, 24 mo; stop if no growth Risk factor* present: surgery | Surgery |
| ACR[29] CAR[30] | 2013 2020 | No evaluation or follow-up recommendations | Follow yearly with ultrasound; surgery if polyp grows If the patient is at higher risk (> 50 years old, sessile or single polyp, PSC, Indian ethnicity), initial follow-up ultrasound at 6 months, then yearly | Surgery |
Figure 1. Flowchart for the management of a gallbladder polyp detected on ultrasound. PSC: primary sclerosing cholangitis; US: ultrasound.
Surgical management of gallbladder polyps
While surveillance with US is a cost-effective strategy for small gallbladder polyps[31], once a gallbladder polyp meets the criteria for surgery, the operation most commonly performed is cholecystectomy. Given the low malignancy rate, more radical resection or lymph node dissection beyond cholecystectomy alone is not required for polyps without a histologic confirmation or otherwise high suspicion of cancer.
If, however, based on preoperative factors, there is a high suspicion of cancer within the polyp (for example, a very large single sessile polyp in an older patient), the operation should include a frozen section of the gallbladder to determine the presence of malignancy. In addition, the technique may include resection of the cystic plate en bloc with the gallbladder, particularly if the polyp is located on the hepatic side of the gallbladder, as T2 tumors on the hepatic side are much more likely to have cancer cells remaining in the gallbladder bed after simple cholecystectomy than tumors on the peritoneal side of the gallbladder[32]. Care should be taken to avoid spillage of bile during the cholecystectomy, as intraoperative bile spillage and surgical drain placement are associated with worse progression-free and overall survival[33]. In order to ensure negative margins, a frozen section of the cystic duct on the gallbladder specimen and sampling of the cystic duct node are reasonable. If malignancy is confirmed on intraoperative frozen sections and hepatobiliary expertise is available, then definitive radical resection can be performed at the same operation. If cancer is discovered at cholecystectomy but experience with portal dissection and hepatectomy or other hepatobiliary expertise is not available for radical resection at the center performing the cholecystectomy, documentation of all findings and referral to a center with hepatobiliary expertise is also an option. An alternative scenario of the discovery of an incidental adenocarcinoma occurs postoperatively following cholecystectomy on the final pathologic analysis of the gallbladder specimen. When malignancy is found and the final stage is T1a or only involves the lamina propria with negative margins, then cholecystectomy alone is sufficient. However, if any margins are positive, the pathologic stage is T1b (invading the muscle layer) or greater, or any node is positive, then complete staging is followed by a second operation for radical resection consisting of hepatectomy with segment IVb/V resection and portal lymphadenectomy to achieve negative margins and an R0 resection is warranted[34,35]. Data suggests that immediate or early reoperation for radical resection is not required, and, in fact, delay of radical resection to about 4-8 weeks is oncologically safe[36] and that disease biology, rather than time to reoperation, is more significant in determining the overall outcome[37].
Minimally invasive surgery for gallbladder polyps
The historical method of gallbladder resection was open cholecystectomy (OC), usually with a subcostal incision. Laparoscopic cholecystectomy (LC) was first reported in 1987[38] and was subsequently shown to have lower complication rate and faster recovery compared to OC for benign gallbladder disease, including cholelithiasis and acute cholecystitis[39-41]. The laparoscopic approach for cholecystectomy was then expanded to include gallbladder polyps as the majority are in fact benign. The laparoscopic approach was initially utilized for gallbladder polyps with caution, given their malignant potential, as a 1998 study reported 2 cases of disseminated gallbladder cancer after LC, including one for a gallbladder polyp[42]. However, other early case series of laparoscopic cholecystectomies for gallbladder polyps [Table 2][43-46] each concluded that laparoscopic resection of even early T1 malignant lesions arising in gallbladder polyps was safe. More recently, advances in laparoscopic technique have reported the utilization of a single port laparoscopic approach to LC. While multiple studies have evaluated single port LC (SP-LC), Choi et al.[47] compared 56 SP-LC specifically for gallbladder polyps to an equal number of conventional LC and found no difference in complication rate, bile spillage, postoperative pain, or hospital stay, and all conversions to open were in the conventional LC cohort. The findings suggest SP-LC is a safe minimally invasive surgical approach to the management of gallbladder polyps in addition to standard LC.
