Original Article
Surgical Indications in Gallbladder Polyps
Indicaciones quirúrgicas en los pólipos de vesícula biliar
Read
20462
Timeswas read the article
1850
Total PDF
18612
Total HTML
Share statistics
array:24 [ "pii" => "S2173507713001622" "issn" => "21735077" "doi" => "10.1016/j.cireng.2013.10.012" "estado" => "S300" "fechaPublicacion" => "2013-05-01" "aid" => "917" "copyright" => "AEC" "copyrightAnyo" => "2011" "documento" => "article" "crossmark" => 0 "subdocumento" => "fla" "cita" => "Cir Esp. 2013;91:324-30" "abierto" => array:3 [ "ES" => true "ES2" => true "LATM" => true ] "gratuito" => true "lecturas" => array:2 [ "total" => 6011 "formatos" => array:3 [ "EPUB" => 17 "HTML" => 5128 "PDF" => 866 ] ] "Traduccion" => array:1 [ "es" => array:19 [ "pii" => "S0009739X12001893" "issn" => "0009739X" "doi" => "10.1016/j.ciresp.2012.04.018" "estado" => "S300" "fechaPublicacion" => "2013-05-01" "aid" => "917" "copyright" => "AEC" "documento" => "article" "crossmark" => 0 "subdocumento" => "fla" "cita" => "Cir Esp. 2013;91:324-30" "abierto" => array:3 [ "ES" => true "ES2" => true "LATM" => true ] "gratuito" => true "lecturas" => array:2 [ "total" => 85027 "formatos" => array:3 [ "EPUB" => 13 "HTML" => 82104 "PDF" => 2910 ] ] "es" => array:13 [ "idiomaDefecto" => true "cabecera" => "<span class="elsevierStyleTextfn">Original</span>" "titulo" => "Indicaciones quirúrgicas en los pólipos de vesícula biliar" "tienePdf" => "es" "tieneTextoCompleto" => "es" "tieneResumen" => array:2 [ 0 => "es" 1 => "en" ] "paginas" => array:1 [ 0 => array:2 [ "paginaInicial" => "324" "paginaFinal" => "330" ] ] "titulosAlternativos" => array:1 [ "en" => array:1 [ "titulo" => "Surgical indications in gallbladder polyps" ] ] "contieneResumen" => array:2 [ "es" => true "en" => true ] "contieneTextoCompleto" => array:1 [ "es" => true ] "contienePdf" => array:1 [ "es" => true ] "resumenGrafico" => array:2 [ "original" => 0 "multimedia" => array:7 [ "identificador" => "fig0020" "etiqueta" => "Figura 4" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr4.jpeg" "Alto" => 1463 "Ancho" => 950 "Tamanyo" => 256894 ] ] "descripcion" => array:1 [ "es" => "<p id="spar0070" class="elsevierStyleSimplePara elsevierViewall">Imagen ecográfica de un adenocarcinoma papilar, con su correspondiente histología (hematoxilina-eosina 10×).</p>" ] ] ] "autores" => array:1 [ 0 => array:2 [ "autoresLista" => "Francisco José Morera-Ocón, Javier Ballestín-Vicente, Ana María Calatayud-Blas, Leonardo Cataldo de Tursi-Rispoli, Juan Carlos Bernal-Sprekelsen" "autores" => array:5 [ 0 => array:2 [ "nombre" => "Francisco José" "apellidos" => "Morera-Ocón" ] 1 => array:2 [ "nombre" => "Javier" "apellidos" => "Ballestín-Vicente" ] 2 => array:2 [ "nombre" => "Ana María" "apellidos" => "Calatayud-Blas" ] 3 => array:2 [ "nombre" => "Leonardo Cataldo" "apellidos" => "de Tursi-Rispoli" ] 4 => array:2 [ "nombre" => "Juan Carlos" "apellidos" => "Bernal-Sprekelsen" ] ] ] ] ] "idiomaDefecto" => "es" "Traduccion" => array:1 [ "en" => array:9 [ "pii" => "S2173507713001622" "doi" => "10.1016/j.cireng.2013.10.012" "estado" => "S300" "subdocumento" => "" "abierto" => array:3 [ "ES" => true "ES2" => true "LATM" => true ] "gratuito" => true "lecturas" => array:1 [ "total" => 0 ] "idiomaDefecto" => "en" "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S2173507713001622?idApp=UINPBA00004N" ] ] "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S0009739X12001893?idApp=UINPBA00004N" "url" => "/0009739X/0000009100000005/v1_201305021703/S0009739X12001893/v1_201305021703/es/main.assets" ] ] "itemSiguiente" => array:19 [ "pii" => "S2173507713001683" "issn" => "21735077" "doi" => "10.1016/j.cireng.2013.10.018" "estado" => "S300" "fechaPublicacion" => "2013-05-01" "aid" => "1037" "copyright" => "AEC" "documento" => "article" "crossmark" => 0 "subdocumento" => "fla" "cita" => "Cir Esp. 2013;91:331-4" "abierto" => array:3 [ "ES" => true "ES2" => true "LATM" => true ] "gratuito" => true "lecturas" => array:2 [ "total" => 3623 "formatos" => array:3 [ "EPUB" => 16 "HTML" => 2933 "PDF" => 674 ] ] "en" => array:13 [ "idiomaDefecto" => true "cabecera" => "<span class="elsevierStyleTextfn">Innovation in surgical technique</span>" "titulo" => "Parastomal Hernia Prevention Through Laparoscopic Modified Sugarbaker Technique With Composite Mesh (Physiomesh<span class="elsevierStyleSup">®</span>)" "tienePdf" => "en" "tieneTextoCompleto" => "en" "tieneResumen" => array:2 [ 0 => "en" 1 => "es" ] "paginas" => array:1 [ 0 => array:2 [ "paginaInicial" => "331" "paginaFinal" => "334" ] ] "titulosAlternativos" => array:1 [ "es" => array:1 [ "titulo" => "Prevención laparoscópica de la hernia paraestomal mediante técnica de Sugarbaker modificada con malla compuesta (Physiomesh<span class="elsevierStyleSup">®</span>)" ] ] "contieneResumen" => array:2 [ "en" => true "es" => true ] "contieneTextoCompleto" => array:1 [ "en" => true ] "contienePdf" => array:1 [ "en" => true ] "resumenGrafico" => array:2 [ "original" => 0 "multimedia" => array:7 [ "identificador" => "fig0010" "etiqueta" => "Fig. 2" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr2.jpeg" "Alto" => 690 "Ancho" => 925 "Tamanyo" => 110762 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0020" class="elsevierStyleSimplePara elsevierViewall">Placement of the mesh with reabsorbable straps.</p>" ] ] ] "autores" => array:1 [ 0 => array:2 [ "autoresLista" => "Manuel López-Cano, Xavier Serra-Aracil" "autores" => array:2 [ 0 => array:2 [ "nombre" => "Manuel" "apellidos" => "López-Cano" ] 1 => array:2 [ "nombre" => "Xavier" "apellidos" => "Serra-Aracil" ] ] ] ] ] "idiomaDefecto" => "en" "Traduccion" => array:1 [ "es" => array:9 [ "pii" => "S0009739X13000638" "doi" => "10.1016/j.ciresp.2013.01.003" "estado" => "S300" "subdocumento" => "" "abierto" => array:3 [ "ES" => true "ES2" => true "LATM" => true ] "gratuito" => true "lecturas" => array:1 [ "total" => 0 ] "idiomaDefecto" => "es" "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S0009739X13000638?idApp=UINPBA00004N" ] ] "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S2173507713001683?idApp=UINPBA00004N" "url" => "/21735077/0000009100000005/v1_201311210034/S2173507713001683/v1_201311210034/en/main.assets" ] "itemAnterior" => array:19 [ "pii" => "S2173507713001634" "issn" => "21735077" "doi" => "10.1016/j.cireng.2013.10.013" "estado" => "S300" "fechaPublicacion" => "2013-05-01" "aid" => "962" "copyright" => "AEC" "documento" => "article" "crossmark" => 0 "subdocumento" => "fla" "cita" => "Cir Esp. 2013;91:316-23" "abierto" => array:3 [ "ES" => true "ES2" => true "LATM" => true ] "gratuito" => true "lecturas" => array:2 [ "total" => 2975 "formatos" => array:3 [ "EPUB" => 16 "HTML" => 2425 "PDF" => 534 ] ] "en" => array:13 [ "idiomaDefecto" => true "cabecera" => "<span class="elsevierStyleTextfn">Original Article</span>" "titulo" => "Use of Multidetector Computed Tomography for Locating the Site of Gastrointestinal Tract Perforations" "tienePdf" => "en" "tieneTextoCompleto" => "en" "tieneResumen" => array:2 [ 0 => "en" 1 => "es" ] "paginas" => array:1 [ 0 => array:2 [ "paginaInicial" => "316" "paginaFinal" => "323" ] ] "titulosAlternativos" => array:1 [ "es" => array:1 [ "titulo" => "Utilidad de la tomografía computarizada multidetector para identificar la localización de las perforaciones gastrointestinales" ] ] "contieneResumen" => array:2 [ "en" => true "es" => true ] "contieneTextoCompleto" => array:1 [ "en" => true ] "contienePdf" => array:1 [ "en" => true ] "resumenGrafico" => array:2 [ "original" => 0 "multimedia" => array:7 [ "identificador" => "fig0005" "etiqueta" => "Fig. 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 553 "Ancho" => 1514 "Tamanyo" => 117081 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0045" class="elsevierStyleSimplePara elsevierViewall">37-Year-old male with perforation of the small intestine by birdshot pellets: (A) MDCT with IV contrast showing an axial slice of the upper abdomen with pneumoperitoneum (bold arrow); (B) axial slice of the same patient with multiple intraabdominal birdshot pellets (arrow). The perforation of the small intestine was identified during surgery.