ESGAR/EAES/EFISDS/ESGE Guidelines for Gallbladder Polyps
In 2017, the European Society of Gastrointestinal and Abdominal Radiology (ESGAR), the European Association for Endoscopic Surgery and other Interventional Techniques (EAES), the International Society of Digestive Surgery–European Federation (EFISDS), and the European Society of Gastrointestinal Endoscopy (ESGE) issued joint guidelines regarding the management and follow-up of gallbladder polyps, [24] which included the following:
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For a polypoid gallbladder lesion ≥10 mm, cholecystectomy is recommended if the patient is fit for and accepts surgery (moderate-quality evidence; 89% agreement)
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For a polypoid gallbladder lesion with symptoms attributable to the gallbladder, cholecystectomy is suggested if there is no other cause for the symptoms and the patient is fit for and accepts surgery (low-quality evidence; 89% agreement)
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If cholecystectomy is not indicated, risk factors for gallbladder malignancy (age >50 years; history of primary sclerosing cholangitis; Indian ethnicity; sessile polyp, including focal gallbladder wall thickening >4 mm) should be established and a more intensive management plan followed (low- to moderate-quality evidence; 78% agreement).
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If the patient has risk factors for gallbladder malignancyand a polyp 6-9 mm, cholecystectomy is recommended if the patient is fit for and accepts surgery (low- to moderate-quality evidence; 78% agreement)
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If the patient has either (a) no risk factors for gallbladder malignancy and a polyp of 6-9 mm or (b) risk factors for malignancy and a gallbladder polyp ≤5 mm, follow-up ultrasonography (US) of the gallbladder is recommended at 6 months and 1 year and then yearly up to 5 years; If the patient has no risk factors for malignancy and a polyp of ≤5 mm or less, follow-up is advised at 1, 3, and 5 years (low-quality evidence, 78% agreement)
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If polyp size increases by ≥2 mm during follow-up, cholecystectomy is advised (moderate-quality evidence; 78% agreement)
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If polyp size reaches 10 mm during follow-up, cholecystectomy is advised (moderate-quality evidence; 100% agreement)
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If the polyp disappears during follow-up, then follow-up should be discontinued (moderate-quality evidence; 100%agreement)
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Primary investigation should be with abdominal US, and routine use of other imaging modalities is not recommended; if appropriate expertise and resources are available, other modalities (eg, endoscopic US [EUS]) may be considered as aids to decision-making in difficult cases (low-quality evidence; 100% agreement)
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A schematic drawing of the extent of lymphadenectomy for gallbladder cancer, especially when the extrahepatic biliary tree is resected.
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Gallbladder tumors. A schematic drawing of the extent of resection of liver segments IV-b and V for gallbladder cancer.
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Sagittal ultrasonogram in a 71-year-old woman. This image demonstrates heterogeneous thickening of the gallbladder wall (arrows). The diagnosis was primary papillary adenocarcinoma of the gallbladder.
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A transaxial enhanced computed tomography (CT) scan of a 60-year-old man with right upper quadrant pain shows a partially calcified gallbladder (arrow). At laparotomy and histology, an infiltrating adenocarcinoma of the gallbladder was confirmed.
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Computed tomography (CT) scan in a 65-year-old man. This image depicts squamous cell carcinoma of the gallbladder and invasion of the liver.
Tables
Tumor (T), Node (N), Metastasis (M) |
Description |
TX |
Primary tumor cannot be assessed |
T0 |
No evidence of primary tumor |
Tis |
Carcinoma in situ |
T1 |
Tumor invades lamina propria (T1a) or muscle layer (T1b) |
T2 |
Tumor invades perimuscular connective tissue on peritoneal side, without involvement of serosa (visceral peritoneum) (T2a); or tumor invades perimuscular connective tissue on hepatic side, with no extension into liver (T2b) |
T3 |
Tumor perforates serosa (visceral peritoneum) and/or directly invades liver and/or 1 other adjacent organ or structure, such as stomach, duodenum, colon, pancreas, omentum, or extrahepatic bile ducts |
T4 |
Tumor invades main portal vein or hepatic artery or invades multiple extrahepatic organs or structures |
NX |
Regional lymph nodes cannot be assessed |
N0 |
No regional lymph node metastasis |
N1 |
Metastases to 1-3 regional lymph nodes |
N2 |
Metastases to ≥4 regional lymph nodes |
MX |
Distant metastasis cannot be assessed |
M0 |
No distant metastasis |
M1 |
Distant metastasis |
AJCC Stage |
TNM |
0 |
Tis, N0, M0 |
I |
T1(a/b), N0, M0 |
IIA |
T2a, N0, M0 |
| IIB | T2b, N0, M0 |
IIIA |
T3, N0, M0 |
IIIB |
T1-3, N1, M0 |
IVA |
T4, N0-1, M0 |
IVB |
Any T, N2, M0 Any T, any N, M1 |