Studies evaluating minimally invasive surgery that specifically include gallbladder polyps
| Kubota et al.[43] | Lap | 26 | 3 | Laparoscopy feasible even with early cancer |
| Kubota et al.[44] | Lap | 34 | 4 | Laparoscopy feasible even with early cancer |
| Yeh et al.[45] | Lap | 123 | 7 | Laparoscopy safe and feasible but suspect cancer when > 15 mm |
| Huang et al.[46] | Lap | 143 | 6 | 5/6 patients with early cancer had no recurrence at 2-3 year follow-up |
| Miller et al.[50] | Rob | 2 | 0 | No complications or conversions to open with RC |
| Choi et al.[47] | SP Lap | 56 SP Lap, 56 Lap | 1 SP Lap, 1 Lap | No difference in LOS, bile spillage, conversion to open, or complication between SP lap and lap |
| Pietrabissa | Lap and SI Rob | NR | NR | No difference in postoperative pain, bleeding, or bile spillage |
| Tao et al.[53] | Rob and Lap | 12 (2.7%) Lap, 7 (4.1%) Rob (P > 0.05) | NR | RC superior in LOS, EBL, or conversion to open (P < 0.05) |
In the mid-1990s, the robotic approach to cholecystectomy was first described[48,49]. The United States Food and Drug Administration (FDA) approved the da Vinci robotic surgical system in 2000. The robotic technique allows for several advantages over laparoscopy, including 3D camera visualization and wrist articulation of the instruments. Early series of robotic cholecystectomy (RC) for benign disease included small percentages of cholecystectomies performed for polyps and showed that RC was safe without complications or conversions to open [Table 2][50]. In general, systematic reviews and meta-analyses of LC vs. RC show that LC has shorter operative times, but there are no significant differences in complications, hospital length of stay, or readmission rate for RC or LC[51,52]. A recent retrospective study compared outcomes of 612 LC and RC that included a total of 19 gallbladder polyps (3.1% of the cholecystectomies were for gallbladder polyps). Amongst all cases, the authors found that RC had improved hospital length of stay, blood loss, and conversion to open compared to LC, with no difference in grade 3 or higher Clavien-Dindo complications[53]. A randomized controlled trial of single incision RC (SI-RC) vs. LC with conventional 4 ports included gallbladder polyps as inclusion criteria for cholecystectomy and demonstrated no statistically significant differences between SI-RC and LC in postoperative pain or adverse events including bile spillage and bleeding, while SI-RC had improved cosmesis[54]. Therefore, for those with experience and comfort with robotic surgery, RC can be a viable alternative to LC for minimally invasive treatment of gallbladder polyps.
Minimally invasive surgery for incidentally discovered gallbladder cancer
A minimally invasive approach for radical resection of gallbladder cancer using laparoscopy was shown in institutional case series to have low blood loss, minimal morbidity, and negative margins[55]. A retrospective institutional series comparing laparoscopic management of patients with known gallbladder cancer to those with incidentally discovered gallbladder cancer showed that the conversion rate was higher without statistical significance in known cancer vs. incidentally discovered cancer groups (29% vs. 9%, respectively). 73% of the procedures had at least 7 lymph nodes retrieved during the lymphadenectomy[56]. In comparing laparoscopic radical resection vs. open, another retrospective study showed lower blood loss and hospital stay with laparoscopy with similar 1-year overall survival[57]. Mayo reported institutional data showing less blood loss and shorter length of stay for laparoscopic vs. open liver resection for intrahepatic cholangiocarcinoma and gallbladder cancer, with no difference in negative margin rate, complete lymphadenectomy rate, and 3-year overall and disease-free survival rate[58]. The similar survival rate between open and laparoscopic surgery for gallbladder cancer was shown to be consistent in T2 cancers regardless of nodal status (N0 or N1)[59]. Two meta-analyses of laparoscopic vs. open surgery for gallbladder cancer[60,61] showed less intraoperative blood loss and shorter hospital stay for laparoscopic surgery with no differences in overall or disease-free survival. Robotic radical resection for gallbladder cancer is also feasible, with studies showing median lymph node retrieval of > 7 and the ability to achieve negative margins[62]. A retrospective single-institution study of 8 patients who underwent robotic surgery for suspected or confirmed gallbladder cancer also demonstrated safety, with intraoperative blood loss of 199 mL, no conversions to open, one (12.5%) complication for postoperative bleeding, and one (12.5%) complication for port site hernia[63]. Comparisons of open and minimally invasive surgery for gallbladder cancer are summarized in Table 3. While no prospective or randomized controlled trials have been performed due to the relatively low frequency of gallbladder cancer, the literature supports the assertion that either a laparoscopic or robotic approach to radical gallbladder resection for a cancer if found at the time of cholecystectomy for polyps or other benign disease appears to be safe at experienced laparoscopic or robotic centers but may not be generalizable to all centers.