</p>" ] ] ] "autores" => array:1 [ 0 => array:2 [ "autoresLista" => "Laura Cadenas Rodríguez, Milagros Martí de Gracia, Nuria Saturio Galán, Virginia Pérez Dueñas, Leopoldo Salvatierra Arrieta, Gonzalo Garzón Moll" "autores" => array:6 [ 0 => array:2 [ "nombre" => "Laura" "apellidos" => "Cadenas Rodríguez" ] 1 => array:2 [ "nombre" => "Milagros" "apellidos" => "Martí de Gracia" ] 2 => array:2 [ "nombre" => "Nuria" "apellidos" => "Saturio Galán" ] 3 => array:2 [ "nombre" => "Virginia" "apellidos" => "Pérez Dueñas" ] 4 => array:2 [ "nombre" => "Leopoldo" "apellidos" => "Salvatierra Arrieta" ] 5 => array:2 [ "nombre" => "Gonzalo" "apellidos" => "Garzón Moll" ] ] ] ] ] "idiomaDefecto" => "en" "Traduccion" => array:1 [ "es" => array:9 [ "pii" => "S0009739X12002771" "doi" => "10.1016/j.ciresp.2012.06.004" "estado" => "S300" "subdocumento" => "" "abierto" => array:3 [ "ES" => true "ES2" => true "LATM" => true ] "gratuito" => true "lecturas" => array:1 [ "total" => 0 ] "idiomaDefecto" => "es" "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S0009739X12002771?idApp=UINPBA00004N" ] ] "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S2173507713001634?idApp=UINPBA00004N" "url" => "/21735077/0000009100000005/v1_201311210034/S2173507713001634/v1_201311210034/en/main.assets" ] "en" => array:20 [ "idiomaDefecto" => true "cabecera" => "<span class="elsevierStyleTextfn">Original Article</span>" "titulo" => "Surgical Indications in Gallbladder Polyps" "tieneTextoCompleto" => true "paginas" => array:1 [ 0 => array:2 [ "paginaInicial" => "324" "paginaFinal" => "330" ] ] "autores" => array:1 [ 0 => array:4 [ "autoresLista" => "Francisco José Morera-Ocón, Javier Ballestín-Vicente, Ana María Calatayud-Blas, Leonardo Cataldo de Tursi-Rispoli, Juan Carlos Bernal-Sprekelsen" "autores" => array:5 [ 0 => array:4 [ "nombre" => "Francisco José" "apellidos" => "Morera-Ocón" "email" => array:1 [ 0 => "fmoreraocon@aecirujanos.es" ] "referencia" => array:2 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">a</span>" "identificador" => "aff0005" ] 1 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">¿</span>" "identificador" => "cor0005" ] ] ] 1 => array:3 [ "nombre" => "Javier" "apellidos" => "Ballestín-Vicente" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">b</span>" "identificador" => "aff0010" ] ] ] 2 => array:3 [ "nombre" => "Ana María" "apellidos" => "Calatayud-Blas" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">c</span>" "identificador" => "aff0015" ] ] ] 3 => array:3 [ "nombre" => "Leonardo Cataldo" "apellidos" => "de Tursi-Rispoli" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">a</span>" "identificador" => "aff0005" ] ] ] 4 => array:3 [ "nombre" => "Juan Carlos" "apellidos" => "Bernal-Sprekelsen" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">a</span>" "identificador" => "aff0005" ] ] ] ] "afiliaciones" => array:3 [ 0 => array:3 [ "entidad" => "Servicio de Cirugía General, Hospital de Requena, Valencia, Spain" "etiqueta" => "a" "identificador" => "aff0005" ] 1 => array:3 [ "entidad" => "Servicio de Radiología, Hospital de Requena, Valencia, Spain" "etiqueta" => "b" "identificador" => "aff0010" ] 2 => array:3 [ "entidad" => "Servicio de Anatomía Patológica, Hospital de Requena, Valencia, Spain" "etiqueta" => "c" "identificador" => "aff0015" ] ] "correspondencia" => array:1 [ 0 => array:3 [ "identificador" => "cor0005" "etiqueta" => "⁎" "correspondencia" => "Corresponding author." ] ] ] ] "titulosAlternativos" => array:1 [ "es" => array:1 [ "titulo" => "Indicaciones quirúrgicas en los pólipos de vesícula biliar" ] ] "resumenGrafico" => array:2 [ "original" => 0 "multimedia" => array:7 [ "identificador" => "fig0010" "etiqueta" => "Fig. 2" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr2.jpeg" "Alto" => 1504 "Ancho" => 1550 "Tamanyo" => 442824 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0060" class="elsevierStyleSimplePara elsevierViewall">(A) Pseudopolyps (arrowhead) as well as calculi (bold arrow) in the same specimen (B–C) confirmed as cholesterol polyps on histology (B: hematoxylin–eosin 10×; C: hematoxylin–eosin 20×).</p>" ] ] ] "textoCompleto" => "<span class="elsevierStyleSections"><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0075">Introduction</span><p id="par0005" class="elsevierStylePara elsevierViewall">In 1970, Christensen and Ishak classified gallbladder polyps as benign tumors (adenoma), pseudotumors (adenomatous hyperplasia, adenomyoma, inflammatory polyp and cholesterol polyps), and malignant tumors (adenocarcinoma).<a class="elsevierStyleCrossRef" href="#bib0005"><span class="elsevierStyleSup">1</span></a></p><p id="par0010" class="elsevierStylePara elsevierViewall">The polyp-carcinoma sequence in the gallbladder, similar to what happens in colorectal carcinomas, was proposed years ago<a class="elsevierStyleCrossRefs" href="#bib0010"><span class="elsevierStyleSup">2,3</span></a> as a carcinogenic theory for gallbladder cancer, and it is one of the main reasons for ultrasound follow-up in patients diagnosed with gallbladder polyps (GBP). The other hypothesis for the genesis of gallbladder cancer that seems to prevail is the metaplasia–dysplasia–cancer sequence.<a class="elsevierStyleCrossRef" href="#bib0020"><span class="elsevierStyleSup">4</span></a> A molecular study on the DNA of gallbladder adenomas and carcinomas demonstrated that the changes detected in dysplasia, carcinoma <span class="elsevierStyleItalic">in situ</span> and invasive cancer were absent in adenomas, and the authors concluded that the latter were not precursors for gallbladder adenocarcinoma.<a class="elsevierStyleCrossRef" href="#bib0025"><span class="elsevierStyleSup">5</span></a> Other molecular studies suggest that, even though the 2 hypotheses may be true, the adenoma–carcinoma sequence is involved in the majority of gallbladder cancers.<a class="elsevierStyleCrossRefs" href="#bib0030"><span class="elsevierStyleSup">6–9</span></a></p><p id="par0015" class="elsevierStylePara elsevierViewall">The published prevalence of GBP in the healthy population is 4.3% in Denmark,<a class="elsevierStyleCrossRef" href="#bib0050"><span class="elsevierStyleSup">10</span></a> 5.9% in Japan,<a class="elsevierStyleCrossRef" href="#bib0055"><span class="elsevierStyleSup">11</span></a> 6.1% in Germany (Ulm),<a class="elsevierStyleCrossRef" href="#bib0060"><span class="elsevierStyleSup">12</span></a> 6.9% in China (Taiwan),<a class="elsevierStyleCrossRef" href="#bib0065"><span class="elsevierStyleSup">13</span></a> and 6.1% in Korea (Seoul).<a class="elsevierStyleCrossRef" href="#bib0070"><span class="elsevierStyleSup">14</span></a> Most GBP are cholesterol polyps and require no treatment unless they are symptomatic.</p><p id="par0020" class="elsevierStylePara elsevierViewall">Arguments in favor of an aggressive approach to GBP are that laparoscopic cholecystectomy—with low morbidity and anecdotal mortality—could resolve the problem, while the appearance of gallbladder cancer is associated with a poor prognosis.</p><p id="par0025" class="elsevierStylePara elsevierViewall">Arguments against an aggressive approach to GBP are the anecdotal incidence of cancer in polyps smaller than 10<span class="elsevierStyleHsp" style=""></span>mm, the absence of malignization in cholesterolosis, and the serious prognosis of some lesions of the bile duct associated with cholecystectomy.</p><p id="par0030" class="elsevierStylePara elsevierViewall">There are no clinical guidelines or evidence-based studies for the management of GBP. This paper provides the experience of our Hospital and retrospectively analyzes the diagnostic-therapeutic approach in order to review GBP management.</p></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0080">Material and Methods</span><p id="par0035" class="elsevierStylePara elsevierViewall">From the Pathology Department database, we gathered the histologic reports of gallbladder specimens with polyps from the period between January 2002 and June 2011. We included all those patients who had been treated surgically for GBP even though the definitive histologic results demonstrated absence of lesions. We carried out a retrospective study of the medical files of patients who underwent cholecystectomy, analyzing age, sex, preoperative diagnosis, surgical indication and histologic diagnosis of the polyps.