I. Etiology
Gallbladder stones are associated with a variety of factors. Any factor that affects the altered cholesterol to bile acid concentration ratio and causes bile stagnation can lead to stone formation. Residents of individual regions and races, female hormones, obesity, pregnancy, high-fat diet, long-term parenteral nutrition, diabetes mellitus, hyperlipidemia, post-gastrectomy or gastrointestinal anastomosis, terminal ileal disease and ileal resection, liver cirrhosis, and hemolytic anemia can all cause gallbladder stones.
II. Clinical manifestations
Most patients are asymptomatic and only found during physical examination, surgery and autopsy, which is called stationary gallbladder stones. The typical symptoms of gallbladder stones in a few patients are biliary colic, which manifests as acute or chronic cholecystitis. The main clinical manifestations are as follows.
1.Biliary colic
Patients often have colic due to contraction of the gallbladder or displacement of stones plus vagus nerve excitation after a full meal, eating fatty food or during sleep when the position changes, the stones are embedded in the abdomen or neck of the gallbladder, gallbladder emptying is obstructed, the pressure in the gallbladder rises, and the gallbladder contracts strongly. The pain is located in the right upper abdomen or epigastrium and is paroxysmal, or the pain may increase in paroxysms, radiating to the right scapula and back, and may be accompanied by nausea and vomiting. Some patients are unable to name the exact site of pain because of its intensity. After the first occurrence of biliary colic, most of the patients will have recurrent attacks.
2.Hidden pain in the upper abdomen
Most patients only feel vague pain in the upper abdomen or right upper abdomen when they over-eat, eat high-fat food, work under stress or have poor rest, or have discomfort of fullness, belching, eructation, etc., which can be easily misdiagnosed as “stomach disease”.
3.Gallbladder fluid accumulation
When gallbladder stones are embedded for a long time or obstruct the gallbladder duct but are not combined with infection, the gallbladder mucosa absorbs bile pigments from the bile. Mucus material is secreted, forming gallbladder effusion. The fluid is transparent and colorless, also known as white bile.
4.Other
(1) It rarely causes jaundice.
(2) Small stones may enter the common bile duct through the cystic duct and become common bile duct stones.
(3) Stones from the common bile duct become embedded in the jugular abdomen through the sphincter of Oddi, leading to pancreatitis, called biliary pancreatitis.
(4) inflammation and chronic perforation of the gallbladder due to stone compression, which can result in cholecystoduodenal fistula or cholecystocolic fistula, and large stones entering the intestine through the fistula causing intestinal obstruction called gallstone intestinal obstruction
(5) Stones and long-term inflammatory stimulation can induce gallbladder cancer.
5.Mirizzi’s syndrome
Mirizzi’s syndrome is a special type of gallbladder stone, which is caused by the low confluence of the cystic duct and the common hepatic duct, and the persistent embedment in the neck of the gallbladder and the compression of the common hepatic duct by large cystic duct stones, resulting in the narrowing of the common hepatic duct. The clinical manifestations are recurrent episodes of cholecystitis and cholangitis, and marked obstructive jaundice. Imaging of the biliary tract reveals an enlarged gallbladder or enlarged, dilated common hepatic duct, and normal common bile duct.
III. Diagnosis
Based on the typical clinical history of colic, imaging examination can confirm the diagnosis. Ultrasound examination is the first choice, and the diagnosis of gallbladder stones can be confirmed by the presence of a strong echogenic mass in the gallbladder, which moves with position change and is followed by acoustic shadow. Only 10%-15% of gallbladder stones contain calcium, and the diagnosis can be confirmed by abdominal X-ray. However, it is not used as a routine examination.
IV. Treatment
Our department is one of the first units in China to carry out laparotomy. Through the efforts and development of several generations for more than 20 years, especially in recent years, under the leadership of the head of the department, Prof. Hong Defei, the hospital has introduced Da Vinci surgical system at a huge cost , so that the level of laparoscopic technology has advanced by leaps and bounds, carrying out laparoscopic or combined Da Vinci pancreaticoduodenectomy and other difficult surgeries, reaching the international advanced level.