Retrospective studies comparing minimally invasive vs. open radical resection for gallbladder cancer
| Agarwal et al.[64] | Open: 123 Lap: 24 | Open: 275 Lap: 200 | Open: 5 Lap: 5 | Open: 17% Lap: 13% | No difference in R0 rate or number of lymph nodes resected |
| Feng et al.[65] | Open: 61 Lap: 41 | Open: 386 Lap: 358 | Open: 11 Lap: 5 | Open: 9.8% Lap: 7.3% | 5-year OS Open: 56% Lap: 52% |
| Vega et al.[66] | Open: 190 Lap: 65 | Open: 200 Lap: 300 | Open: 6 Lap 4 | Open: 20% Lap: 18% | 3-year OS Open: 62% Lap: 87% |
| Dou et al.[57] | Open: 31 Lap: 32 | Open: 503 Lap: 267 | Open: 14 Lap: 11 | No difference in the rate of Clavien-Dindo grade 0-2 or 3-4 events | 1-year OS Open: 48% Lap: 73% (P = 0.09) |
| Navarro et al.[67] | Open: 43 Lap: 43 | Open: 208 Lap: 72 | Open: 13 Lap 6 | Open: 4 Clavien-Dindo ≥ 2 Lap: 0 Clavien-Dindo ≥ 2 | 5-year OS Open: 64% Lap: 80% (P = 0.21) |
| Yang et al.[68] | Open: 56 Rob: 28 | Open: 156 Rob: 99 | Open: 13 Rob: 10 | Open: 21% Rob: 10% | 3-year OS Open: 63% Rob: 75% |
| Lee et al.[69] | Open: 24 Lap: 20 | Open: 594 Lap: 320 | Open: 12 Lap: 11 | Open: 21% Lap: 10% | 5-year OS Open: 54% Lap: 80% |
| Cho et al.[70] | Open: 19 Lap: 19 | NR | Open: 14 Lap: 8 | Open: 10% Lap: 21% | 5-year OS Open: 82% Lap: 78% |
| Dou et al.[71] | Open: 30 Lap: 30 | Open: 484 Lap: 257 | Open: 14 Lap: 10 | Open: 7% Lap: 10% | 3-year OS Open: 30% Lap: 40% |
Endoscopic management of gallbladder polyps
Given the low rate of malignancy within polyps, especially those that are small in size, the drive for more minimally invasive procedures has led to studies investigating the use of endoscopy without gallbladder resection to manage gallbladder polyps. A described minimally invasive alternative to cholecystectomy is a combined laparoscopic/endoscopic approach with polyp removal but instead sparing of the gallbladder. In 2014, Wang et al. reported on 9 pigs that were treated with microwaves 50-70 mA for 9 seconds and experienced recovery of gallbladder mucosa to normal 2 weeks later, and then applied this technique to 60 patients with gallbladder polyps. The polyps were cauterized and removed, with the procedure taking 60-135 min with a 93% technical success rate. Finally, the authors report that at 3 months, the polyps had not recurred[72]. A separate group from China reported a similar case report of a combined endoscopic and laparoscopic gallbladder preserving treatment of a 13 × 9 mm gallbladder polyp. The procedure describes a laparoscopic incision to open and access the gallbladder, followed by placing the endoscope through an umbilical laparoscopic port to perform a polypectomy of the gallbladder, and finally, closure of the gallbladder incision using laparoscopic suturing[73].
