I. Treatment of gallbladder stones
(i) Conservative treatment
1.Treatment of asymptomatic gallbladder stones: some patients with gallbladder stones can be asymptomatic. For asymptomatic gallbladder stones, they can be temporarily observed without any treatment.
2.Stone removal treatment: gallbladder stones must pass through the gallbladder duct which is only 2~3mm in diameter to leave the gallbladder and enter the common bile duct. For gallbladder stone removal treatment, the two conditions of good gallbladder contraction function and maximum stone diameter <2~3mm must be present. Therefore, before treatment, cholecystography and ultrasound must be performed and observed before and after fatty meal to compare the change in gallbladder volume in order to understand the size of gallbladder stones and gallbladder contraction function. This treatment was prevalent in the 1970s and 1980s and was effective in some patients. The number of stones could be reduced by lithotripsy, but evacuation was difficult. Even if the stones are emptied, the mucosa of the gallbladder is damaged and the lesioned gallbladder still exists, which means that the lithogenic environment is not eliminated, so it is very easy to regenerate and recur. In addition, a series of complications are likely to occur during lithotripsy treatment, such as: induced biliary colic, acute cholecystitis, acute cholangitis, acute pancreatitis, and in serious cases, obstruction of the bile cyst duct, acute dilatation or even perforation of the gallbladder, obstructing the lower part of the common bile duct, causing obstructive jaundice, liver function impairment and purulent cholangitis, leading to obstruction of the pancreatic duct and acute necrotizing pancreatitis, all of which can be life-threatening. Therefore, lithotripsy treatment is rarely used in regular hospitals now.
3.Lithotripsy: oral lithotripsy and lithotripsy by perfusion. Oral lithotripsy: Among the many Chinese and Western drugs, the drugs that are recognized to dissolve gallbladder cholesterol stones are goose deoxycholic acid and ursodeoxycholic acid. The former has a large toxic side effect and is less used now, while the latter has relatively light side effect, 8~10mg/kg per day, divided into 3 times orally after meals or 1 time orally after dinner, the course of treatment is 1~2 years, the efficiency is 50~90%, if there is no obvious lithotripsy effect after 9 months of lithotripsy treatment, it is not suitable to continue taking the drug. The recurrence rate after lithotripsy is about 10% per year, and the cumulative recurrence rate in the first 5 years is 50%. The fatal weakness of this method is its long duration, high cost and easy recurrence, but it is still a treatment method. Perfusion lithotripsy: This method is to inject the stone dissolving drug directly into the gallbladder, which requires the establishment of a perfusion lithotripsy channel, and there are two methods. The first is percutaneous transhepatic gallbladder puncture under ultrasound guidance and placement of a catheter; the second is placement of a nasogallbladder tube through the duodenal papilla via fiberoptic duodenoscopy. The former is an invasive placement, which may cause bleeding, bile leakage leading to diffuse peritonitis and shock, and may cause infection or aggravate infection; the latter requires high skills and conditions, and some patients cannot succeed due to malformation of the duodenal papilla or bile cyst duct. After the channel is established, litholytic drugs are injected directly into the gallbladder. There is a wide variety of litholytic drugs for direct perfusion, most of which have good in vitro effects but poor in vivo effects, and have high toxic side effects. Currently, the better drugs are octylglycerol monolipid (MO) and methyl tert-butyl ether (MTBE). The indications for performing direct perfusion lithotripsy are: patients with symptomatic gallbladder stones, good gallbladder contraction, soluble stones without calcium and small stones in diameter (<2 cm) and number (<5), no malformation of the gallbladder and non-tethered gallbladder bed, no significant liver or kidney cardiac dysfunction, and non-pregnancy.
4, lithotripsy treatment; lithotripsy treatment of gallbladder stones is not ideal due to many factors such as anatomical structure (anatomical variation, easy folding of gallbladder tract, two narrow gaps between gallbladder duct and duodenal papilla), gallbladder contraction function, bile properties, composition of gallstones, etc., and it is easy to cause side injury to gallbladder, liver, intestines and other surrounding organs or easy to embed in the gallbladder duct after the stones become small fragments. It is less commonly used in clinical practice because it can cause acute obstructive cholecystitis, cholangitis and pancreatitis after the stone has become small fragments and can easily become embedded in the gallbladder duct, duodenal papilla and cause serious complications.
