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Editor,—The paper by Moriguchi et al(Gut 1996; 39: 860–2) raises a number of questions. The authors state that this is the first study to describe the natural history of these lesions, but their solitary conclusion, that most polypoid lesions of the gall bladder detected by ultrasonography are benign, is not new. Indeed, they seem to underestimate the risk of malignancy compared with other larger series.
Yang et al 1 studied 182 patients who underwent cholecystectomy and who had an ultrasonographic or pathological diagnosis of polypoid lesions of the gall bladder. There were 10 false positive ultrasound diagnoses. All the lesions less than 1 cm in diameter were benign. There were 13 malignant lesions, 11 of which were greater than 1.5 cm in diameter. All the malignant lesions were solitary. All but two of the 182 patients underwent cholecystectomy and the calculated sensitivity of ultrasonography was 90.1% and specificity was 93.9%.
These findings were in patients with right upper quadrant symptoms. Moriguchi et al do not indicate how their patients were selected, nor whether they were symptomatic. However, it seems likely that most were asymptomatic as only four patients underwent cholecystectomy during a five year follow up period. It may be that differences in selection explain their much lower incidence of polyps greater than 1 cm (6.4% v 19.8%) and of malignant tumours (1.8% v 7.6%).
While most gall bladder polypoid lesions may indeed be benign, those which exceed 1 cm in diameter and are single have a high risk of malignancy and should be removed surgically, especially if the patient is over 50 years old.1 Unfortunately, Moriguchi et al’s study does not give us any information about the relationship between symptoms and gall bladder polypoid lesions. It seems reasonable to recommend, however, that cholecystectomy be performed in symptomatic patients, particularly if gallstones are also present.
Editor,—We are grateful to Dr Johnson for his interest in our recent paper. As we described in the title, we studied the natural history of polypoid lesions in the gall bladder. The study by Yang et al cited by Dr Johnson, however, showed the prevalence of gall bladder carcinoma in patients who had undergone cholecystectomy. In their paper, the prognosis of polypoid lesions of the gall bladder is not described. To our knowledge, there are no papers that describe the natural history of polypoid lesions in the gall bladder in the literature. Therefore, it is difficult to say whether our study underestimates the risk of malignancy. A large study does not necessarily result in the correct conclusion, but we do feel that our study would have benefitted from a larger series of patients.
All of the patients presented to the outpatient with heterogeneous abdominal complaints, but were asymptomatic during follow up, differing in this regard from the patients studied by Yang et al. In our opinion patients with right upper quadrant symptoms should not be followed for five years without treatment.
Finally, we agree with Dr Johnson that patients with gallstones should be monitored carefully. However, none of our patients had gallstones despite the close association between gall bladder carcinoma and gallstones.
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