Another technique aimed to use endoscopy alone and was first described for the treatment of gallstones. One study uses endoscopic ultrasound-guided cholecystostomy (either via cholecystoduodenostomy or cholecystogastrostomy) to place a metal stent for access to the gallbladder. Several days later, the patient returns for endoscopic per oral gallbladder polypectomy. Shen et al.[74] report their experience with 4 patients with multiple polyps using this technique (3 cholecystoduodenostomy and 1 cholecystogastrostomy) and found that 1 patient developed significant pancreatitis and another later underwent LC for cholelithiasis, but none of the 4 patients developed gallbladder polyp recurrence at 3-15 months and all eventually had the stent removed. Another group reported on 22 patients who underwent a similar technique of endoscopic gallbladder polypectomy, but as one procedure without metal stent placement. Zhang et al.[75] describe an endoscopic anterior gastrotomy and introduction of the endoscope into the peritoneal cavity, followed by identification and incision into the gallbladder. After suctioning bile, polypectomy is performed with snare, biopsy forceps, or argon beam coagulation. The cholecystotomy is closed with clips and the gastrotomy is closed with endoloop and clips. This study reports a median hospital stay of 5 days and 4 (18.2%) patients with complications of localized peritonitis. One patient developed recurrent gallstones but wished not to undergo LC as he was asymptomatic. Another endoscopic strategy employed is embryonic-natural orifice transumbilical endoscopic surgery (E-NOTES), which uses a 10 mm trochar placed through the umbilicus, followed by gallbladder incision with an endoscope, polypectomy, and gallbladder closure with clips. He et al.[76] report their experience of 12 patients who underwent E-NOTES and describe minimal post-procedural pain and satisfactory cosmetic outcome with no recurrence of polyps at 12 months. As the current literature is retrospective, subject to publication bias, and includes less than 100 total patients, additional data is needed to confirm the safety and efficacy of these approaches, and only patients with very low risk of cancer are appropriate for these techniques as they involve cholecystotomy and significant risk of bile spillage which would worsen survival in the event a cancerous polyp was discovered. The endoscopic techniques summarized in Table 4 nonetheless represent continued advancement and innovation toward increasingly minimally invasive and organ-sparing treatment of gallbladder polyps.
Studies evaluating endoscopic gallbladder polyp management
| Wang et al.[72] | Combined lap and endo, with lap cholecystotomy and endo polypectomy | 60 | 93% technical success with no polyp recurrence at 3 months |
| Shen et al.[74] | EUS guided cholecystostomy with metal stent placement, followed by second endo gallbladder polypectomy | 4 | 1 patient with pancreatitis, 1 patient underwent LC for gallstones, no polyp recurrence |
| Zheng et al.[73] | Combined lap and endo with laparoscopy used to identify and incise gallbladder, followed by transumbilical endo electroresection, and lap suture of gallbladder | 1 | Operative time 96 min with EBL of 10 mL |
| Zhang et al.[75] | Endo gastrotomy to allow endoscope into peritoneum followed by endo incision in gallbladder for access to polypectomy, endoloop and clips to close both | 22 | 4 patients with localized peritonitis, median LOS 5 days, 1 recurrent gallstone |
| He et al.[76] | E-NOTES: insertion of endoscope via 10 mm umbilical trochar to incise gallbladder, perform polypectomy, and close gallbladder with clips | 12 | No recurrence of polyps at 12 months |
CONCLUSION
Gallbladder polyps are occasionally encountered on abdominal US, given the overall common incidence of cholelithiasis. A minimally invasive strategy for managing gallbladder polyps not only aims to minimize procedural morbidity but also balances the overall low risk of either harboring or developing into gallbladder cancer, with a high rate of mortality from gallbladder cancer when diagnosed at later stages. In select low-risk patients, no follow-up or US follow-up is appropriate. When cholecystectomy is indicated, laparoscopic cholecystectomy is preferred and single port or single incision laparoscopic surgery has been used for gallbladder polyps as well with acceptable results. In addition to laparoscopic surgery, robotic surgery has advantages that include wrist motion of the instruments and 3D visualization from the camera, and potential benefits include future technological advances in indocyanine green (ICG) fluorescence, artificial intelligence, or augmented reality applications to the robotic platform. Laparoscopic and robotic surgery not only has benefits over open surgery with respect to short-term outcomes, but also appears to be oncologically safe in the event that either an early cancer that can be treated with cholecystectomy alone is encountered, or in the event a more radical resection is required in experienced centers. Finally, several authors have attempted gallbladder sparing polypectomies using either combined endoscopic/laparoscopic or purely endoscopic techniques for benign gallbladder polyps to further reduce the invasiveness of the management of gallbladder polyps. Small retrospective studies appear to demonstrate some safety and feasibility of these techniques in select patients with polyps without a high risk of harboring cancer; however, more evidence is required before broad adoption of these approaches over the standard laparoscopic or robotic cholecystectomy.
