In recent years, the use of the “new minimally invasive bile preservation” method to treat gallbladder stones has become popular in China, which is very much in line with the psychology of ordinary people for patients who do not know about medicine. ” to receive patients, and even some individual well-known specialists in hepatobiliary surgery have begun to accept this procedure with reservations. For a time, the internationally accepted method of gallbladder removal for gallbladder stones has been greatly subverted.
However, if we think about it calmly, it is not difficult to find that this biliary surgery with Chinese characteristics, which has emerged in China, is not only theoretically flashy, but also problematic in practice, and its long-term efficacy is also uncomplimentary. At the same time, the evaluation of cholecystectomy by the biliary conservative party seems to be unjustified, either by fabrication, exaggeration, or alarmist, or by quoting some hepatobiliary surgery experts out of context.
Bile preservation and bile cutting is a dispute between the principles of surgical treatment, the concept of the dispute, the vital interests of the majority of patients, the author does not presume to clinical practice, based on their understanding of the issue, I would like to put forward their personal views, with a view to seek expert correction, for the reference of peers.
A. Cholecystectomy is an ancient and long eliminated operation
Cholecystectomy was started in 1882 by Langenbuch in Germany, in fact, cholecystolithotomy is earlier than cholecystectomy, but the high recurrence rate of stones after cholecystolithotomy still prompted the popularity of cholecystectomy, based on historical review, cholecystectomy has actually been throughout the history of cholecystectomy;
However, for the majority of patients, cholecystectomy is safe and the results are good. In the comparison between cholecystectomy and cholecystectomy, cholecystectomy has been tested in practice for more than 100 years and has been continued for more than 100 years because of its definite efficacy, while cholecystolithotomy has been abolished at home and abroad because of the high recurrence rate of postoperative stones, except for cholecystostomy under emergency conditions. The choledochostomy has been abolished at home and abroad because of the high recurrence rate of postoperative stones, except for emergency conditions.
Second, the theory of biliary preservation is flashy but not realistic
Removal of the gallbladder directly affects the patient’s quality of life and even endangers the patient’s life, with endless consequences. Only removing the stones and preserving the gallbladder and its function is the right thing to do, which is the core view of gallbladder preservation. Preserving the “normal function” of the gallbladder is also the basis for advocating gallbladder stone retrieval. Preserving the normal function of the gallbladder is quite reasonable and minimally invasive (lumpectomy, small incision), but it actually does not stand up to scrutiny and is a flashy theory.
To clarify this issue, we should first look at what functions the gallbladder has, how big these functions are, and how to detect the functions of the gallbladder in clinical practice.
1.About the function of gallbladder
Bile is secreted by the liver, stored in the gallbladder, and discharged into the intestine after a person eats. In fact, the gallbladder is mainly an organ for storing, concentrating and discharging bile, and it plays more of a role of a transit station, which does not affect the secretion of bile. The bile secretion is still normal after gallbladder removal, but the process of bile excretion is changed.
After cholecystectomy, the common bile duct can be slightly compensated with enlargement, thickening of the duct wall and increased hypertrophy of mucosal glands, thus allowing a certain concentration of bile when passing through the bile duct system, which also partially compensates for the function of the gallbladder. It is a non-essential organ of life, unlike the heart and liver, which cannot survive the removal of the heart or liver, hence the liver transplant and heart transplant, and the removal of the gallbladder, which can live perfectly well and has little impact on the digestive function of the person.
Who would have a gallbladder transplant to preserve the function of the gallbladder? Infinitely exaggerating the function of the gallbladder does not provide any more reason to preserve it.
2. Does the gallbladder have an important immune function?
In order to justify gallbladder preservation, gallbladder preservationists strongly exaggerate the so-called “complex” immune function of the gallbladder. We know that the immune system of the human body consists of immune organs and tissues, immune cells and immune molecules. The important ones are the bone marrow, spleen, tonsils, thymus, lymph nodes, etc. There is nothing about the gallbladder here. These crude knowledge of immunology is well known to every doctor.
Is it not alarming to magnify the role of the limited immune molecules secreted by the gallbladder mucosa, giving the illusion that the removal of the gallbladder will impair the overall immune function of the body and even cause colon cancer? There are countless clinical patients after cholecystectomy, which one of them has a decreased immune system because of the removal of gallbladder? Have there been cases of malignant tumors and serious infections associated with immune deficiency?