</p><p id="par0040" class="elsevierStylePara elsevierViewall">Abdominal ultrasounds (Philips SD800 with 5<span class="elsevierStyleHsp" style=""></span>MHz abdominal transducer, and Toshiba Aplio XV with 3.5<span class="elsevierStyleHsp" style=""></span>MHz abdominal transducer) were performed by radiologists with experience in the field of abdominal ultrasound, with the patient in supine decubitus and in right lateral decubitus, after 6<span class="elsevierStyleHsp" style=""></span>h of fasting. According to the ultrasound images, the gallbladder polyps were classified as pseudotumor or tumor lesions. The group of pseudotumor lesions included focal adenomyomatosis or adenomyoma (focal wall thickening, cystic spaces in the interior with echogenic content within the cyst, and “comet-tail” artifact; <a class="elsevierStyleCrossRef" href="#fig0005">Fig. 1</a>); cholesterol polyps (focal form of cholesterolosis characterized by oval-shaped, multiple, hyperechogenic lesions in contact with the wall, without posterior shading, that are immobile with changes in posture; <a class="elsevierStyleCrossRef" href="#fig0010">Fig. 2</a>); and inflammatory polyps reactive to an acute or chronic inflammatory process, although there are no descriptions in the radiological literature that characterize them and the diagnosis is made by pathology study after cholecystectomy. Within the group of the tumor lesions, we find adenomas (echogenicity similar to the liver, pedunculated or sessile, may present Doppler flow in the interior; <a class="elsevierStyleCrossRef" href="#fig0015">Fig. 3</a>), suspicious large-sized lesions, thickening adjacent to the gallbladder wall, internal circulation or associated signs of malignancy such as lymphadenopathies or metastases.</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><elsevierMultimedia ident="fig0010"></elsevierMultimedia><elsevierMultimedia ident="fig0015"></elsevierMultimedia></span><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0085">Results</span><p id="par0045" class="elsevierStylePara elsevierViewall">During the study period, GBP was diagnosed in 30 patients. Twenty-seven patients were included from the Pathology Department database, and another 3 patients had a preoperative diagnosis of GBP. Mean age was 52.24±15.6 (range 22–83, median 51), and 21 were women. Seventeen of the 30 patients were 50 years of age or older.</p><p id="par0050" class="elsevierStylePara elsevierViewall">Out of the 30 patients, 19 had a previous ultrasound diagnosis of GBP, 7 GBP and calculi, and 4 calculi without polyps. Diagnoses associated with GBP included: 3 patients with associated multiple hemangiomas, one patient with suspicion of a hydatid cyst that was actually a simple cyst, and one patient with multiple simple cysts. The majority of the polyps were cholesterol polyps (<a class="elsevierStyleCrossRef" href="#tbl0005">Table 1</a>). In 4 cases, the polyps were true neoplastic lesions. Two gallbladders contained tubular adenomas while another gallbladder contained multiple adenomatous lesions. There were no cases of dysplasia. In one patient, there was an incidental detection (during an ultrasound study for acute pancreatitis) of a polyp that was suspicious for malignancy due to size (32<span class="elsevierStyleHsp" style=""></span>mm) and shape (sessile) that turned out to be a papillary adenocarcinoma (<a class="elsevierStyleCrossRef" href="#fig0020">Fig. 4</a>). In this patient, the study was completed with abdominal CT, which provided no additional information, and open cholecystectomy was performed with resection of the hepatic gallbladder bed at a thickness of 2<span class="elsevierStyleHsp" style=""></span>cm and lymphadenectomy of the hepatic pedicle. The result was T1N0M0. In 2 patients, there was a coincidence of different types of polyps in the same cholecystectomy specimen. One presented adenomatous hyperplasia together with cholesterol polyps and inflammatory polyps. The other patient associated 2 hyperplastic polyps, one cholesterol polyp and gallbladder cholesterolosis.</p><elsevierMultimedia ident="tbl0005"></elsevierMultimedia><elsevierMultimedia ident="fig0020"></elsevierMultimedia><p id="par0055" class="elsevierStylePara elsevierViewall">In 3 cases with previous ultrasound diagnosis for GBP, the lesions were not found during the pathology examination.</p><p id="par0060" class="elsevierStylePara elsevierViewall">With regard to symptoms, 11 patients presented typical pain (pain in the right hypochondrium radiating toward the scapula). Of these, 5 presented ultrasound images of GBP without associated calculi. One of the patients included in these 11 cases was diagnosed with GBP as an incidental finding on a gynecological ultrasound, and during follow-up developed typical symptoms. Eight patients debuted with nonspecific pain (including in this group dyspepsia and epigastralgia). After cholecystectomy, the nonspecific pain persisted in 3 out of 8 cases, and the other 5 were asymptomatic.</p></span><span id="sec0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0090">Discussion</span><p id="par0065" class="elsevierStylePara elsevierViewall">Among the indications for cholecystectomy, we found symptomatic calculi, symptomatic polyps or polyps larger than 10<span class="elsevierStyleHsp" style=""></span>mm, ultrasound suspicion for symptomatic cholesterolosis, and ultrasound suspicion for adenomyomatosis, both symptomatic and asymptomatic. The number of polyps alone is not an indication for surgery but, if it were, solitary polyps would be a reason for alarm, as there is a lower probability for lesions with uncertain prognosis when the polyps are multiple. The symptoms do not differ from those that appear in symptomatic cholelithiasis. There is an anecdotal case described in which a detached cholesterol polyp originated an otherwise acalculous cholecystitis.<a class="elsevierStyleCrossRef" href="#bib0075"><span class="elsevierStyleSup">15</span></a></p><p id="par0070" class="elsevierStylePara elsevierViewall">For most groups, there is no indication for surgery if the polyp is smaller than 10<span class="elsevierStyleHsp" style=""></span>mm. Nonetheless, there are isolated groups who support a more aggressive attitude after having found cases of cancer with smaller polyps. Kubota et al.<a class="elsevierStyleCrossRef" href="#bib0080"><span class="elsevierStyleSup">16</span></a> discovered 13% of gallbladder carcinomas in polyps smaller than 10<span class="elsevierStyleHsp" style=""></span>mm. Shinkai et al.<a class="elsevierStyleCrossRef" href="#bib0085"><span class="elsevierStyleSup">17</span></a> have proposed cholecystectomy when the number of lesions is fewer than 3, regardless of size. In the series of polyps smaller than 20<span class="elsevierStyleHsp" style=""></span>mm that they analyzed, the mean size of the malignant polyps was 10.8<span class="elsevierStyleHsp" style=""></span>mm±4.16. This incidence of malignant polyps in lesions smaller than 1<span class="elsevierStyleHsp" style=""></span>cm has not been seen in most published series. De Matos et al.<a class="elsevierStyleCrossRef" href="#bib0090"><span class="elsevierStyleSup">18</span></a> found 2 malignant polyps out of the 93 analyzed in their series, and the mean size in both lesions was 21.5<span class="elsevierStyleHsp" style=""></span>mm. Kwon et al.<a class="elsevierStyleCrossRef" href="#bib0095"><span class="elsevierStyleSup">19</span></a> found 35 malignant polyps out of 291 analyzed, and their mean size was 27.97<span class="elsevierStyleHsp" style=""></span>mm±2.46, although among them there was one of 8<span class="elsevierStyleHsp" style=""></span>mm and another of 9<span class="elsevierStyleHsp" style=""></span>mm. Out of 80 patients who underwent cholecystectomy due to polyps, Ito et al.<a class="elsevierStyleCrossRef" href="#bib0100"><span class="elsevierStyleSup">20</span></a> found one 14<span class="elsevierStyleHsp" style=""></span>mm lesion with high-grade dysplasia (carcinoma <span class="elsevierStyleItalic">in situ</span>) and no invasive adenocarcinoma.</p><p id="par0075" class="elsevierStylePara elsevierViewall">The increasing size of the polyps during follow-up, their association with calculi, or the suspicious characteristics of the lesions may determine the indication for cholecystectomy in some cases. The definition of <span class="elsevierStyleItalic">increase in size</span> has not been clearly established in the literature. If a polyp grows 4–6<span class="elsevierStyleHsp" style=""></span>mm in an interval of 18 months, should we perform cholecystectomy? For some groups, the growth of a polyp is only significant if it surpasses 3<span class="elsevierStyleHsp" style=""></span>mm or more,<a class="elsevierStyleCrossRefs" href="#bib0070"><span class="elsevierStyleSup">14,20,21</span></a> which is a measurement that was established arbitrarily as there are no evidence-based data to either support or revise this threshold.</p><p id="par0080" class="elsevierStylePara elsevierViewall">Some authors have warned about the increased risk for cancer when the polyps are associated with calculi.<a class="elsevierStyleCrossRef" href="#bib0110"><span class="elsevierStyleSup">22</span></a> Choi et al.,<a class="elsevierStyleCrossRef" href="#bib0115"><span class="elsevierStyleSup">23</span></a> however, did not detect the appearance of gallbladder cancer in 361 patients who had been followed for 6.5 years in a study comparing the change in polyp size among patients with asymptomatic calculi and polyps (176 patients) and those with just polyps (185 patients), without finding differences in the behavior of the GBP. Kwon et al.