DECLARATIONS
Authors’ contributionsLiterature review, writing manuscript, editing and review: Sullivan KM, Fong Y
Availability of data and materialsNot applicable.
Financial support and sponsorshipNone.
Conflicts of interestFong Y is a paid scientific consultant for Medtronics, Johnson & Johnson, and Imugene. Fong Y receives royalties for inventions from Merck and Imugene. Sullivan KM declares no conflict of interest.
Ethical approval and consent to participateNot applicable.
Consent for publicationNot applicable.
Copyright© The Author(s) 2023.
REFERENCES
1. Segawa K, Arisawa T, Niwa Y, et al. Prevalence of gallbladder polyps among apparently healthy Japanese: ultrasonographic study. Am J Gastroenterol 1992;87:630-3.
2. Lin WR, Lin DY, Tai DI, et al. Prevalence of and risk factors for gallbladder polyps detected by ultrasonography among healthy Chinese: analysis of 34 669 cases. J Gastroenterol Hepatol 2008;23:965-9.
3. Shinchi K, Kono S, Honjo S, Imanishi K, Hirohata T. Epidemiology of gallbladder polyps: an ultrasonographic study of male self-defense officials in Japan. Scand J Gastroenterol 1994;29:7-10.
4. Heitz L, Kratzer W, Gräter T, Schmidberger J. EMIL study group. Gallbladder polyps - a follow-up study after 11 years. BMC Gastroenterol 2019;19:42.
5. McCain RS, Diamond A, Jones C, Coleman HG. Current practices and future prospects for the management of gallbladder polyps: a topical review. World J Gastroenterol 2018;24:2844-52.
6. Elmasry M, Lindop D, Dunne DF, Malik H, Poston GJ, Fenwick SW. The risk of malignancy in ultrasound detected gallbladder polyps: a systematic review. Int J Surg 2016;33 Pt A:28-35.
8. Okamoto M, Okamoto H, Kitahara F, et al. Ultrasonographic evidence of association of polyps and stones with gallbladder cancer. Am J Gastroenterol 1999;94:446-50.
9. Kozuka S, Tsubone M, Yasui A, Hachisuka K. Relation of adenoma to carcinoma in the gallbladder. Cancer 1982;50:2226-34.
10. Rafaelsen SR, Otto PO, Pedersen MRV. Long-term ultrasound follow-up in patients with small gallbladder polyps. Dan Med J 2020:67.
11. Corwin MT, Siewert B, Sheiman RG, Kane RA. Incidentally detected gallbladder polyps: is follow-up necessary? Radiology 2011;258:277-82.
12. Szpakowski JL, Tucker LY. Outcomes of gallbladder polyps and their association with gallbladder cancer in a 20-year cohort. JAMA Netw Open 2020;3:e205143.
13. Kwon W, Jang JY, Lee SE, Hwang DW, Kim SW. Clinicopathologic features of polypoid lesions of the gallbladder and risk factors of gallbladder cancer. J Korean Med Sci 2009;24:481-7.
14. Taskin OC, Basturk O, Reid MD, et al. Gallbladder polyps: correlation of size and clinicopathologic characteristics based on updated definitions. PLoS One 2020;15:e0237979.
15. Han JW, Choi YH, Lee IS, Choi HJ, Hong TH, You YK. Gallbladder polyps growth rate is an independent risk factor for neoplastic polyps. United European Gastroenterol J 2022;10:651-6.
16. Deng Z, Xuan Y, Li X, et al. Effect of metabolic syndrome components on the risk of malignancy in patients with gallbladder lesions. J Cancer 2021;12:1531-7.
17. Aldouri AQ, Malik HZ, Waytt J, et al. The risk of gallbladder cancer from polyps in a large multiethnic series. Eur J Surg Oncol 2009;35:48-51.
18. Babu BI, Dennison AR, Garcea G. Management and diagnosis of gallbladder polyps: a systematic review. Langenbecks Arch Surg 2015;400:455-62.
19. Buckles DC, Lindor KD, Larusso NF, Petrovic LM, Gores GJ. In primary sclerosing cholangitis, gallbladder polyps are frequently malignant. Am J Gastroenterol 2002;97:1138-42.
20. Said K, Glaumann H, Bergquist A. Gallbladder disease in patients with primary sclerosing cholangitis. J Hepatol 2008;48:598-605.
21. Park JK, Yoon YB, Kim YT, et al. Management strategies for gallbladder polyps: is it possible to predict malignant gallbladder polyps? Gut Liver 2008;2:88-94.