(ii) Surgical treatment
Cholecystectomy for gallbladder diseases such as gallbladder stones, cholecystitis and gallbladder polyps has a history of one hundred years, and it has been proved to be a very successful, effective, safe and reliable classical treatment method.
(iii) Minimally invasive treatment
Minimally invasive surgery is a new surgical technique developed rapidly in the last decade or so, which is very different from the traditional surgical methods in the past, and its basic concept is to use modern high-tech means to obtain the best treatment effect with minimal trauma. It has the characteristics of small trauma, fast recovery, safety and reliability in line with the beauty.
1.Laparoscopic cholecystectomy
Laparoscopic cholecystectomy is the most mature, representative and exemplary minimally invasive surgery in minimally invasive surgery. This method is performed through 3~4 small incisions of 0.5~1.0cm in the abdominal wall, and the gallbladder is removed with special instruments and under TV surveillance. The operation is minimally invasive, painless, with almost no intraoperative bleeding, and the patient can get out of bed and eat the next day after the operation, and can be discharged from the hospital in 2~3 days without leaving a scar. At present, it has been widely accepted by patients and medical personnel, and more than 90% of simple gallbladder surgery is done by laparoscopy in hospitals in China that have the conditions. The laparoscopic cholecystectomy carried out in our hospital is more advanced and less traumatic compared with other hospitals. Its method is to reduce the usual four abdominal wall poke holes (2 φ1cm, 2 φ0.5cm) to three (1 φ1cm, 2 φ0.5cm). The total length of the abdominal wound was reduced from 3cm to 2cm, and the treatment of the bile cyst duct and biliary artery was performed by using silk ligation without metal titanium clips, thus avoiding the influence of metal foreign bodies left in the body when CT and MRI examinations are required later. We have also carried out 2-hole (1 φ1cm, 1 φ0.5cm) and single-hole (1 φ2.5~3cm) laparoscopic cholecystectomy.
2.Minimally invasive gallbladder preservation surgery
Gallbladder not only has the functions of storage, concentration and excretion, but also has the functions of secretion, regulation of bile duct pressure and immunity; after gallbladder removal, it can bring a series of problems. For example, some patients have chronic diarrhea, poor digestive function and increased incidence of bile reflux gastritis; due to the loss of biliary regulation, the lower part of the common bile duct is prone to vortex flow, and mud and stone-like material can be easily precipitated, which increases the possibility of stone formation in the common bile duct; the primary bile acids secreted by the liver are unregulated and continuously discharged into the intestine, and the persistence of secondary bile acids with carcinogenic effects under the action of bacteria increases the risk of colon tumors. The persistence of secondary bile acids with carcinogenic effect under the action of bacteria increases the risk factors for colon tumors, etc. Therefore, in recent years, the function of gallbladder has regained the attention of scholars, and a new concept of gallbladder preservation surgery has been proposed through exploration – minimally invasive biliary surgery.
Minimally invasive biliary preservation requires the use of a choledochoscope, a small incision at the base of the gallbladder, insertion of a choledochoscope, and removal of intracapsular stones with a mesh basket under direct view of the choledochoscope, or removal of intracapsular polyps with a biopsy forceps. The prerequisites for this procedure are the absence of significant inflammation and severe adhesions in the gallbladder, thin gallbladder wall (<3 mm), and good gallbladder contraction function.
In our hospital, we have carried out laparoscopic surgery with fiberoptic choledochoscope to remove stones or polyps, which only makes 2 small incisions of 10mm and 1 small incision of 5mm in the abdomen to temporarily ligate the cystic duct to prevent stones from falling into the common bile duct, and then use fiberoptic choledochoscope to remove stones with a mesh basket under direct vision or use biopsy forceps to remove polyps, which can completely remove stones or polyps and avoid residual. The operation is less traumatic, with quick recovery and short hospital stay, and has achieved very good results.