<a class="elsevierStyleCrossRef" href="#bib0095"><span class="elsevierStyleSup">19</span></a> studied 291 patients who underwent cholecystectomy with histologic confirmation of GBP: 256 were benign and 35 malignant. The association with calculi was not a statistically significant difference between the two groups (21.5% in benign [55/256]; 17.1% in malignant [6/35], <span class="elsevierStyleItalic">P</span>=.554). Park et al.<a class="elsevierStyleCrossRef" href="#bib0070"><span class="elsevierStyleSup">14</span></a> found 25 (14%) adenocarcinomas in 280 patients, only 2 of which had associated calculi. Therefore, it seems highly probable that calculi associated with GBP is not a risk factor, at least no greater than when they are not associated with polyps.</p><p id="par0085" class="elsevierStylePara elsevierViewall">In contrast with cholesterolosis, adenomyomatosis has been associated with carcinoma.<a class="elsevierStyleCrossRefs" href="#bib0120"><span class="elsevierStyleSup">24,25</span></a> Adenomyomatosis is a mucosal hyperplasia with growth toward the muscular layer, which is thickened. Cholesterolosis is a mucosal hyperplasia with accumulation of cholesteryl esters and triglycerides in the epithelial macrophages. The differential diagnosis between these entities can be performed with abdominal ultrasound.</p><p id="par0090" class="elsevierStylePara elsevierViewall">A study by the Radiology Department at Beth Israel Deaconess Medical Center<a class="elsevierStyleCrossRef" href="#bib0130"><span class="elsevierStyleSup">26</span></a> concluded that it is not necessary to follow-up polyps measuring less than 6<span class="elsevierStyleHsp" style=""></span>mm. They reviewed 346 patients with an ultrasound diagnosis of GBP and a mean follow-up of 8 years (range, 5–10.4 years). But the ultrasound follow-up was only done in 149 (43%), clinical follow-up in 155 (45%), and cholecystectomy was performed in 42 patients (12%). No cases of cancer were found in the 346 patients, but this result must be considered with the possible bias of the absence of ultrasound data for 197 patients, and the logical absence of histology in the 304 patients without cholecystectomy. Thus, although GBP seem to be mostly benign in behavior and may not even require further ultrasound studies, this approach has not been shown to be reliable based only on a size smaller than 6<span class="elsevierStyleHsp" style=""></span>mm, either in this study or any other studies. Therefore, as we still have no cost analysis studies or large-scale assays, it is still daring, as argued by Mitchell E. Tublin in 2001,<a class="elsevierStyleCrossRef" href="#bib0135"><span class="elsevierStyleSup">27</span></a> not to normally recommend ultrasound follow-up.</p><p id="par0095" class="elsevierStylePara elsevierViewall">The analysis of our series of cholecystectomies due to polyps suggests an aggressive tendency toward this diagnosis, since only 16 patients out of 30 presented an age over 49. The pathology results confirm the suspicion since the majority were cholesterol polyps diagnosed as incidental findings or with nonspecific abdominal symptoms. As there are no evidence-based clinical guidelines, the decision to operate for diagnosis of GBP will be conditioned by the information that the surgeon offers the patient. With the current published data, the probability that a polyp smaller than 10<span class="elsevierStyleHsp" style=""></span>mm is malignant is small, the probability that a true polyp smaller than 10<span class="elsevierStyleHsp" style=""></span>mm will degenerate over time into an adenocarcinoma is small, and the probability that multiple lesions smaller than 10<span class="elsevierStyleHsp" style=""></span>mm are pseudopolyps is high.</p><p id="par0100" class="elsevierStylePara elsevierViewall">In the series by the Memorial Sloan Kettering Cancer Center group, which is renowned for its prestigious work in hepatobiliary surgery, only 80 patients out of 470 underwent cholecystectomy. Out of these 80, 17 (21%) had surgery for lesions greater than 10<span class="elsevierStyleHsp" style=""></span>mm, 18 (22.5%) because of symptoms, 11 (14%) due to patient choice despite having polyps smaller than 10<span class="elsevierStyleHsp" style=""></span>mm, and 34 (42.5%) during surgery due to another unrelated abdominal disease. These data demonstrate a restrictive approach with regards to the surgical indication for GBP.</p><p id="par0105" class="elsevierStylePara elsevierViewall">In our series, the cholecystectomy specimens reported no findings in 3 patients. In the literature, this is not uncommon. Ito et al.<a class="elsevierStyleCrossRef" href="#bib0100"><span class="elsevierStyleSup">20</span></a> found no polyps in 26 (32.5%) out of 80 patients who underwent cholecystectomy with diagnosis for GBP. In their discussion, they provide no explanation for this datum and consider these cases false positives of the ultrasound studies. Csendes et al.<a class="elsevierStyleCrossRef" href="#bib0105"><span class="elsevierStyleSup">21</span></a> found no lesions in 3 (11%) out of 27 cholecystectomy pieces, but did not discuss this fact. With the few cases seen in our analysis, we cannot reach any conclusions in this regard, but it was suspected that opening the gallbladder after having removed it in the operating room could have influenced in the loss of polyps in 2 cases, especially cholesterol polyps, when the specimens were put into formaldehyde. And it was also suspected in the third case that the cholesterol polyps could have easily become detached and lost with the bile when the gallbladder was being opened in the pathology laboratory.</p><p id="par0110" class="elsevierStylePara elsevierViewall">Some authors have studied possible risk factors that would help predict the malignancy of polyps. In a univariate study, Park et al.<a class="elsevierStyleCrossRef" href="#bib0070"><span class="elsevierStyleSup">14</span></a> found risk factors to be age (≥57<span class="elsevierStyleHsp" style=""></span>yrs), presence of symptoms, size (≥10<span class="elsevierStyleHsp" style=""></span>mm), and morphology (sessile). In their multivariate analysis, only age and size were maintained as independent predictors for malignancy. In the univariate analysis of the study by Kwon et al.,<a class="elsevierStyleCrossRef" href="#bib0095"><span class="elsevierStyleSup">19</span></a> risk factors for malignancy included age, presence of symptoms, sessile morphology, size, and single polyps. The multivariate analysis maintained age, morphology, and size as prognostic criteria for malignancy. The cut-off levels for age and size obtained with ROC curves were 57.5<span class="elsevierStyleHsp" style=""></span>yrs and 12.5<span class="elsevierStyleHsp" style=""></span>mm, but these were rounded up and down to 60<span class="elsevierStyleHsp" style=""></span>yrs and 10<span class="elsevierStyleHsp" style=""></span>mm, respectively, and the sessile criterion was added. With these variations, 77.8% (14/18) of the malignant polyps met the 3 criteria, 28.6% (12/42) met 2 criteria and 7.8% (9/116) met one criterion. In the 115 patients without any of the 3 criteria, there were no cases of malignant polyps.</p><p id="par0115" class="elsevierStylePara elsevierViewall">As for the surgical approach of GBP, the laparoscopic method is most widely used. Nevertheless, when there is a preoperative suspicion for malignancy (for example, sessile polyp and size larger than one centimeter, or other radiographic signs), the general recommendations are to use an open approach. For this reason, we decided on open cholecystectomy in one patient of the series who presented with a large, sessile polyp. This topic is also controversial, however, and more studies would be required to support the advantages of the open technique in this type of polyps.</p><p id="par0120" class="elsevierStylePara elsevierViewall">In conclusion, the ultrasound diagnosis of a gallbladder polyp should be accompanied by a detailed report of its size, shape and number. When the polyps are symptomatic, cholecystectomy should be offered as treatment. Polyps smaller than 10<span class="elsevierStyleHsp" style=""></span>mm detected in patients under the age of 50 have a minimal probability of malignancy, and ultrasound follow-up is safe. The presence of multiple lesions in a young patient suggests benignity. In patients with polyps larger than 10<span class="elsevierStyleHsp" style=""></span>mm, cholecystectomy is recommended. In patients with smaller polyps but with suspicious characteristics seen on ultrasound who are over the age of 50, surgery should be recommended even though the probability of malignancy is low. Care should be taken when opening the surgical specimen for inspection, and this should be done on a surface for proper collection.