22. Güneş Y, Taşdelen İ, Ergin A, et al. A new risk scoring system to predict malignancy in gallbladder polyps: a single-center study. J Gastrointest Surg 2022;26:1846-52.
23. Foley KG, Riddell Z, Coles B, Roberts SA, Willis BH. Risk of developing gallbladder cancer in patients with gallbladder polyps detected on transabdominal ultrasound: a systematic review and meta-analysis. Br J Radiol 2022;95:20220152.
24. Chou SC, Chen SC, Shyr YM, Wang SE. Polypoid lesions of the gallbladder: analysis of 1204 patients with long-term follow-up. Surg Endosc 2017;31:2776-82.
25. Ito H, Hann LE, D'Angelica M, et al. Polypoid lesions of the gallbladder: diagnosis and followup. J Am Coll Surg 2009;208:570-5.
26. Kamaya A, Fung C, Szpakowski JL, et al. Management of incidentally detected gallbladder polyps: society of radiologists in ultrasound consensus conference recommendations. Radiology 2022;305:277-89.
27. Wiles R, Thoeni RF, Barbu ST, et al. Management and follow-up of gallbladder polyps : Joint guidelines between the European Society of Gastrointestinal and Abdominal Radiology (ESGAR), European Association for Endoscopic Surgery and other Interventional Techniques (EAES), International Society of Digestive Surgery - European Federation (EFISDS) and European Society of Gastrointestinal Endoscopy (ESGE). Eur Radiol 2017;27:3856-66.
28. Foley KG, Lahaye MJ, Thoeni RF, et al. Management and follow-up of gallbladder polyps: updated joint guidelines between the ESGAR, EAES, EFISDS and ESGE. Eur Radiol 2022;32:3358-68.
29. Sebastian S, Araujo C, Neitlich JD, Berland LL. Managing incidental findings on abdominal and pelvic CT and MRI, Part 4: white paper of the ACR Incidental Findings Committee II on gallbladder and biliary findings. J Am Coll Radiol 2013;10:953-6.
30. Bird JR, Brahm GL, Fung C, Sebastian S, Kirkpatrick IDC. Recommendations for the management of incidental hepatobiliary findings in adults: endorsement and adaptation of the 2017 and 2013 acr incidental findings committee white papers by the canadian association of radiologists incidental findings working group. Can Assoc Radiol J 2020;71:437-47.
31. Patel K, Dajani K, Vickramarajah S, Huguet E. Five year experience of gallbladder polyp surveillance and cost effective analysis against new European consensus guidelines. HPB 2019;21:636-42.
32. Shindoh J, de Aretxabala X, Aloia TA, et al. Tumor location is a strong predictor of tumor progression and survival in T2 gallbladder cancer: an international multicenter study. Ann Surg 2015;261:733-9.
33. Blakely AM, Wong P, Chu P, et al. Intraoperative bile spillage is associated with worse survival in gallbladder adenocarcinoma. J Surg Oncol 2019;120:603-10.
34. Aloia TA, Járufe N, Javle M, et al. Gallbladder cancer: expert consensus statement. HPB 2015;17:681-90.
35. Benson AB, D'Angelica MI, Abbott DE, et al. Hepatobiliary cancers, version 2.2021, NCCN clinical practice guidelines in oncology. J Natl Compr Canc Netw 2021;19:541-65.
36. Ethun CG, Postlewait LM, Le N, et al. Association of optimal time interval to re-resection for incidental gallbladder cancer with overall survival: a multi-institution analysis from the US extrahepatic biliary malignancy consortium. JAMA Surg 2017;152:143-9.
37. Søreide K, Guest RV, Harrison EM, Kendall TJ, Garden OJ, Wigmore SJ. Systematic review of management of incidental gallbladder cancer after cholecystectomy. Br J Surg 2019;106:32-45.
38. Litynski GS. Profiles in laparoscopy: Mouret, Dubois, and Perissat: the laparoscopic breakthrough in Europe (1987-1988). JSLS-J Soc Laparoend 1999;3:163-7.
39. Lujan JA, Parrilla P, Robles R, Marin P, Torralba JA, Garcia-Ayllon J. Laparoscopic cholecystectomy vs open cholecystectomy in the treatment of acute cholecystitis: a prospective study. Arch Surg 1998;133:173-5.
