Referral Destination for Gallbladder Polyps
Patients with gallbladder polyps requiring intervention should be referred to a surgeon for cholecystectomy evaluation, not to a specific location, as the decision for surgical consultation depends on polyp size, morphology, and risk factors rather than geographic referral patterns. 1
When Surgical Consultation is Required
The decision to refer for surgical evaluation follows a clear size-based and risk-stratified algorithm:
Immediate Surgical Referral Indicated For:
- Polyps ≥15 mm in size - These have the highest malignancy risk and warrant surgical consultation regardless of other features 2, 3
- Polyps ≥10 mm - Cholecystectomy is recommended as the standard threshold, with size being the strongest predictor of malignancy 2, 4
- Rapid growth of ≥4 mm within any 12-month period - This constitutes concerning rapid growth even if absolute size remains <10 mm 2, 5, 3
- Polyps reaching 15 mm during surveillance - Surgical consultation is recommended when this threshold is reached during follow-up 1, 5
Surgical Consultation for Intermediate-Risk Polyps (6-9 mm):
Cholecystectomy should be considered for polyps 6-9 mm when accompanied by risk factors including: 4
- Age >50-60 years 4, 6
- Primary sclerosing cholangitis (PSC) - dramatically elevated malignancy risk of 18-50%, with lower threshold of ≥8 mm for intervention 2, 3
- Sessile (broad-based) morphology rather than pedunculated 3, 4
- Focal wall thickening ≥4 mm adjacent to polyp 3, 4
- Symptomatic patients with biliary-type pain 4
Polyps NOT Requiring Surgical Referral
No Follow-Up Needed:
- Pedunculated "ball-on-the-wall" polyps ≤9 mm - These have extremely low risk with thin stalk configuration 1, 2, 3
- Polyps ≤5-6 mm without risk factors - Virtually zero malignancy risk with no documented cases of cancer in polyps <10 mm at initial detection 3, 4
- Sessile polyps ≤6 mm - Low risk category not requiring surveillance 1
Surveillance Rather Than Surgical Referral:
- Polyps 10-14 mm in extremely low risk category (pedunculated with thin stalk) - Follow-up ultrasound at 6,12, and 24 months 1, 2
- Polyps 10-14 mm in low risk category (sessile or thick stalk) - Follow-up ultrasound at 6,12,24, and 36 months 1
- Polyps 7-9 mm in low risk category - Single follow-up ultrasound at 12 months 1
Surgical Risk Considerations
The decision for surgical referral must balance malignancy risk against cholecystectomy morbidity: 1
- Overall morbidity risk: 2-8% 1
- Bile duct injury risk: 3-6 per 1,000 patients 1
- Mortality: 2-7 per 1,000 patients, related to operative complexity and comorbidities 1
- Significantly higher surgical risk in patients with cirrhosis 1
Critical Pitfall to Avoid
Ensure the lesion is a true polyp rather than tumefactive sludge - Sludge is mobile and layering, while true polyps are fixed, non-mobile, and non-shadowing. 3 For polyps ≥10 mm where differentiation is challenging, contrast-enhanced ultrasound (CEUS) is preferred if available before surgical referral. 2
Shared Decision-Making
Patient selection for surgery is multifactorial and requires shared decision-making that accounts for patient health status, surgical risk profile, and imaging risk stratification. 1 The individual surgical risk must be balanced against the indication for surgery, particularly in high-risk surgical candidates. 1