</p><p id="par0125" class="elsevierStylePara elsevierViewall">Although some published studies do not recommend the ultrasound follow-up of unremoved polyps, we recommend a 6-month ultrasound and then annual ultrasounds for 2 or 3 years until studies are published with greater evidence for ruling out this recommendation.</p></span><span id="sec0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0095">Conflict of Interests</span><p id="par0130" class="elsevierStylePara elsevierViewall">The authors have no conflict of interests to declare.</p></span></span>" "textoCompletoSecciones" => array:1 [ "secciones" => array:10 [ 0 => array:2 [ "identificador" => "xres293525" "titulo" => array:6 [ 0 => "Abstract" 1 => "Introduction" 2 => "Objective" 3 => "Material and methods" 4 => "Results" 5 => "Conclusions" ] ] 1 => array:2 [ "identificador" => "xpalclavsec277464" "titulo" => "Keywords" ] 2 => array:2 [ "identificador" => "xres293524" "titulo" => array:6 [ 0 => "Resumen" 1 => "Introducción" 2 => "Objetivo" 3 => "Material y métodos" 4 => "Resultados" 5 => "Conclusiones" ] ] 3 => array:2 [ "identificador" => "xpalclavsec277465" "titulo" => "Palabras clave" ] 4 => array:2 [ "identificador" => "sec0005" "titulo" => "Introduction" ] 5 => array:2 [ "identificador" => "sec0010" "titulo" => "Material and Methods" ] 6 => array:2 [ "identificador" => "sec0015" "titulo" => "Results" ] 7 => array:2 [ "identificador" => "sec0020" "titulo" => "Discussion" ] 8 => array:2 [ "identificador" => "sec0025" "titulo" => "Conflict of Interests" ] 9 => array:1 [ "titulo" => "References" ] ] ] "pdfFichero" => "main.pdf" "tienePdf" => true "fechaRecibido" => "2011-09-27" "fechaAceptado" => "2012-04-30" "PalabrasClave" => array:2 [ "en" => array:1 [ 0 => array:4 [ "clase" => "keyword" "titulo" => "Keywords" "identificador" => "xpalclavsec277464" "palabras" => array:5 [ 0 => "Gallbladder polyp" 1 => "Pseudopolyp" 2 => "Adenoma" 3 => "Adenocarcinoma" 4 => "Cholecystectomy" ] ] ] "es" => array:1 [ 0 => array:4 [ "clase" => "keyword" "titulo" => "Palabras clave" "identificador" => "xpalclavsec277465" "palabras" => array:5 [ 0 => "Pólipo vesicular" 1 => "Pseudopólipo" 2 => "Adenoma" 3 => "Adenocarcinoma" 4 => "Colecistectomía" ] ] ] ] "tieneResumen" => true "resumen" => array:2 [ "en" => array:2 [ "titulo" => "Abstract" "resumen" => "<span class="elsevierStyleSectionTitle" id="sect0010">Introduction</span><p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">The surgery of gallbladder polyps is not well defined due to the lack of evidence-based clinical guidelines.</p> <span class="elsevierStyleSectionTitle" id="sect0015">Objective</span><p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">To analyze the management of polyps in Spain, and a review of the literature and treatment standards.</p> <span class="elsevierStyleSectionTitle" id="sect0020">Material and methods</span><p id="spar0015" class="elsevierStyleSimplePara elsevierViewall">The reports on cholecystectomy with gallbladder polyps (GBP) were extracted from the Pathology data base. Patients subjected to surgery with a diagnosis of GBP were identified in the Surgery data base. A single list was prepared and a review was made of the clinical histories, including, age, gender, clinical data, ultrasound report, and histopathology report.</p> <span class="elsevierStyleSectionTitle" id="sect0025">Results</span><p id="spar0020" class="elsevierStyleSimplePara elsevierViewall">A total of 30 patients, with a median age of 51 years (range 22–83), 21 of whom were female, were included. The ultrasound diagnosis was GBP in 19 patients, GBP and calculi in 7 cases, and calculi with no polyps in 4 cases. Other diagnoses concurrent with GBP were multiple haemangiomas (3), large single simple cyst (1), and multiple simple cysts (1). Eleven patients had typical pain (biliary origin), 5 of which showed no calculi on ultrasound. Eight had non-specific pain, which persisted in 3 cases after the cholecystectomy. Pseudopolyps were found in 20 gallbladders, and true polyps in 4 cases. In 3 cases, polyps were not found in the pathology study.</p> <span class="elsevierStyleSectionTitle" id="sect0030">Conclusions</span><p id="spar0025" class="elsevierStyleSimplePara elsevierViewall">The ultrasound report must specify the size, shape, and number of polyps. Patients with biliary type pain would benefit from a cholecystectomy. The probability of malignancy is minimum if the GBP is less than 10<span class="elsevierStyleHsp" style=""></span>mm and aged under 50 years, and a cholecystectomy is not required. A GBP greater than 10<span class="elsevierStyleHsp" style=""></span>mm should be an indication of cholecystectomy.</p>" ] "es" => array:2 [ "titulo" => "Resumen" "resumen" => "<span class="elsevierStyleSectionTitle" id="sect0040">Introducción</span><p id="spar0030" class="elsevierStyleSimplePara elsevierViewall">La cirugía por pólipo de vesícula biliar está poco definida debido a la carencia de guías clínicas basadas en la evidencia.</p> <span class="elsevierStyleSectionTitle" id="sect0045">Objetivo</span><p id="spar0035" class="elsevierStyleSimplePara elsevierViewall">Analizar el manejo de los pólipos en nuestro medio, y revisión de la literatura y estándares de tratamiento.</p> <span class="elsevierStyleSectionTitle" id="sect0050">Material y métodos</span><p id="spar0040" class="elsevierStyleSimplePara elsevierViewall">De la base de datos de Patología se extrajeron los informes de colecistectomía con pólipos vesiculares (PV). De la base de datos de Cirugía se identificó a pacientes intervenidos con diagnóstico de PV. Se confeccionó un listado único y se llevó a cabo la revisión de las historias clínicas incluyendo edad, sexo, clínica, informe ecográfico e informe anatomopatológico.</p> <span class="elsevierStyleSectionTitle" id="sect0055">Resultados</span><p id="spar0045" class="elsevierStyleSimplePara elsevierViewall">Se incluyó a 30 pacientes, mediana de edad 51 años (rango 22-83), 21 mujeres. En 19 pacientes el diagnóstico ecográfico fue PV, 7 de PV y litiasis, y 4 de litiasis sin pólipo. Otros diagnósticos concurrentes con PV fueron hemangiomas múltiples (3), gran quiste simple único (1), quistes simples múltiples (1). Once pacientes tuvieron dolor típico (origen biliar), 5 de los cuales sin litiasis ecográfica. Ocho presentaron dolor inespecífico, persistiendo en 3 tras la colecistectomía. Se encontraron pseudopólipos en 20 vesículas, y pólipos verdaderos en 4 casos. En 3 casos no se hallaron pólipos en el examen patológico.</p> <span class="elsevierStyleSectionTitle" id="sect0060">Conclusiones</span><p id="spar0050" class="elsevierStyleSimplePara elsevierViewall">El informe ecográfico debe especificar el tamaño, forma y número de pólipos. Los pacientes con dolor biliar típico se beneficiarán de una colecistectomía. Ante un PV menor de 10<span class="elsevierStyleHsp" style=""></span>mm y edad menor de 50 años la probabilidad de malignidad es mínima y no requiere colecistectomía. Los PV mayores de 10<span class="elsevierStyleHsp" style=""></span>mm deben ser indicación de colecistectomía.</p>" ] ] "NotaPie" => array:1 [ 0 => array:2 [ "etiqueta" => "☆" "nota" => "<p class="elsevierStyleNotepara" id="npar0010">Please cite this article as: Morera-Ocón FJ, Ballestín-Vicente J, Calatayud-Blas AM, de Tursi-Rispoli LC, Bernal-Sprekelsen JC. Indicaciones quirúrgicas en los pólipos de vesícula biliar. Cir Esp. 2013;91:324–330.</p>" ] ] "multimedia" => array:5 [ 0 => array:7 [ "identificador" => "fig0005" "etiqueta" => "Fig. 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 798 "Ancho" => 982 "Tamanyo" => 120124 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0055" class="elsevierStyleSimplePara elsevierViewall">Focal adenomyomatosis, with wall thickening in the fundus (arrowhead), small internal cysts and echogenic content in their interior (bold arrow).</p>" ] ] 1 => array:7 [ "identificador" => "fig0010" "etiqueta" => "Fig. 2" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr2.jpeg" "Alto" => 1504 "Ancho" => 1550 "Tamanyo" => 442824 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0060" class="elsevierStyleSimplePara elsevierViewall">(A) Pseudopolyps (arrowhead) as well as calculi (bold arrow) in the same specimen (B–C) confirmed as cholesterol polyps on histology (B: hematoxylin–eosin 10×; C: hematoxylin–eosin 20×).