Gallbladder stones are a common disease with a high incidence, and currently account for 8% to 10% of the population in China. They are more common in women among adults, especially in menstruating mothers and those taking birth control pills. The ratio of men to women is about 1:3, but the gender difference decreases with age, and the ratio of men to women is 1:1.5 at the age of 50, and the incidence of men and women is basically equal in the elderly, which may be related to the role of estrogen in the formation of gallbladder stones. For decades, people have been seeking and exploring safer and more effective, less painful, microplane injuries, and more acceptable treatment methods for patients.
I. Conservative treatment.
For asymptomatic gallbladder stones, i.e. quiescent gallbladder stones, it is generally believed that immediate cholecystectomy is not necessary, but regular review and dynamic observation can be given, and litholytic drug therapy can also be given selectively
1.Oral lithotripsy therapy
There are two main types of oral lithotripsy drugs used in clinical practice: goose deoxycholic acid and ursodeoxycholic acid. These two drugs desaturate bile by reducing the secretion of bile cholesterol, and unsaturated bile has the effect of dissolving cholesterol, so that the cholesterol molecules on the surface of gallstones are continuously dissolved, and the volume of gallstones is gradually reduced to complete dissolution.
However, these drugs are not effective for non-cholesterol stones, and they are not effective for stones ≥l 5mm, calcified, non-floating stones, and those with a long history of disease. Secondly, they are long, expensive and prone to recurrence after discontinuation. In addition, long-term use is likely to lead to side effects such as liver function damage, arteriosclerosis, and diarrhea. For this reason, the treatment effect of this method is not ideal.
2.Lithotripsy by perfusion
It refers to the direct infusion of drugs into the bile duct, and the solvent includes cholesterol stone solvent and bile pigment stone solvent. For example, cholesterol stones are treated by dripping octanoic acid monoester through T-tube, alternating dripping glycerol octanoic acid monoester and BA-ED-TA through a nasal biliary duct (refers to a drug containing ursodeoxycholic acid, bile acid. It is also used to treat mixed or bile pigment stones.
However, this method is time-consuming to operate and technically difficult to promote, and the perfused drug is prone to damage the gallbladder mucosa, leading to serious toxic side effects and complications such as cholangitis, pancreatitis, and even hemolysis. The prospect is to discover a new solvent that can dissolve stones of various nature without major side effects.
3.Extracorporeal impact lithotripsy
This method is only suitable for negative stones with X-ray transmission, less than 3 stones, diameter <15-25mm, no bile duct obstruction, and normal contractile function of the primary gallbladder, and in most cases, the lithotripsy is not complete and often requires reshock after 30d interval. As the diameter of the stone decreases, lithotripsy is also required. Lithotripsy is not easy to grasp and promote because the steps are tedious.
4.Chinese medicine lithotripsy therapy
Chinese medicine scholars say different things about the cause of gallbladder stones. Some people believe that gallbladder stones are the result of phlegm and stasis intertwined with tangible real evil, mostly due to disorders of emotions, diet, feeling external evil, insect accumulation, etc., resulting in dysfunction of internal organs, dysfunction of liver and gallbladder drainage, liver and gallbladder damp heat, bile stagnation. It is also believed that this disease is caused by damp-heat accumulation in the liver and gallbladder, liver loss, stagnation of Qi and blood or excessive alcohol and food. As the patient’s condition varies, the methods used by TCM scholars also vary. The methods include Chinese herbal medicine, proprietary Chinese medicine, acupuncture and moxibustion, and ear acupressure.
The role of TCM in gallbladder stone removal has been confirmed and proven. However, the cure rate is low, the recurrence rate is high, and the course of treatment is long. Therefore, it is very necessary to investigate the specific prescriptions of Chinese medicine that can prevent stone production, have better lithotripsy effect, have no toxic side effects, have low recurrence rate, are easy to use and can be promoted.
Once gallstones are formed, it is difficult to dissolve or dissolve the stones with drugs, and it is not easy to empty them. During the process of stone removal, it may also induce acute attacks of cholecystitis, form secondary bile duct stones or cause acute pancreatitis.
B. Percutaneous transhepatic intervention
1.Percutaneous cholecystoscopic ultrasonic lithotripsy
Under the guidance of ultrasound, percutaneous cholecystocentesis is done first, and then the puncture needle tract is enlarged and inserted into the cholecystoscope to the gallbladder. After the operation, a human balloon drainage tube is built into the gallbladder.