II. Treatment of bile duct stones
(i) Treatment of common bile duct stones
1.Conservative treatment: A small number of small stones in the common bile duct can be removed by lithotripsy treatment, but this method has a great risk of causing duodenal papillary obstruction and pancreatitis.
2.Surgical treatment: The usual and effective treatment is to remove the stone by conventional surgical method – dissection and choledochotomy.
3.Lumpectomy: retrograde cholangiography can also be performed through fiberoptic duodenoscopy, and after understanding the specific location, number and size of the stone, a duodenal papillotomy is performed and the stone is retrieved with a metal mesh basket; this method is minimally invasive and does not require surgery but can only be performed in hospitals with certain conditions, and there is also a risk of serious complications such as pancreatitis, bleeding and perforation.
4.Laparoscopic treatment: laparoscopy combined with fiberoptic choledochoscope can treat patients with a small number of choledocholithiasis, this method is less invasive and faster recovery, but the technology is complex, laparoscopic technology needs to reach a high level to be competent, our hospital has been successfully carried out.
(ii) Treatment of intrahepatic bile duct stones
1.Conservative treatment: Intrahepatic bile duct stones are often different in number, distribution and size, and are often combined with biliary stenosis, which makes the condition complicated, and the stones are not easily discharged.
2.Surgical treatment: There are many surgical methods, such as: choledochotomy up to the hilar bile duct or left or right hepatic duct, hepatic parenchymal lithotomy, hepatic lobectomy or hepatic segment resection, and internal and external drainage by T and U duct drainage or various bile-intestinal anastomoses. The basic surgical principles are: release the obstruction, remove the lesion, and clear the drainage. However, the characteristics of intrahepatic bile duct stones are that they are not easy to be removed, and they are easy to remain and recur. Before the operation, the patient’s general condition and the number, size and distribution of bile duct stones combined with bile duct stenosis, liver tissue fibrosis, liver atrophy and hepatic portal transposition are fully understood through systemic examination, ultrasound, CT, cholangiography (PTC or ERCP, MRCP) and other special examinations, and a reasonable operation plan is an important step to reduce and prevent the residual stones and recurrence. Intraoperative and postoperative application of fiberoptic choledochoscopy to guide the surgery and stone extraction is an important tool and basic guarantee to reduce and prevent stone retention and recurrence. Therefore, hospitals carrying out complex biliary surgery must have fiberoptic choledochoscopes, and physicians engaged in biliary surgery must master the use of fiberoptic choledochoscopes and skills.
3. Prevention and treatment of residual stones or recurrent stones.
(1) Prevention of residual stones or recurrence of stones: ① Patients with common bile duct stones or intrahepatic bile duct stones must have a comprehensive understanding of the basic situation of stones before surgery, adopt a reasonable surgical approach, and apply fiberoptic choledochoscopy to guide the operation during surgery; ② Avoid emergency surgery as much as possible, as inadequate preoperative preparation makes surgery not easy to be complete; ③ Preserve a short path and straight thick extracorporeal drainage channel at the end of surgery to facilitate postoperative choledochoscopy, and for In case of recurrence, the stone can be retrieved through the blind loop without further surgery; ④ In addition to routine cholangiography, choledochoscopy must be performed after surgery, and the author has often met people who found no stones in the cholangiography but found stones in the choledochoscopy. treatment of roundworm and liver fluke elimination, and pay attention to prevent the reinfection of parasites.
(2) Treatment of residual stones or recurrent stones: residual stones can be examined and retrieved by fiberoptic choledochoscopy through the sinus tract preserved by the T-tube or U-tube, and mechanical lithotripsy, liquid electrolysis or laser lithotripsy under the choledochoscope is feasible for larger stones; recurrent stones can be treated by fiberoptic choledochoscopy through the preset subcutaneous blind loop. If the above access is not preserved, some patients can undergo duodenal papillotomy and mesh basket stone retrieval through fiberoptic duodenoscopy; most patients can only be treated by reoperation.