</p>" ] ] 2 => array:7 [ "identificador" => "fig0015" "etiqueta" => "Fig. 3" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr3.jpeg" "Alto" => 1528 "Ancho" => 981 "Tamanyo" => 259706 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0065" class="elsevierStyleSimplePara elsevierViewall">Tubular adenoma tubular (bold arrow); cholelithiasis in sloping area (arrowheads) confirmed by histology (hematoxylin–eosin preparation 40×).</p>" ] ] 3 => array:7 [ "identificador" => "fig0020" "etiqueta" => "Fig. 4" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr4.jpeg" "Alto" => 1512 "Ancho" => 982 "Tamanyo" => 288814 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0070" class="elsevierStyleSimplePara elsevierViewall">Ultrasound image of a papillary adenocarcinoma, with its corresponding histology (hematoxylin–eosin 10×).</p>" ] ] 4 => array:7 [ "identificador" => "tbl0005" "etiqueta" => "Table 1" "tipo" => "MULTIMEDIATABLA" "mostrarFloat" => true "mostrarDisplay" => false "tabla" => array:2 [ "tablatextoimagen" => array:1 [ 0 => array:2 [ "tabla" => array:1 [ 0 => """ <table border="0" frame="\n \t\t\t\t\tvoid\n \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="" valign="\n \t\t\t\t\ttop\n \t\t\t\t" style="border-bottom: 2px solid black"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="center" valign="\n \t\t\t\t\ttop\n \t\t\t\t" style="border-bottom: 2px solid black">Number \t\t\t\t\t\t\n \t\t\t\t</td></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " colspan="2" align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"><span class="elsevierStyleItalic">Cholesterol polyp</span></td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Multiple \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">11 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Single \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">9 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " colspan="2" align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"><span class="elsevierStyleVsp" style="height:0.5px"></span></td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleItalic">Hyperplasia</span> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">2 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleItalic">Adenomyomatous polyp</span> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">2 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleItalic">Inflammatory polyps</span> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">1 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " colspan="2" align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"><span class="elsevierStyleVsp" style="height:0.5px"></span></td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " colspan="2" align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"><span class="elsevierStyleItalic">Adenoma</span></td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Multiple \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">1 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Single \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">2 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " colspan="2" align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"><span class="elsevierStyleVsp" style="height:0.5px"></span></td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleItalic">Papillary adenocarcinoma</span> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">1 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleItalic">No lesions</span> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">3 \t\t\t\t\t\t\n \t\t\t\t</td></tr></tbody></table> """ ] "imagenFichero" => array:1 [ 0 => "xTab427243.png" ] ] ] "notaPie" => array:1 [ 0 => array:3 [ "identificador" => "tblfn0005" "etiqueta" => "a" "nota" => "<p class="elsevierStyleNotepara" id="npar0005">Coexistence of different types of polyps in the same cholecystectomy specimen.</p>" ] ] ] "descripcion" => array:1 [ "en" => "<p id="spar0075" class="elsevierStyleSimplePara elsevierViewall">Anatomic Pathology Diagnoses of the Polyps Found on Cholecystectomy.<a class="elsevierStyleCrossRef" href="#tblfn0005"><span class="elsevierStyleSup">a</span></a></p>" ] ] ] "bibliografia" => array:2 [ "titulo" => "References" "seccion" => array:1 [ 0 => array:2 [ "identificador" => "bibs0005" "bibliografiaReferencia" => array:27 [ 0 => array:3 [ "identificador" => "bib0005" "etiqueta" => "1" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Benign tumors and pseudotumors of the gallbladder. Report of 180 cases" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:2 [ 0 => "A.H. Christensen" 1 => "K.G. Ishak" ] ] ] ] ] "host" => array:1 [ 0 => array:1 [ "Revista" => array:6 [ "tituloSerie" => "Arch Pathol" "fecha" => "1970" "volumen" => "90" "paginaInicial" => "423" "paginaFinal" => "432" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/4319984" "web" => "Medline" ] ] ] ] ] ] ] ] 1 => array:3 [ "identificador" => "bib0010" "etiqueta" => "2" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Gallbladder cancer: the polyp-cancer sequence" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:2 [ 0 => "M.C. Aldridge" 1 => "H. Bismuth" ] ] ] ] ] "host" => array:1 [ 0 => array:1 [ "Revista" => array:6 [ "tituloSerie" => "Br J Surg" "fecha" => "1990" "volumen" => "77" "paginaInicial" => "363" "paginaFinal" => "364" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/2187556" "web" => "Medline" ] ] ] ] ] ] ] ] 2 => array:3 [ "identificador" => "bib0015" "etiqueta" => "3" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Relation of adenoma to carcinoma in the gallbladder" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:4 [ 0 => "S. Kozuka" 1 => "N. Tsubone" 2 => "A. Yasui" 3 => "K. Hachisuka" ] ] ] ] ] "host" => array:1 [ 0 => array:1 [ "Revista" => array:6 [ "tituloSerie" => "Cancer" "fecha" => "1982" "volumen" => "50" "paginaInicial" => "2226" "paginaFinal" => "2234" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/7127263" "web" => "Medline" ] ] ] ] ] ] ] ] 3 => array:3 [ "identificador" => "bib0020" "etiqueta" => "4" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Non-neoplastic polypoid lesions and adenomas of the gallbladder" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:3 [ 0 => "J. Albores-Saavedra" 1 => "C.J. Vardaman" 2 => "F. Vuitch" ] ] ] ] ] "host" => array:1 [ 0 => array:1 [ "Revista" => array:6 [ "tituloSerie" => "Pathol Annu" "fecha" => "1993" "volumen" => "28" "paginaInicial" => "145" "paginaFinal" => "147" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/8416136" "web" => "Medline" ] ] ] ] ] ] ] ] 4 => array:3 [ "identificador" => "bib0025" "etiqueta" => "5" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Gallbladder adenomas have molecular abnormalities different from those present in gallbladder carcinomas" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:4 [ 0 => "I.I. Witsuba" 1 => "J.F. Miquel" 2 => "A.F. Gazdar" 3 => "J. Albores-Saavedra" ] ] ] ] ] "host" => array:1 [ 0 => array:1 [ "Revista" => array:6 [ "tituloSerie" => "Hum Pathol" "fecha" => "1999" "volumen" => "30" "paginaInicial" => "21" "paginaFinal" => "25" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/9923922" "web" => "Medline" ] ] ] ] ] ] ] ] 5 => array:3 [ "identificador" => "bib0030" "etiqueta" => "6" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "K-ras gene mutation in gall bladder carcinomas and dysplasia" "autores" => array:1 [ 0 => array:2 [ "etal" => true "autores" => array:6 [ 0 => "T. Ajiki" 1 => "T. Fujimori" 2 => "H. Onoyama" 3 => "M. Yamamoto" 4 => "S. Kitazawa" 5 => "S. Maeda" ] ] ] ] ] "host" => array:1 [ 0 => array:1 [ "Revista" => array:6 [ "tituloSerie" => "GUT" "fecha" => "1996" "volumen" => "38" "paginaInicial" => "426" "paginaFinal" => "429" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/8675098" "web" => "Medline" ] ] ] ] ] ] ] ] 6 => array:3 [ "identificador" => "bib0035" "etiqueta" => "7" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Desde la distancia hasta el cáncer de la vesícula biliar" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:4 [ 0 => "E.I. Roa" 1 => "N.S. Muñoz" 2 => "S.G. Ibacache" 3 => "U.X. Aretxabala" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "/S0034-98872009000700002" "Revista" => array:6 [ "tituloSerie" => "Rev Méd Chile" "fecha" => "2009" "volumen" => "137" "paginaInicial" => "873" "paginaFinal" => "880" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/19802413" "web" => "Medline" ] ] ] ] ] ] ] ] 7 => array:3 [ "identificador" => "bib0040" "etiqueta" => "8" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Preneoplastic lesions in gallbladder