Since this method has been used in clinical practice for a short period of time, its exact effect has yet to be observed.
2.Percutaneous transhepatic choledochoscopic cholecystolithotomy
In this method, the percutaneous transhepatic gallbladder puncture and drainage is performed under ultrasound guidance, and the intrahepatic sinus tract to the gallbladder starts to expand after 1~2 weeks, and the drainage catheter is gradually thickened to 4~5mm, after about 3~5 weeks, a solid sinus tract has been formed. At this time, it is feasible to examine the gallbladder choledochoscope through this sinus tract, and the gallbladder stones can be removed by choledochoscope.
However, the clinical application time of this method is also relatively short, and its exact effect is yet to be further observed.
In conclusion, the above two methods have been used in clinical application for a relatively short period of time, and their exact effects are yet to be further observed.
Third, surgical treatment
1.Cholecystectomy: there are two kinds of surgical methods commonly used at present
① Open cholecystectomy (OC): open surgery to remove the gallbladder is a traditional surgical method and is currently the main surgical method in primary hospitals. It is suitable for symptomatic gallbladder stones, acute cholecystitis or gallbladder stones, gallbladder perforation and gangrene, chronic cholecystitis with gallbladder stones, etc.
Advantages: It removes the “hotbed” of stones and completely cures the gallbladder stones. Disadvantages: all the effects of open surgery such as incisional infection, adhesive intestinal obstruction, transient effects on cardiopulmonary, hepatic and renal functions, etc.; possible side effects of the surgery itself such as postoperative bleeding, bile leak, hepatobiliary duct injury, peritonitis, etc.
② Laparoscopic cholecystectomy (LC): It is a milestone in the history of general surgery using minimally invasive treatment of gallbladder stones. It is suitable for symptomatic gallbladder stones and chronic cholecystitis with gallbladder stones.
Advantages: less trauma, less bleeding, faster recovery, less pain, etc. Disadvantages: the laparoscopic surgery may be turned on at any time (that is, if the laparoscopic surgery is inconsistent with the preoperative judgment or if uncontrollable bleeding is found and the surgery cannot be completed laparoscopically, the abdomen should be opened immediately. In other words, every laparoscopic procedure must be performed with an open procedure as a safeguard).
In conclusion, cholecystectomy is one of the most common surgical procedures performed in abdominal surgery, which can relieve the patient’s pain in a timely manner. However, it is not a foolproof solution to “get rid of everything”, and there are still many drawbacks.
(1) Postoperative dyspepsia.
(ii) The development of gastroesophageal reflux disease.
(iii) occurrence of common bile duct stones.
(iv) damage to the bile duct.
(5) The possibility of colon cancer. Therefore, people are again seeking new methods, whether bile preservation surgery?
2.Minimally invasive endoscopic bile preservation lithotripsy
With the help of fiberoptic choledochoscope, biliary rigidoscope, laparoscope and other related equipment, a small incision (1.5-2cm) is made under the rib cage into the abdomen, the bottom of the gallbladder is cut, and the stones in the gallbladder are removed under the direct view of fiberoptic choledochoscope or biliary rigidoscope. The concept of “minimal invasion” is fully reflected.
To carry out this procedure, the following indications should be mastered.
(1) Gallbladder stones diagnosed by ultrasound and with symptoms.
(2) Gallbladder imaging with Te99ECT or oral contrast agent, which confirms normal gallbladder function.
(3) No malignancy or malignant tendency of the gallbladder.
(4) No significant organ damage and better health to tolerate this procedure.
(5) Progressive enlargement of stones with rapid growth rate on ultrasound review.
(6) Frequent recurrence of symptoms, frequent biliary colic, which affects the patient’s quality of life.
(7) For single gallbladder stones <10 mm in diameter and asymptomatic, they can be reviewed every 3-6 months, and ultrasound can be used for dynamic observation, and endoscopic minimally invasive biliary stone extraction cannot be performed for the time being.
In summary, with the progress of science and technology, the treatment of gallbladder stones is constantly changing, methods are constantly updated and tried, different treatment methods will be used for different patients, choosing safe and effective, less painful, less traumatic and easily accepted by patients is the direction of our research. Endoscopic minimally invasive cholecystectomy is the new trend at present, but it cannot completely replace the traditional treatment of cutting the gallbladder for stone extraction.