We thank Dr. Schramm and Dr. Lohse for their generous comments regarding our review and for sharing their experience with malignant gallbladder disease in primary sclerosing cholangitis (PSC) patients. As noted, our recommendations do differ slightly from the European Association for the Study of the Liver (EASL) and the American Association for the Study of Liver Diseases (AASLD) guidelines, which recommend prompt cholecystectomy for gall bladder polyps of any size in PSC patients. Our review (fig. 2) also recommends consideration of prompt cholecystectomy in PSC patients with gall bladder polyps of any size in patients with good liver function. However, in patients with impaired liver function there is a risk in performing a cholecystectomy, and using a polyp size cutoff of 0.8 cm adds specificity to the likelihood that the patient has neoplastic disease. Obviously, recommendations are only meant to guide an “individualized” approach regarding management decisions that must take into account the variety of unique patient factors. We hope this clarifies our recommendations and places them in context vis-à-vis the EASL and AASLD guidelines and provides impetus for further investigations on the subject.
To the Editor:
Gregory Gores M.D., F.A.C.P.*, Keith D. Lindor M.D.*, Nataliya Razumilava M.D.*, * Division of Gastroenterology and Hepatology, Mayo Medical School, Rochester, MN.