cancer" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:4 [ 0 => "I. Roa" 1 => "X. Aretxabala" 2 => "J.C. Araya" 3 => "J. Roa" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1002/jso.20527" "Revista" => array:6 [ "tituloSerie" => "J Surg Oncol" "fecha" => "2006" "volumen" => "93" "paginaInicial" => "615" "paginaFinal" => "623" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/16724345" "web" => "Medline" ] ] ] ] ] ] ] ] 8 => array:3 [ "identificador" => "bib0045" "etiqueta" => "9" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Microsatelite instability in preneoplastic and neoplastic lesions of the gallbladder" "autores" => array:1 [ 0 => array:2 [ "etal" => true "autores" => array:6 [ 0 => "J.C. Roa" 1 => "I. Roa" 2 => "P. Correa" 3 => "Q. Vo" 4 => "J.C. Araya" 5 => "M. Villaseca" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1007/s00535-004-1497-4" "Revista" => array:6 [ "tituloSerie" => "J Gastroenterol" "fecha" => "2005" "volumen" => "40" "paginaInicial" => "79" "paginaFinal" => "86" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/15692793" "web" => "Medline" ] ] ] ] ] ] ] ] 9 => array:3 [ "identificador" => "bib0050" "etiqueta" => "10" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Polyps in the gallbladder: a prevalence study" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:2 [ 0 => "T. Jorgersen" 1 => "K.H. Jensen" ] ] ] ] ] "host" => array:1 [ 0 => array:1 [ "Revista" => array:5 [ "tituloSerie" => "Scan J Gastroenterol" "fecha" => "1990" "volumen" => "25" "paginaInicial" => "281" "paginaFinal" => "286" ] ] ] ] ] ] 10 => array:3 [ "identificador" => "bib0055" "etiqueta" => "11" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Prevalence of gallbladder polyps among apparently healthy Japanese: ultrasonographic study" "autores" => array:1 [ 0 => array:2 [ "etal" => true "autores" => array:6 [ 0 => "K. Segawa" 1 => "T. Arisawa" 2 => "Y. Niwa" 3 => "T. Suzuki" 4 => "Y. Tsukamoto" 5 => "H. Goto" ] ] ] ] ] "host" => array:1 [ 0 => array:1 [ "Revista" => array:6 [ "tituloSerie" => "Am J Gastroenterol" "fecha" => "1992" "volumen" => "87" "paginaInicial" => "630" "paginaFinal" => "633" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/1595653" "web" => "Medline" ] ] ] ] ] ] ] ] 11 => array:3 [ "identificador" => "bib0060" "etiqueta" => "12" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Gallbladder polyps: prevalence and risk factors" "autores" => array:1 [ 0 => array:2 [ "etal" => true "autores" => array:6 [ 0 => "W. Kratzer" 1 => "A. Schmid" 2 => "A.S. Akinli" 3 => "R. Thiel" 4 => "R.A. Mason" 5 => "A. Schuler" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1055/s-0029-1245265" "Revista" => array:7 [ "tituloSerie" => "Ultraschall Med" "fecha" => "2011" "volumen" => "32" "numero" => "Suppl 1" "paginaInicial" => "S68" "paginaFinal" => "S73" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/20414857" "web" => "Medline" ] ] ] ] ] ] ] ] 12 => array:3 [ "identificador" => "bib0065" "etiqueta" => "13" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Risk factors for gallbladder polyps in the Chinese population" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:4 [ 0 => "C.Y. Chen" 1 => "C.L. Lu" 2 => "F.Y. Chang" 3 => "S.D. Lee" ] ] ] ] ] "host" => array:1 [ 0 => array:1 [ "Revista" => array:6 [ "tituloSerie" => "Am J Gastroenterol" "fecha" => "1997" "volumen" => "92" "paginaInicial" => "2066" "paginaFinal" => "2068" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/9362194" "web" => "Medline" ] ] ] ] ] ] ] ] 13 => array:3 [ "identificador" => "bib0070" "etiqueta" => "14" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Management strategies for gallbladder polyps: is it possible to predict malignant gallbladder polyps?" "autores" => array:1 [ 0 => array:2 [ "etal" => true "autores" => array:6 [ 0 => "J.K. Park" 1 => "Y.B. Yoon" 2 => "Y.T. Kim" 3 => "J.K. Ryu" 4 => "W.J. Yoon" 5 => "S.H. Lee" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.5009/gnl.2008.2.2.88" "Revista" => array:6 [ "tituloSerie" => "Gut and Liver" "fecha" => "2008" "volumen" => "2" "paginaInicial" => "88" "paginaFinal" => "94" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/20485616" "web" => "Medline" ] ] ] ] ] ] ] ] 14 => array:3 [ "identificador" => "bib0075" "etiqueta" => "15" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Acute cholecystitis caused by a cholesterol polyp" "autores" => array:1 [ 0 => array:2 [ "etal" => true "autores" => array:6 [ 0 => "H. Yoshida" 1 => "M. Onda" 2 => "T. Tajiri" 3 => "Y. Mamada" 4 => "N. Taniani" 5 => "Y. Mizuguchi" ] ] ] ] ] "host" => array:1 [ 0 => array:1 [ "Revista" => array:6 [ "tituloSerie" => "J Nippon Med Sch" "fecha" => "2001" "volumen" => "68" "paginaInicial" => "259" "paginaFinal" => "261" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/11404773" "web" => "Medline" ] ] ] ] ] ] ] ] 15 => array:3 [ "identificador" => "bib0080" "etiqueta" => "16" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "How should polypoid lesions of the gallbladder be treated in the era of laparoscopic cholecystectomy?" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:6 [ 0 => "K. Kubota" 1 => "Y. Bandai" 2 => "T. Noie" 3 => "Y. Ishizaki" 4 => "M. Teruya" 5 => "M. Makuuchi" ] ] ] ] ] "host" => array:1 [ 0 => array:1 [ "Revista" => array:6 [ "tituloSerie" => "Surgery" "fecha" => "1995" "volumen" => "117" "paginaInicial" => "481" "paginaFinal" => "487" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/7740417" "web" => "Medline" ] ] ] ] ] ] ] ] 16 => array:3 [ "identificador" => "bib0085" "etiqueta" => "17" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Surgical indications for small polypoid lesions of the gallbladder" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:3 [ 0 => "H. Shinkai" 1 => "W. Kimura" 2 => "T. Muto" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1016/S0002-9610(97)00262-6" "Revista" => array:6 [ "tituloSerie" => "Am J Surg" "fecha" => "1998" "volumen" => "175" "paginaInicial" => "114" "paginaFinal" => "117" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/9515526" "web" => "Medline" ] ] ] ] ] ] ] ] 17 => array:3 [ "identificador" => "bib0090" "etiqueta" => "18" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Gallbladder polyps: how should they be treated and when?" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:3 [ 0 => "A.S. De Matos" 1 => "C. Bpatista HNm Pinheiro" 2 => "F. Martinho" ] ] ] ] ] "host" => array:1 [ 0 => array:1 [ "Revista" => array:6 [ "tituloSerie" => "Rev Assoc Med Bras" "fecha" => "2010" "volumen" => "56" "paginaInicial" => "318" "paginaFinal" => "321" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/20676540" "web" => "Medline" ] ] ] ] ] ] ] ] 18 => array:3 [ "identificador" => "bib0095" "etiqueta" => "19" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Clinicopathologic features of polypoid lesions of the gallbladder and risk factors of gallbladder cancer" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:5 [ 0 => "W. Kwon" 1 => "J.Y. Jang" 2 => "S.E. Lee" 3 => "D.W. Hwang" 4 => "S.W. Kim" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.3346/jkms.2009.24.3.481" "Revista" => array:6 [ "tituloSerie" => "J Korean Med Sci" "fecha" => "2009" "volumen" => "24" "paginaInicial" => "481" "paginaFinal" => "487" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/19543513" "web" => "Medline" ] ] ] ] ] ] ] ] 19 => array:3 [ "identificador" => "bib0100" "etiqueta" => "20" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Polypoid lesions of the gallbladder: diagnosis and followup" "autores" => array:1 [ 0 => array:2 [ "etal" => true "autores" => array:6 [ 0 => "H. Ito" 1 => "L.E. Hann" 2 => "M. D’angelica" 3 => "P. Allen" 4 => "Y. Fong" 5 => "R.P. Dematteo" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1016/j.jamcollsurg.2009.01.011" "Revista" => array:6 [ "tituloSerie" => "J Am Coll Surg" "fecha" => "2009" "volumen" => "208" "paginaInicial" => "570" "paginaFinal" => "575" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/19476792" "web" => "Medline" ] ] ] ] ] ] ] ] 20 => array:3 [ "identificador" => "bib0105" "etiqueta" => "21" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Late follow-up of polypoid lesions of the gallbladder smaller than 10<span class="elsevierStyleHsp" style=""></span>mm" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:5 [ 0 => "A. Csendes" 1 => "A.M. Burgos" 2 => "P. Csendes" 3 => "G. Smok" 4 => "J. Rojas" ] ] ] ] ] "host" => array:1 [ 0 => array:1 [ "Revista" => array:6 [ "tituloSerie" => "Ann Surg" "fecha" => "2001" "volumen" => "234" "paginaInicial" => "657" "paginaFinal" => "660" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/11685029" "web" => "Medline" ] ] ] ] ] ] ] ] 