1. Historical evolution of gallbladder stone treatment Gallbladder stones are a common surgical disease. According to epidemiological survey, its incidence is 10%-15% in western countries and about 4.42%-8.20% in China. 92.4% of patients need to receive drug or surgical treatment during the course of the disease. The complication rate of gallbladder stone surgery is 5% and the mortality rate is 0.2%. In the 100 years since Langenbuch proposed open cholecystectomy for gallbladder stones in 1882, the treatment of gallbladder stones and the causes of gallbladder stones have been studied and explored relentlessly. From open cholecystectomy, lithotripsy with oral drugs, lithotripsy with perfusion, extracorporeal shock wave lithotripsy, combined Chinese and Western medicine to laparoscopic cholecystectomy, the purpose of these studies and explorations is to find a treatment method with wide indications, non-invasive or minimally invasive, clear efficacy, low recurrence rate, few complications, and at the same time preserving the function of gallbladder as much as possible. Unfortunately, however, a treatment method that fully meets these criteria has not been found. Oral lithotripsy, perfusion lithotripsy, extracorporeal shock wave lithotripsy, and percutaneous cholecystolithotripsy and lithotripsy are all aimed at removing stones and preserving the gallbladder. However, these treatments have narrow indications, certain requirements on the nature, number and size of gallbladder stones, longer treatment courses, and certain side effects of oral lithotripsy drugs themselves. Lithotripsy treatment, especially extracorporeal lithotripsy, can cause mechanical damage to adjacent organs, and lithotripsy must be combined with stone removal, which may induce complications such as acute cholangitis and pancreatitis during stone removal. In addition, these treatments are associated with the problem of recurrence of gallbladder stones. The average rate of stone regeneration after lithotripsy and lithotripsy is 10% per year, with a cumulative recurrence rate of 50% in the first 5 years and 83% in the 15-year follow-up. Since the introduction of laparoscopic cholecystectomy in 1985, it has gradually replaced all other treatments as the gold standard of gallbladder stone treatment because of its minimally invasive nature, few complications, broad indications, clear efficacy, and absence of gallbladder stone recurrence. In addition, in the study of the causes of gallbladder stones, a theory that can fully explain the causes of gallbladder stones has not yet been found, resulting in no substantial progress in non-surgical treatment methods such as lithoprevention and lithotripsy. Therefore, laparoscopic cholecystectomy is now considered to be the best option for the treatment of symptomatic gallbladder stones. In the historical evolution of gallbladder stone treatment, the various methods of stone removal and gallbladder preservation were eventually replaced by laparoscopic cholecystectomy because, although laparoscopic cholecystectomy has complications, its overall advantages of minimal invasiveness and few complications overcame the disadvantages of other treatment methods of long duration, narrow indications, many complications, and high recurrence rate. Therefore, even for gallbladder stones with good gallbladder function, we have to sacrifice the gallbladder in the treatment to obtain a stable outcome. 2. Problems associated with cholecystectomy Although laparoscopic cholecystectomy is the gold standard for the treatment of symptomatic gallbladder stones, there are always complications and surgical risks associated with any surgery, especially complications of bile duct injury that bring often disastrous consequences to the patient. According to bulk case statistics, the incidence of vascular injury in laparoscopic cholecystectomy is 0.2%, the incidence of bile duct injury is 0.2% to 0.8%, and the incidence of intestinal duct injury is 0.07% to 0.87%. More importantly, surgical removal of the gallbladder, although avoiding the recurrence of gallbladder stones, also brings problems caused by the loss of the gallbladder. After gallbladder removal, the patient loses the function of concentrating, storing and discharging bile from the gallbladder, causing the body to be unable to provide enough bile when eating, especially when eating high-fat and high-protein foods, so the incidence of indigestion, bloating and diarrhea in patients increases significantly. Some scholars believe that after cholecystectomy, the incidence of bile stones in the common bile duct increases due to compensatory dilatation of the common bile duct, resulting in the relative narrowing of the terminal opening of the common bile duct and changes in the fluid mechanics of bile in the common bile duct. After cholecystectomy, the incidence of reflux esophagitis and inflammation of the stomach and duodenum is significantly higher in some patients. In addition, the gallbladder mucosa has certain secretory and immune functions, and removal of the gallbladder will have certain effects on the immune defense function of the biliary tract. The primary bile acids secreted by the liver after gallbladder removal are continuously excreted to the intestine, and secondary bile acids are produced by the action of Escherichia coli. Increased secondary bile acids and increased number of enterohepatic cycles tend to lead to abnormal intestinal mucosal proliferation, which may lead to increased incidence of colon cancer. As seen above, laparoscopic cholecystectomy has become the gold standard for gallbladder stone treatment only relatively. The advantages are minimally invasive and no recurrence of gallstones, but its removal of the gallbladder deprives the patient of gallbladder function, and there are certain surgical complications, especially the problem of bile duct injury. Therefore, laparoscopic cholecystectomy is not yet a truly ideal treatment for gallbladder stones. 