Current evidence from 10 sources supports a consensus-based, size-stratified approach to gallbladder polyp management. Cholecystectomy is universally recommended for polyps ≥10 mm, where malignancy rates range from 8.5% to 37-55%. For smaller polyps, management depends on risk stratification: polyps ≤5 mm without risk factors require no follow-up, while polyps 6-9 mm warrant surveillance ultrasound at 6 months, 1 year, and 2 years. Established risk factors for malignancy include age >50-60 years, sessile morphology, solitary polyps, primary sclerosing cholangitis, and Asian/Indian ethnicity. Patients with 6-9 mm polyps and one or more risk factors should be offered cholecystectomy. Laparoscopic cholecystectomy remains the predominant surgical approach, with trans-abdominal ultrasound serving as the primary diagnostic and surveillance modality.
The overall incidence of malignant polyps is low (0.57%), and during surveillance most polyps remain stable (60%) or resolve (34%). While the 10 mm threshold is well-established, it is acknowledged as arbitrary with limited high-quality supporting evidence. Key areas of uncertainty include optimal surveillance duration, with some guidelines recommending indefinite yearly monitoring while others suggest discontinuation after 2 years without growth. Ethnic variations in risk necessitate more intensive surveillance protocols in Asian populations. Longitudinal studies are needed to better characterize the natural history of intermediate-sized polyps.
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