21 => array:3 [ "identificador" => "bib0110" "etiqueta" => "22" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Polypoid lesions of the gallbladder: report of 100 cases with special reference to operative indications" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:5 [ 0 => "C. Terzi" 1 => "S. Sokmen" 2 => "S. Seckin" 3 => "L. Albayrak" 4 => "M. Ugurul" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1067/msy.2000.105870" "Revista" => array:6 [ "tituloSerie" => "Surgery" "fecha" => "2000" "volumen" => "127" "paginaInicial" => "622" "paginaFinal" => "627" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/10840356" "web" => "Medline" ] ] ] ] ] ] ] ] 22 => array:3 [ "identificador" => "bib0115" "etiqueta" => "23" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Is it necessary to perform prophylactic cholecystectomy for asymptomatic subjects with gallbladder polyps and gallstones?" "autores" => array:1 [ 0 => array:2 [ "etal" => true "autores" => array:6 [ 0 => "S.Y. Choi" 1 => "T.S. Kim" 2 => "H.J. Kim" 3 => "J.H. Park" 4 => "D.I. Park" 5 => "Y.K. Cho" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1111/j.1440-1746.2010.06288.x" "Revista" => array:6 [ "tituloSerie" => "J Gastroenterol Hepatol" "fecha" => "2010" "volumen" => "25" "paginaInicial" => "1099" "paginaFinal" => "1104" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/20594225" "web" => "Medline" ] ] ] ] ] ] ] ] 23 => array:3 [ "identificador" => "bib0120" "etiqueta" => "24" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Noninvasive carcinoma of the gallbladder arising in localized type adenomyomatosis" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:4 [ 0 => "T. Katoh" 1 => "T. Nakai" 2 => "S. Hayashi" 3 => "T. Satake" ] ] ] ] ] "host" => array:1 [ 0 => array:1 [ "Revista" => array:6 [ "tituloSerie" => "Am J Gastroenterol" "fecha" => "1988" "volumen" => "83" "paginaInicial" => "670" "paginaFinal" => "674" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/3376922" "web" => "Medline" ] ] ] ] ] ] ] ] 24 => array:3 [ "identificador" => "bib0125" "etiqueta" => "25" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Adenomyomatosis of the gallbladder. A premalignant lesion?" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:4 [ 0 => "M.C. Aldridge" 1 => "F. Gruffa" 2 => "D. Castaing" 3 => "H. Bismuth" ] ] ] ] ] "host" => array:1 [ 0 => array:1 [ "Revista" => array:6 [ "tituloSerie" => "Surgery" "fecha" => "1991" "volumen" => "109" "paginaInicial" => "107" "paginaFinal" => "110" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/1984629" "web" => "Medline" ] ] ] ] ] ] ] ] 25 => array:3 [ "identificador" => "bib0130" "etiqueta" => "26" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Incidentally detected gallbladder polyps: is follow-up necessary? Long-term clinical and US analysis of 346 patients" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:4 [ 0 => "M.T. Corwin" 1 => "B. Siewert" 2 => "R.G. Sheiman" 3 => "R.A. Kane" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1148/radiol.10100273" "Revista" => array:6 [ "tituloSerie" => "Radiology" "fecha" => "2011" "volumen" => "258" "paginaInicial" => "277" "paginaFinal" => "282" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/20697115" "web" => "Medline" ] ] ] ] ] ] ] ] 26 => array:3 [ "identificador" => "bib0135" "etiqueta" => "27" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Question and answer" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:1 [ 0 => "M.E. Tublin" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.2214/ajr.177.2.1770467a" "Revista" => array:5 [ "tituloSerie" => "AJR" "fecha" => "2001" "volumen" => "177" "paginaInicial" => "467" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/11461886" "web" => "Medline" ] ] ] ] ] ] ] ] ] ] ] ] ] "idiomaDefecto" => "en" "url" => "/21735077/0000009100000005/v1_201311210034/S2173507713001622/v1_201311210034/en/main.assets" "Apartado" => array:4 [ "identificador" => "7417" "tipo" => "SECCION" "en" => array:2 [ "titulo" => "Original articles" "idiomaDefecto" => true ] "idiomaDefecto" => "en" ] "PDF" => "https://static.elsevier.es/multimedia/21735077/0000009100000005/v1_201311210034/S2173507713001622/v1_201311210034/en/main.pdf?idApp=UINPBA00004N&text.app=https://www.elsevier.es/" "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S2173507713001622?idApp=UINPBA00004N" ]
| Year/Month | Html | Total | |
|---|---|---|---|
| 2024 November | 58 | 0 | 58 |
| 2024 October | 365 | 12 | 377 |
| 2024 September | 370 | 19 | 389 |
| 2024 August | 503 | 17 | 520 |
| 2024 July | 466 | 12 | 478 |
| 2024 June | 291 | 6 | 297 |
| 2024 May | 303 | 10 | 313 |
| 2024 April | 270 | 6 | 276 |
| 2024 March | 291 | 11 | 302 |
| 2024 February | 387 | 11 | 398 |
| 2024 January | 377 | 3 | 380 |
| 2023 December | 298 | 15 | 313 |
| 2023 November | 343 | 23 | 366 |
| 2023 October | 312 | 8 | 320 |
| 2023 September | 235 | 9 | 244 |
| 2023 August | 225 | 7 | 232 |
| 2023 July | 278 | 24 | 302 |
| 2023 June | 214 | 14 | 228 |
| 2023 May | 286 | 19 | 305 |
| 2023 April | 230 | 5 | 235 |
| 2023 March | 252 | 20 | 272 |
| 2023 February | 204 | 12 | 216 |
| 2023 January | 149 | 14 | 163 |
| 2022 December | 170 | 14 | 184 |
| 2022 November | 209 | 33 | 242 |
| 2022 October | 157 | 24 | 181 |
| 2022 September | 169 | 32 | 201 |
| 2022 August | 156 | 40 | 196 |
| 2022 July | 130 | 17 | 147 |
| 2022 June | 147 | 27 | 174 |
| 2022 May | 153 | 10 | 163 |
| 2022 April | 185 | 25 | 210 |
| 2022 March | 196 | 16 | 212 |
| 2022 February | 221 | 20 | 241 |
| 2022 January | 235 | 9 | 244 |
| 2021 December | 164 | 17 | 181 |
| 2021 November | 162 | 16 | 178 |
| 2021 October | 197 | 27 | 224 |
| 2021 September | 149 | 15 | 164 |
| 2021 August | 147 | 17 | 164 |
| 2021 July | 150 | 16 | 166 |
| 2021 June | 154 | 8 | 162 |
| 2021 May | 194 | 22 | 216 |
| 2021 April | 492 | 46 | 538 |
| 2021 March | 414 | 79 | 493 |
| 2021 February | 254 | 15 | 269 |
| 2021 January | 251 | 14 | 265 |
| 2020 December | 294 | 9 | 303 |
| 2020 November | 290 | 17 | 307 |
| 2020 October | 155 | 17 | 172 |
| 2020 September | 163 | 18 | 181 |
| 2020 August | 166 | 14 | 180 |
| 2020 July | 167 | 17 | 184 |
| 2020 June | 119 | 10 | 129 |
| 2020 May | 132 | 19 | 151 |
| 2020 April | 145 | 6 | 151 |
| 2020 March | 209 | 15 | 224 |
| 2020 February | 168 | 13 | 181 |
| 2020 January | 137 | 17 | 154 |
| 2019 December | 93 | 6 | 99 |
| 2019 November | 134 | 16 | 150 |
| 2019 October | 137 | 15 | 152 |
| 2019 September | 156 | 11 | 167 |
| 2019 August | 113 | 12 | 125 |
| 2019 July | 140 | 18 | 158 |
| 2019 June | 186 | 29 | 215 |
| 2019 May | 303 | 41 | 344 |
| 2019 April | 148 | 37 | 185 |
| 2019 March | 89 | 8 | 97 |
| 2019 February | 89 | 16 | 105 |
| 2019 January | 58 | 5 | 63 |
| 2018 December | 57 | 10 | 67 |
| 2018 November | 79 | 4 | 83 |
| 2018 October | 70 | 7 | 77 |
| 2018 September | 39 | 26 | 65 |
| 2018 August | 25 | 12 | 37 |
| 2018 July | 42 | 5 | 47 |
| 2018 June | 28 | 2 | 30 |
| 2018 May | 36 | 3 | 39 |
| 2018 April | 38 | 4 | 42 |
| 2018 March | 54 | 3 | 57 |
| 2018 February | 27 | 1 | 28 |
| 2018 January | 25 | 2 | 27 |
| 2017 December | 40 | 1 | 41 |
| 2017 November | 40 | 4 | 44 |
| 2017 October | 48 | 2 | 50 |
| 2017 September | 62 | 5 | 67 |
| 2017 August | 50 | 5 | 55 |
| 2017 July | 44 | 3 | 47 |
| 2017 June | 55 | 4 | 59 |
| 2017 May | 76 | 9 | 85 |
| 2017 April | 69 | 8 | 77 |
| 2017 March | 65 | 7 | 72 |
| 2017 February | 61 | 8 | 69 |
| 2017 January | 60 | 4 | 64 |
| 2016 December | 73 | 9 | 82 |
| 2016 November | 114 | 14 | 128 |
| 2016 October | 118 | 20 | 138 |
| 2016 September | 145 | 6 | 151 |
| 2016 August | 94 | 11 | 105 |
| 2016 July | 105 | 7 | 112 |
| 2016 June | 75 | 14 | 89 |
| 2016 May | 80 | 17 | 97 |
| 2016 April | 93 | 17 | 110 |
| 2016 March | 96 | 27 | 123 |
| 2016 February | 58 | 26 | 84 |
| 2016 January | 44 | 30 | 74 |
| 2015 December | 46 | 21 | 67 |
| 2015 November | 47 | 21 | 68 |
| 2015 October | 51 | 25 | 76 |
| 2015 September | 40 | 19 | 59 |
| 2015 August | 69 | 9 | 78 |
| 2015 July | 66 | 6 | 72 |
| 2015 June | 51 | 11 | 62 |
| 2015 May | 38 | 12 | 50 |
| 2015 April | 27 | 13 | 40 |
| 2015 March | 45 | 11 | 56 |
| 2015 February | 35 | 10 | 45 |
| 2015 January | 27 | 5 | 32 |
| 2014 December | 66 | 13 | 79 |
| 2014 November | 42 | 12 | 54 |
| 2014 October | 39 | 11 | 50 |
| 2014 September | 21 | 9 | 30 |
| 2014 August | 33 | 18 | 51 |
| 2014 July | 43 | 16 | 59 |
| 2014 June | 36 | 5 | 41 |
| 2014 May | 25 | 3 | 28 |
| 2014 April | 26 | 9 | 35 |
| 2014 March | 24 | 9 | 33 |
| 2014 February | 31 | 4 | 35 |
| 2014 January | 25 | 5 | 30 |
| 2013 December | 14 | 10 | 24 |
| 2013 November | 6 | 4 | 10 |
Show all