3. How to recognize the problem of biliary stone extraction Biliary stone extraction, like open cholecystectomy, has a long history, but it was phased out at the end of the 20th century because of its high recent recurrence rate. The literature reports that more than 50% of patients will have recurrent stones within 5 years of stone extraction. Even with preoperative screening, the recurrence rate is still as high as 39.6% to 41.6% 5 years after biliary stone extraction for functional gallbladder only. In recent years, Zhang Baoshan and a group of other experts have again proposed the concept of biliary stone extraction, and confirmed that biliary stone extraction is an effective treatment with 1520 cases of endoscopic biliary stone extraction and 15-year follow-up, with a follow-up rate of 66.32% and a postoperative recurrence rate of 2% to 10%. Zhang Baoshan attributed the high recurrence rate of biliary stone extraction in the past to the failure to remove all the stones, and a large part of the recurrence was actually residual stones. They also found that the acute and chronic inflammation of the gallbladder mucosa caused by stones is often reversible, and 84% of the patients had their gallbladder wall changed from thick to thin within 2 years after biliary stone extraction, and the contraction function and visualization rate of the gallbladder improved significantly. Its concept is reasonable. If its efficacy is confirmed, it should be a better treatment for gallbladder stones than laparoscopic cholecystectomy. Even if there is a certain recurrence rate of gallbladder stones with cholecystectomy, if not within a short period of time, it has considerable clinical application value. The current debate on the feasibility of biliary stone extraction focuses on four aspects: (1) whether the presence of the gallbladder is a hotbed of gallbladder stone recurrence, which is the cornerstone of theoretical validity of biliary stone extraction; (2) the indications for biliary stone extraction, i.e., whether all gallbladder stones need to be or can be biliary stone extracted; (3) what is the immediate and long-term recurrence rate after surgery; (4) whether the original gallbladder (4) whether the original pathological changes of the gallbladder can be reversed. The formation of gallbladder stones is an intricate process involving multiple factors, links and steps, which has not been fully elucidated so far. It is currently believed that the formation of gallbladder stones is associated with abnormal cholesterol metabolism, bile nucleation, and gallbladder emptying dysfunction. In the process of gallbladder stone formation, some patients have a continuous and progressive stone formation process, developing from one stone to the whole gallbladder-filled stone; some patients have a staged stone formation process, with only one stone for life. The causes and processes of gallbladder stone formation are different for each individual. While it is true that stones growing in the gallbladder are related to the factors of the gallbladder, before the mechanism of stone formation is fully elucidated, all factors of stone formation cannot be attributed to the gallbladder. Obviously, a dysfunctional gallbladder with serious pathological changes is a breeding ground for recurrence of stones and cancer, so the gallbladder should be removed if it is atrophied, non-functional or suspicious of cancer. If calcification is found in the gallbladder wall, the probability of cancer is 7%; if gallbladder stones are accompanied by gallbladder polyps >1.0 cm in diameter, the risk of cancer is up to 50%, and the gallbladder should be removed in all these cases. The question of whether to follow up or to bail out or surgically remove the gallbladder in asymptomatic patients with gallbladder wall thickness <0.3 cm and good gallbladder function deserves investigation. The current guidelines consider a stone diameter <3.0 cm as an indication for follow-up of quiet gallbladder stones. 4. Our recommendation The current debate on whether to treat gallbladder stones with biliary preservation or removal of the gallbladder is due to the fact that neither side can produce newer, high-quality evidence-based medical evidence. Studies on the complications of cholecystectomy surgery are often limited to the recent complications of surgery such as bleeding, bile leak, bile duct injury and intestinal duct injury, while epidemiological surveys of the population after cholecystectomy are lacking to clarify the incidence of common bile duct stones, reflux esophagitis and colon cancer, in order to determine whether the removal of the gallbladder is harmful and how harmful it really is. Although more than 10 retrospective investigations and meta-analyses have been published on endoscopic biliary stone extraction, they are all level 4 evidence according to the quality grading of evidence in evidence-based medicine, and there is a lack of supporting evidence from high-quality randomized controlled trials on its efficacy. We believe that stratified, prospective studies should be done for biliary stone extraction. In cases of gallbladder stones combined with acute cholecystitis, we should study the pathological changes of gallbladder after stone extraction and the recovery of gallbladder function, and the recurrence rate of stones; in cases of symptomatic chronic cholecystitis, we should first do gallbladder function measurement, and for patients with normal gallbladder contraction function, we should group them according to the size, number, and nature of stones, and then do a randomized controlled trial study of cholecystectomy and biliary stone extraction to compare the recent and long-term complications and recurrence after stone extraction. For patients with normal gallbladder systolic function, they were grouped according to the size and number of stones, and then a randomized controlled trial study was done to compare the recent and long-term complications, recurrence rate, and changes in gallbladder pathology and function after stone extraction. For patients with good gallbladder function, we should pay more attention to the perfect combination of gallbladder function preservation and gallbladder stone treatment when choosing treatment. For patients with asymptomatic gallbladder stones, 10%-25% of patients will gradually develop discomfort, but even if they have obvious symptoms, 52.1% of patients will disappear spontaneously within 8 years without treatment, and 16.8% of patients will have reduced symptoms. Therefore, prophylactic removal of the gallbladder is not required for asymptomatic gallbladder stones <3 cm in diameter. Prospective studies are also needed to determine whether this group of patients should be bile-preserved for stone removal or followed up. In the choice of gallbladder stone treatment strategy, the surgical indications for cholecystectomy are clear in most patients with gallbladder stones, such as atrophic cholecystitis, gallbladder wall calcification, gallbladder filling stones and gallbladder stone complications such as gallbladder stones combined with Mirizzi syndrome, gallbladder stones combined with gallbladder cancer, combined with common bile duct stones, combined with cholecystomyelia are clear indications for surgical resection. We can neither use data from more than 10 years ago to argue against today's view of biliary stone extraction supported by endoscopic minimally invasive technical conditions, nor can we use retrospective studies to prove the superiority of biliary stone extraction. We need to conduct in-depth studies on the mechanisms of gallbladder stone formation, especially the role of the gallbladder in gallbladder stone formation. We oppose the blind removal of a functioning gallbladder and the blind biliary preservation for stone extraction regardless of the circumstances.