We recognize that the spleen is an important immune organ, and splenectomy after trauma is extremely common in clinical practice, and there are few spleens removed for other reasons, and how many adults have developed post-splenectomy threatening infection (OPSI) as a result of splenectomy? This is true of the spleen, which is a truly important immune organ, let alone a gallbladder that has little substantive immune function! Linking the gallbladder to the immune function of the body does not change the theoretical basis of the hepatobiliary surgical community for cholecystectomy for gallbladder disease, other than creating fear in the minds of patients who voluntarily undergo gallbladder preservation surgery and bear the frustration of recurrence.
3.How to detect the function of gallbladder?
At present, there is no sensitive and unified standard for the detection and objective evaluation of gallbladder function, and how to detect the function of gallbladder with obvious inflammatory changes is a matter of opinion. The lipid meal test, which is commonly used in clinical practice, only evaluates the contractile function of the gallbladder, but not the concentrated function of the gallbladder. Is it too hasty to evaluate the contractile function of the gallbladder alone to decide whether to cut or preserve the gallbladder? Have the gallbladder’s many important functions, such as concentrating function and immune function, been evaluated before the gallbladder preservationists?
And how were they evaluated? Does biliary surgery preserve the concentrating and immune functions of the gallbladder? Are these functions still present after the biliary surgery? Are they enhanced? No change? Or are they diminished? Have they been evaluated after biliary preservation? If the contractile function of the gallbladder is good, but the immune function is gone, do you still preserve the gallbladder?
Gallbladder preservationists claim to preserve the function of the gallbladder, but in the end, they are only preserving the contractile function of the gallbladder that they can detect, and they do not know or care whether the concentrated function or immune function of the gallbladder is preserved because they cannot detect it.
In fact, the gallbladder has certain functions, but the functions are limited, not like the heart and liver, which cannot be lost, and the clinical means of detecting gallbladder functions are even more limited.
Third, the specific operation of bile preservation problems
The Chinese Physicians Association Endoscopist Branch has developed a technical specification for minimally invasive endoscopic biliary surgery to remove stones (polyps), which is supposed to be the programmatic document for biliary surgery. Read the specification carefully, there are several questions as follows.
1, the specification proposed: the indications for biliary surgery is via Te99ECT or oral cholecystography, the gallbladder is visualized and functions well. Among them, oral cholecystography has been eliminated, few hospitals carry out, and Te99ECT is not only radioactive, but also complicated to operate and requires special instruments, so it is not popular to carry out, how much rate of Te99ECT is given to patients before biliary surgery?
2. The specification requires that endoscopic lithotripsy is feasible for embedded stones, which is very questionable. After lithotripsy, there will be many small stones, which are not only difficult to remove, but also easy to enter the common bile duct, causing secondary bile duct stones and even biliary pancreatitis.
In order to ensure that the residual stones will not be missed after the “endoscopic minimally invasive biliary stone extraction”, it is also stipulated that: when removing stones, no clamps are allowed, no scrapers are allowed to be used to avoid breaking the stones and missing the debris; only the lithotripsy basket is allowed to be used, like a “midwife” to remove the stones intact. Are these two regulations contradictory to each other?
3, the specification recommends intraoperative ultrasound to check whether the gallbladder stones are removed: this is also puzzling, choledochoscopy is a direct observation, while ultrasound is an indirect observation. If the operator is not confident in his choledochoscopy technique, he has resorted to B-ultrasound, so how can people believe in the so-called “fiberoptic choledochoscope, which can be bent at will, and can be illuminated for observation, so that stones can be removed from wherever there are stones, and stones can be completely and thoroughly removed”?
4. The specification requires patients to start taking ursodeoxycholic acid 300mg/day for 6 months 2 weeks after surgery: obviously this is designed to prevent the recurrence of stones after surgery. The question is, if taking ursodeoxycholic acid can prevent stone formation, then the gallbladder can not form stones within 6 months of taking ursodeoxycholic acid after surgery, but what about after 6 months? What about 1 year, 2 years, 3 years after surgery? Is the warranty period for our biliary surgery 6 months?