40. Keus F, de Jong JA, Gooszen HG, van Laarhoven CJ. Laparoscopic versus open cholecystectomy for patients with symptomatic cholecystolithiasis. Cochrane Database Syst Rev ;1996:2010.
41. Coccolini F, Catena F, Pisano M, et al. Open versus laparoscopic cholecystectomy in acute cholecystitis. Systematic review and meta-analysis. Int J Surg 2015;18:196-204.
42. Shirai Y, Ohtani T, Hatakeyama K. Laparoscopic cholecystectomy may disseminate gallbladder carcinoma. Hepato-gastroenterology 1998;45:81-2.
43. Kubota K, Bandai Y, Otomo Y, et al. Role of laparoscopic cholecystectomy in treating gallbladder polyps. Surg Endosc 1994;8:42-6.
44. Kubota K, Bandai Y, Noie T, Ishizaki Y, Teruya M, Makuuchi M. How should polypoid lesions of the gallbladder be treated in the era of laparoscopic cholecystectomy? Surgery 1995;117:481-7.
45. Yeh CN, Jan YY, Chao TC, Chen MF. Laparoscopic cholecystectomy for polypoid lesions of the gallbladder: a clinicopathologic study. Surg Laparosc Endosc Percutan Tech 2001;11:176-81.
46. Huang CS, Lien HH, Jeng JY, Huang SH. Role of laparoscopic cholecystectomy in the management of polypoid lesions of the gallbladder. Surg Laparosc Endosc Percutan Tech 2001;11:242-7.
47. Choi C, Roh YH, Kim MC, Choi HJ, Kim YH, Jung GJ. Single-port laparoscopic cholecystectomy for gall bladder polyps. JSLS 2015:19.
48. Gagner M, Begin E, Hurteau R, Pomp A. Robotic interactive laparoscopic cholecystectomy. Lancet 1994;343:596-7.
49. Himpens J, Leman G, Cadiere GB. Telesurgical laparoscopic cholecystectomy. Surg Endosc 1998;12:1091.
50. Miller DW, Schlinkert RT, Schlinkert DK. Robot-assisted laparoscopic cholecystectomy: initial Mayo Clinic Scottsdale experience. Mayo Clin Proc 2004;79:1132-6.
51. Huang Y, Chua TC, Maddern GJ, Samra JS. Robotic cholecystectomy versus conventional laparoscopic cholecystectomy: a meta-analysis. Surgery 2017;161:628-36.
52. Sun N, Zhang JL, Zhang CS, Li XH, Shi Y. Single-incision robotic cholecystectomy versus single-incision laparoscopic cholecystectomy: a systematic review and meta-analysis. Medicine 2018;97:e12103.
53. Tao Z, Emuakhagbon VS, Pham T, Augustine MM, Guzzetta A, Huerta S. Outcomes of robotic and laparoscopic cholecystectomy for benign gallbladder disease in Veteran patients. J Robot Surg 2021;15:849-57.
54. Pietrabissa A, Pugliese L, Vinci A et al. Short-term outcomes of single-site robotic cholecystectomy versus four-port laparoscopic cholecystectomy: a prospective, randomized, double-blind trial. Surg Endosc 2016;30:3089-97.
55. Ome Y, Hashida K, Yokota M, Nagahisa Y, Okabe M, Kawamoto K. Laparoscopic approach to suspected T1 and T2 gallbladder carcinoma. World J Gastroenterol 2017;23:2556-65.
56. Piccolo G, Ratti F, Cipriani F, Catena M, Paganelli M, Aldrighetti L. Totally laparoscopic radical cholecystectomy for gallbladder cancer: a single center experience. J Laparoendosc Adv Surg Tech A 2019;29:741-6.
57. Dou C, Zhang Y, Liu J, et al. Laparoscopy versus laparotomy approach of a radical resection for gallbladder cancer: a retrospective comparative study. Surg Endosc 2020;34:2926-38.
58. Pery R, Gudmundsdottir H, Nagorney DM, et al. Laparoscopic versus open liver resections for intrahepatic cholangiocarcinoma and gallbladder cancer: the Mayo clinic experience. HPB 2023;25:339-46.
59. Lee J, Han H, Yoon Y, et al. Minimally invasive surgery for gallbladder cancer at an expert center. MIS 2021; doi: 10.20517/2574-1225.2021.139.
