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Objective:
This study aims to compare number and cost of follow-up ultrasound (US) and cholecystectomies recommended in patients with incidentally found gallbladder (GB) polyps in 2016 at our institution based on the SRU 2022 guidelines, the 2017 and 2022 European guidelines, and the 2013 ACR White Paper.

Materials and Methods:
All adult patients between January 1 and December 31, 2016 with a GB polyp on US at our institution were reviewed. EMR were reviewed for age, sex, ethnicity and race, or history of primary sclerosing cholangitis (PSC). Pathologic diagnosis was reviewed in patients who underwent cholecystectomy. Images were retrospectively reviewed by two independent readers blinded to clinical data for polyp size, morphology, and size on follow-up US. Costs were calculated using current Medicare prices for hospital outpatient departments assuming an US costs $139 and cholecystectomy costs $5941.

Results:
A total of 256 consecutive patients with at least one GB polyp were identified. Of these, 86 had subsequent ultrasound imaging and 27 underwent subsequent cholecystectomy. Patient demographics were as follows: 148 were 50 years old, 39 were 51–60 y, and 69 were > 60 y. Eleven were South Asian and 74 were other Asian. One patient had PSC. One patient had GB cancer (26 mm). No intracholecystic papillary neoplasms (ICPN) were identified at pathologic resection. Morphologic assessment of polyps: ball-on-the-wall (177), pedunculated with thin stalk (0), pedunculated with broad base (51), sessile (25), and adjacent wall thickening = 4 mm (3). Size of polyps: 5 mm (179), 6–9 mm (67), 10–14 mm (9), and 15 mm (1). In 86 patients with follow-up imaging, polyps were visible in 64 patients and not visible in 22. Per current SRU guidelines, 10 patients (3.9%) would require 21 follow-up US examinations and 4 (1.56%) would require surgical consultations. Based on growth (4 mm), two additional patients would need surgical consultation. The total cost would be $38,565. Per 2022 European guidelines, 75 patients (29.3%) would require 225 follow-up US examinations and 128 patients (50.0%) would need cholecystectomy. On follow-up, 10 additional patients would need cholecystectomy. Total cost would be $851,113. Per 2017 European guidelines, 126 patients (49.2%) would require 603 follow-up US examinations and 130 patients (50.8%) would require cholecystectomy. On follow-up, 10 additional patients would need cholecystectomy. Total cost would be $915,557. Per ACR 2013 guidelines, 41 patients (16.0%) would require follow-up US (267 total) and 10 patients (3.9%) would require cholecystectomy. On follow-up, 22 additional patients would require cholecystectomy. The cost for all patients would be $227,225.

Conclusion:
The SRU guidelines significantly decreases the number of recommended follow-up US examinations and cholecystectomy compared to European Guidelines (2022 and 2017) and ACR 2013 in the management of incidental GB polyps without compromising sensitivity for GB cancer in our patient cohort.