Beyond 6 months, we are not responsible? And leave the patient to his fate? If ursodeoxycholic acid does not work, why do we require patients to take 300mg/day of ursodeoxycholic acid for 6 months after surgery? Ursodeoxycholic acid is very expensive, is it a sign of responsibility to the patient to spend thousands of dollars and take it for half a year? The fact is that the use of ursodeoxycholic acid to prevent gallbladder stones is just wishful thinking on the part of doctors, and so far there is no evidence-based medical evidence to support it.
5. The incision after gallbladder dissection and stone extraction is closed with absorbable sutures: does the secondary inflammatory reaction caused by the degradation of the absorbable thread induce stone formation?
6. Some people even report that bile can be preserved if bile is seen in the cervical duct of the gallbladder under the microscope: hundreds of stones and dozens of polyps are removed from the gallbladder, but bile is still preserved. Is a gallbladder with hundreds of stones and dozens of polyps still worth preserving?
All these questions seem to be not reasonably explained by the gallbladder preservation experts.
Fourth, it is difficult to avoid the high recurrence rate of stones after bile preservation surgery
Gallbladder surgery inevitably faces two problems: the residual or recurrence of stones after surgery. It is not known how long it takes for stones to form in the gallbladder, but theoretically it should be several months. Therefore, if stones are found in the ultrasound at the time of discharge after biliary surgery, they should be residual stones from the surgery, while stones found several months later are difficult to determine whether they are residual stones from the surgery or postoperative recurrence.
In most domestic and international clinical studies to date, the recurrence rate of stones after gallbladder lithotripsy can be 20%-40% within 5 years. Such a high recurrence rate is obviously not conducive to the development of biliary preservation, and the biliary preservationists have different views on this. This conclusion is completely subjective and speculative, and is not supported by any data in the literature.
How can you prove that the recurrence of stones after old biliary stone extraction is due to intraoperative residual stones and not actual recurrence? Were ultrasounds performed in those patients who had recurrence within a short period of time after surgery? Were all stones found in the gallbladder? Is it responsible to deny the high recurrence rate after biliary surgery with such subjective assumptions?
According to the gallbladder preservationists’ own data, there is a 2-7% recurrence rate after gallbladder stone removal. It is important to know that 2-7% for doctors is 100% for patients with recurrence. Recurrence means failure of the gallstone extraction surgery, and the patient suffers additional trauma, cost, time, psychological torture, and the need to operate again to solve the problem, is this still minimally invasive?
Biliary preservationists are happy to talk about the huge psychological trauma caused by biliary excision, but is it less traumatic for patients to suffer from recurrence of stones after biliary preservation? It is true that gallbladder cutting will bring certain complications to patients, and when these complications are mentioned, some people will say that they finally find a reason to oppose gallbladder cutting, but why is the complication of recurrence of stones after gallbladder preservation surgery only downplayed?
V. The cause of recurrence of gallbladder stones is still unclear
The causes of gallbladder stones are very complex, and although many studies have been done, they are not yet completely clear. At present, it is believed that gallbladder stones belong to metabolic syndrome, the latter including hypertension, hyperlipidemia, diabetes, obesity, fatty liver, all have the pathological basis of lipid metabolism disorder, and are closely related to people’s living habits and diet.
Therefore, gallbladder stone is not only a lesion of the target organ of gallbladder itself, but a systemic disease, social disease, all factors that cause the development of gallstone may lead to the recurrence of stone after stone extraction, and will not change the pathogenesis of gallstone due to gallbladder stone extraction. Therefore, since stones can occur in a healthy gallbladder with the same dietary and lifestyle habits of the patient, what reason do we have to believe that stones will not occur again after the removal of this already relatively unhealthy gallbladder? Is it possible that lithotripsy itself can prevent the occurrence of gallbladder stones?
Since the cause of stone formation is unknown, there is no effective measure to prevent the occurrence of stones, so preserving the gallbladder will inevitably lead to the problem of how to prevent the recurrence of stones in the future. Without solving the problem of lipid metabolism disorders, there is no way to prevent stone recurrence. This problem is not solved by the gallbladder preservationists, and the use of “300mg/day of ursodeoxycholic acid for 6 months starting 2 weeks after surgery” to prevent the occurrence of stones is more of a placebo effect, and is not reliable.