60. Zhang W, Ouyang DL, Che X. Short- and long-term outcomes of laparoscopic vs open surgery for T2 gallbladder cancer: a systematic review and meta-analysis. World J Gastrointest Surg 2022;14:1387-96.
61. Ahmed SH, Usmani SUR, Mushtaq R, et al. Role of laparoscopic surgery in the management of gallbladder cancer: systematic review & meta-analysis. Am J Surg 2023;Online ahead of print.
62. Byun Y, Choi YJ, Kang JS, et al. Robotic extended cholecystectomy in gallbladder cancer. Surg Endosc 2020;34:3256-61.
63. Belli A, Patrone R, Albino V, et al. Robotic surgery of gallbladder cancer. Mini-invasive Surg 2020;4:77.
64. Agarwal AK, Javed A, Kalayarasan R, Sakhuja P. Minimally invasive versus the conventional open surgical approach of a radical cholecystectomy for gallbladder cancer: a retrospective comparative study. HPB 2015;17:536-41.
65. Feng JW, Yang XH, Liu CW, et al. Comparison of laparoscopic and open approach in treating gallbladder cancer. J Surg Res 2019;234:269-76.
66. Vega EA, De Aretxabala X, Qiao W, et al. Comparison of oncological outcomes after open and laparoscopic re-resection of incidental gallbladder cancer. Br J Surg 2020;107:289-300.
67. Navarro JG, Kang I, Hwang HK, Yoon DS, Lee WJ, Kang CM. Oncologic safety of laparoscopic radical cholecystectomy in pT2 gallbladder cancer: a propensity score matching analysis compared to open approach. Medicine 2020;99:e20039.
68. Yang J, Li E, Wang C, et al. Robotic versus open extended cholecystectomy for T1a-T3 gallbladder cancer: A matched comparison. Front Surg 2022;9:1039828.
69. Lee JW, Kwon JH, Lee JW. Oncologic and long-term outcomes of laparoscopic and open extended cholecystectomy for gallbladder cancer. J Clin Med 2022;11:2132.
70. Cho JK, Kim JR, Jang JY, et al. Comparison of the oncological outcomes of open versus laparoscopic surgery for T2 gallbladder cancer: a propensity-score-matched analysis. J Clin Med 2022;11:2644.
71. Dou C, Zhang C, Zhang C, Liu J. Propensity score analysis of outcomes following laparoscopic or open radical resection for gallbladder cancer in T2 and T3 stages. J Gastrointest Surg 2022;26:1416-24.
72. Wang J, Tan Y, Zhao G, Wang D, Ji Z. A new exploration for gallbladder polyps: gallbladder polypectomy by endolap technique. J Laparoendosc Adv Surg Tech A 2014;24:852-7.
73. Zheng Q, Zhang G, Yu XH, et al. Perfect pair, scopes unite - laparoscopic-assisted transumbilical gastroscopy for gallbladder-preserving polypectomy: A case report. World J Clin Cases 2021;9:9617-22.
74. Shen Y, Cao J, Zhou X, et al. Endoscopic ultrasound-guided cholecystostomy for resection of gallbladder polyps with lumen-apposing metal stent. Medicine 2020;99:e22903.
75. Zhang Y, Mao XL, Zhou XB, et al. Feasibility of transgastric endoscopic gallbladder-preserving surgery for benign gallbladder diseases (with video). Surg Endosc 2022;36:2705-11.
Cite This Article
Open Access
How to Cite
Sullivan, K. M.; Fong, Y. Minimally invasive treatment of gallbladder polyps. Mini-invasive. Surg. 2023, 7, 15. http://dx.doi.org/10.20517/2574-1225.2022.106
Download Citation
Export Citation File:
Type of Import
Tips on Downloading Citation
Citation Manager File Format
Type of Import
Direct Import: When the Direct Import option is selected (the default state), a dialogue box will give you the option to Save or Open the downloaded citation data. Choosing Open will either launch your citation manager or give you a choice of applications with which to use the metadata. The Save option saves the file locally for later use.
Indirect Import: When the Indirect Import option is selected, the metadata is displayed and may be copied and pasted as needed.
About This Article
Special Issue
Copyright
Data & Comments
Data
0
Comments
Comments must be written in English. Spam, offensive content, impersonation, and private information will not be permitted. If any comment is reported and identified as inappropriate content by OAE staff, the comment will be removed without notice. If you have any queries or need any help, please contact us at support@oaepublish.com.