For the treatment of gallbladder stones, which is a common disease plaguing many patients, our department has carefully formed a team with Dr. Wang Zhimin and Dr. Wang Zhifei as the chief physicians, and the treatment of gallbladder stones is individualized, which is called “personalized”. Depending on the patient’s condition and needs, conventional laparoscopic cholecystectomy, single-port laparoscopic cholecystectomy (scarless laparoscopic cholecystectomy) and endoscopic minimally invasive cholecystectomy can be chosen. The treatment plan for gallbladder stones has been optimized in the pursuit of excellence and perfection.
1.Laparoscopic cholecystectomy treatment
The 3-hole or 4-hole method is used, which is less invasive and more effective than the classic open cholecystectomy. Asymptomatic gallbladder stones generally do not require active surgical treatment and can be observed and followed up, but the following cases should be considered for surgical treatment.
(1) stone diameter ≥ 75px.
(2) Combined surgery requiring open abdomen.
(3) associated with gallbladder polyps >25px.
(4) thickening of the gallbladder wall.
(5) calcification of the gallbladder wall or porcelain gallbladder.
(6) gallbladder stones in children.
(7) Combined diabetes mellitus.
(8) Cardiopulmonary dysfunction.
(9) remote or underdeveloped transportation areas, field workers
(10) Gallbladder stones found more than 10 years.
2.Single-port laparoscopic cholecystectomy
Also known as “scarless” laparoscopic cholecystectomy less traumatic is the consistent tenet of surgery, and is also the higher realm pursued by the surgical community. In 1969, Wheeless reported the first single-port laparoscopic tubal ligation, and since then, single-port laparoscopic surgery has been performed. Single-port laparoscopic surgery has been performed for 40 years. Currently, single-port laparoscopic surgery is mainly performed through the umbilical cord. Because of the obvious cosmetic effect, light postoperative pain, fast recovery, low infection rate of poke hernia and poke hole, single-port laparoscopic surgery has become the most feasible “scarless” technique at this stage.
The umbilicus is the only inherent scar on the body. The umbilical incision of single-port laparoscopic surgery is about 10-20 mm long, because the skin folds of the umbilicus can cover the incision, thus achieving the purpose of scarless surgery with satisfactory cosmetic effects, and at the same time reducing postoperative pain, thus reducing the amount of intraoperative and postoperative anesthesia and analgesic drugs. Patients recover quickly after surgery, and the length of hospital stay is short, and hospitalization costs are reduced accordingly.
Most of the gallbladder diseases such as gallbladder stones and chronic cholecystitis are applicable, however, under the current technical conditions, it is difficult to use single-hole laparoscopic surgery for patients with acute cholecystitis and combined bile duct stones.
3.Minimally invasive endoscopic bile preservation surgery
With the development and progress of endoscopic technology, the endoscope can see the internal situation of the biliary tract directly, which has played a great role in the diagnosis and treatment of biliary tract diseases. “Endoscopic minimally invasive biliary stone extraction” is to use a soft (fiber) cholangioscope to enter the gallbladder for examination and treatment. The fiber cholangioscope can be bent at will and can be illuminated for observation, so that stones can be removed wherever there are stones, so that the stones can be safely and thoroughly removed and the treatment results are real and reliable.
The endoscopic minimally invasive biliary stone extraction incision is small and lightly damaged, and you can get out of bed the next day after the operation and be discharged from the hospital after 3 days. The 10-year follow-up of nearly 1,000 patients shows that the recurrence rate is only 4% 5 years after surgery.
This technique belongs to a kind of minimally invasive surgery, which is a product of the combination of modern high technology and traditional surgical techniques. Its biggest advantage is that there is no abdominal surgical incision in the traditional sense, avoiding all kinds of damage and discomfort caused by the surgical incision. Patients with symptomatic cholecystitis and gallbladder stones whose gallbladder has been confirmed to be functional by 99mTc-ECT or oral cholecystography can opt for minimally invasive endoscopic biliary preservation surgery.