Improper propaganda does not justify biliary surgery
There are many aspects in the propaganda of biliary surgery that are inappropriate. What “high-tech, new technology, new concept”, and so on. One of the most debatable ones is the “I have gall, I am healthy!” on a well-known website. This is what the experts in medical science should say? Guts and health are completely two concepts, there is no necessary connection, guts is not necessarily healthy, no guts is not necessarily unhealthy.
Can you tell me if the so-called “healthy” gallbladder can be called “healthy” by removing the stones from the diseased gallbladder and keeping a diseased gallbladder, leaving a breeding ground for the recurrence of stones and gallbladder cancer in the future? On the contrary, removing the diseased gallbladder can solve the problem of stone recurrence and gallbladder cancer in the future once and for all. Are patients who have had a cholecystectomy, without a gallbladder, no longer healthy?
They become new patients again? According to this logic, doctors have created many patients in the more than 100 years of cholecystectomy! The slogan “I have gall, I am healthy” is justifiable if it comes from the mouths of charlatans, but unfortunately, it comes from the mouths of some so-called experts in regular hospitals, which seriously misleads patients and causes endless harm, and must be discarded!
Seven, why is it reasonable to cut gallbladder
For gallbladder stones, once stones appear in the gallbladder, it will be accompanied by inflammation of the gallbladder, and the two are causal, the stones aggravate the inflammation of the gallbladder, while the inflammation of the gallbladder in turn promotes the formation of stones. This has long been the consensus of surgeons and is common knowledge. At this point, the gallbladder is no longer a normal gallbladder, but a diseased gallbladder. Therefore, the main treatment should be cholecystectomy, that is, removal of the diseased gallbladder.
Removal of the gallbladder completely solves many serious problems such as recurrent gallbladder inflammation, secondary common bile duct stones, biliary pancreatitis, gallbladder cancer, etc. It fundamentally solves the patient’s worries, and the benefits outweigh the risks, which is undoubtedly better than gallbladder lithotomy. In contrast, cholecystectomy removes the stones and preserves a diseased gallbladder, which is beautifully called “preserving the function of the gallbladder”, which is obviously not in line with the principle of surgical treatment.
Eight, how to correctly understand the complications of cholecystectomy
Cholecystectomy has a variety of serious complications, even leading to death, which is one of the reasons given by gallbladder preservationists to support gallbladder preservation. How do we recognize the complications of cholecystectomy?
Any surgery has risks and complications, and there is no 100% safe surgery in the world. As far as complications are concerned, they are inevitable whenever surgery is performed; the only difference is the severity and the incidence of the complication. The premise of a procedure is not that it is free of complications, but that it is low and that the vast majority of patients gain more from the procedure than the risks they take, whether it is biliary preservation or cholecystectomy.
Therefore, it is clearly wrong to reject or even demonize cholecystectomy because of its various complications, just as it is wrong to be afraid to walk on the road for fear of traffic accidents.
Similarly, we oppose gallbladder preservation not because the stones will recur after gallbladder surgery, but because the recurrence rate of stones is so high that most patients cannot benefit from gallbladder surgery, and the so-called “even if the recurrence rate is as high as 50% after gallbladder surgery, it is still meaningful to keep half of the gallbladder”, no matter what level of expert’s mouth, is Who can accept the cost of recurrence of stones in 50% of patients in exchange for the success of biliary surgery in the other 50%?
Recurrence means failure of biliary surgery, and any procedure with a 50% failure rate cannot be performed in the clinic. In our current medical environment, imagine 50 recurrences out of 100 cases of biliary surgery, and if only 10 of these 50 recurrences come to you, can you still work and live with peace of mind? Yes, patients are informed of the possibility of recurrence before biliary surgery, but which doctor would be naive enough to think that signing before surgery can be a shield to avoid risks?
Therefore, the premise of biliary surgery is that the inflammation of the gallbladder can be reversed after biliary surgery, the formation of gallbladder stones can be prevented, the recurrence rate of gallbladder stones after biliary surgery is low, and the majority of patients benefit from biliary surgery, then biliary preservation is better than biliary excision. Otherwise, gallbladder preservation surgery, should be performed with caution!