Gallbladder stones and benign gallbladder polyps are common benign clinical lesions of the gallbladder, the incidence of which has been increasing year by year in recent years. The overall prevalence of gallbladder stones has reached 10%-20% in adults worldwide. The prevalence of gallbladder polyps in China is also increasing year by year. Cholecystectomy has become the main treatment for benign gallbladder diseases, and with the gradual popularization of laparoscopic cholecystectomy, the indications for cholecystectomy are expanding, while the lack of physiological functions of gallbladder after cholecystectomy is not given due attention for a long time.
Important functions of the gallbladder.
1, the function of storing, absorbing and concentrating bile
2, the function of regulating fluid pressure in the biliary tract
3, maintenance of the normal physiological functions of the intestine
4, the function of postprandial burst excretion of bile to aid digestion
5, secretion of mucin and digestive enzymes and other functions.
6, immune function.
7, regulation of the function of the oddis sphincter.
8, bile acid hepatic and intestinal circulation function.
Post-cholecystectomy complications.
1, post-cholecystectomy sphincter of Oddi dysfunction-related biliary origin abdominal pain; biliary origin abdominal pain is mainly caused by bile duct sphincter of Oddi dysfunction (sphincterofOddidysfunction, SOD). Academician Huang Zhiqiang has pointed out that after cholecystectomy, the original coordination between the gallbladder and the sphincter of Oddi is destroyed, the sphincter is in spasm, the bile is not easily discharged, the common bile duct is dilated, the tension of the duct wall is increased, and the pain in the right quarter rib area appears. Bile duct SOD usually refers to the abnormal function of the sphincter of Oddi with (or can cause) biliary abdominal pain, elevated liver enzymes, and dilated common bile duct.
2.Digestive dysfunction-related bloating and diarrhea after cholecystectomy: The gallbladder has the function of storing and concentrating bile. After entering the intestine, bile can emulsify fat and combine with fatty acids to form water-soluble complexes and promote fat absorption. After cholecystectomy, bile cannot be effectively concentrated and regularly discharged, which reduces the concentration of bile acids and bile salt content in the intestinal lumen. Postoperative SOD patients have elevated biliary tract pressure and slow bile evacuation due to sphincter dysfunction. All these factors will lead to different degrees of postoperative dyspeptic symptoms such as abdominal distension and diarrhea in patients.
3. Residual small bile cyst and residual bile stones
Residual small gallbladder and residual gallbladder stones are complications after cholecystectomy, and their causes are mainly related to anatomical variation of bile ducts, intraoperative difficulties in gallbladder triangle dissection, and unskilled operator techniques.
4. Residual stones in the common bile duct after cholecystectomy
Most of the residual stones in the common bile duct after cholecystectomy are due to preoperative omission of secondary common bile duct stones or intraoperative manipulation of small stones in the gallbladder into the common bile duct.
Should the gallbladder be removed for gallbladder stones or not? Currently, there are two main schools of thought in the domestic medical community. The “gallbladder cutting” school believes that as long as the gallbladder is suffering from gallstones, regardless of the function of the gallbladder, the gallbladder must be removed. Otherwise, one is likely to increase the chance of gallbladder cancer, and the other is that if the gallbladder is preserved, the chance of stone recurrence is very high, which may bring the risk of secondary surgery.
The “gallbladder preservation” school believes that as long as the patient’s gallbladder is intact and the stones can be removed surgically, the gallbladder can be preserved and the stones can be removed. This can avoid many bile-cutting sequelae and ensure the quality of life of patients after surgery. By strictly following the indications for biliary preservation and extraction, and supplementing with dietary correction and medications, the chances of stone regeneration after surgery are very low.
Given the importance of gallbladder function and the series of complications after cholecystectomy, more and more experts and scholars are calling for ! Bile preservation!!!
In recent years, the endoscopic minimally invasive gallbladder-preserving surgery (choledochoscopicgallbladder-preservingsurgery, CGPS) advocated by the pioneer Prof. Zhang Baoshan has become increasingly mature and has become one of the surgical modalities for the treatment of benign gallbladder diseases.
CGPS mainly includes endoscopic minimally invasive gallbladder-preservingcholecystolithotomy (CGPC) and endoscopic minimally invasive gallbladder-preserving polyp removal (choledochoscopicgallbladder? preservingpolypectomy (CGPP), which are indicated for the treatment of gallbladder stones and benign gallbladder polyps, respectively.
The advantages are the combination of laparoscopic techniques with choledochoscopic biliary preservation techniques, further reduction of abdominal wall trauma compared to small incision surgery, and rapid postoperative recovery. l-CGPS can be easily converted to laparoscopic cholecystectomy.
L-CGPC indications
1. Asymptomatic gallbladder stones, so-called “resting state” of stones.
2, the gallbladder must have good contractile function: oral cholecystography or ultrasound after lipid meal suggests that the gallbladder is contracted up to 1/3 or more.
3, the gallbladder should not be too large or too small, the gallbladder length diameter between 6-8cm, and there should be no separation within the bag.
4, the upper abdomen should preferably have no history of open surgery, perforation and other acute inflammation history.
5.Under ultrasound: good intra-biliary translucency of gallbladder, smooth gallbladder mucosa, gallbladder wall within 3-4mm, single or multiple stones (except sediment-like stones), regular morphology, and stones can move with changes in vitro.
6.In the past, gallbladder polyps larger than 10mm were considered as the surgical indication for cholecystectomy, but only 88% of malignant polyps were larger than 10mm in diameter, so it is not reliable to consider gallbladder polyps larger than 10mm as the surgical criteria, but there are few reports of malignant gallbladder polyps smaller than 5mm. Therefore, <
Contraindications to endoscopic minimally invasive bile preservation
1.Gallbladder atrophy, gallbladder wall thickening, disappearance of gallbladder lumen, combined with common bile duct stones
2.Stones in the gallbladder duct cannot be removed, and it is expected that they will not be removed after surgery.
3.The gallbladder duct is confirmed to be obstructed by intraoperative imaging.
4.Mirizz syndrome (refers to a series of syndromes characterized by cholangitis and obstructive jaundice due to obstruction of the common hepatic duct or common bile duct to varying degrees caused by stone impaction in the gallbladder neck or cystic duct and/or other benign disease compression or inflammatory spread, which is actually a complication of cholelithiasis rather than an independent disease. (The definition of Mirizzi syndrome and the group of diseases in which there are no stones in the gallbladder neck or gallbladder duct or stones in the gallbladder are not embedded, but due to the inflammatory involvement of the gallbladder causing the narrowing of the common hepatic duct are classified as Mirizzi syndrome.)
5.It was confirmed that the gallbladder had completely lost its function.
6, Intraoperative ultrasonography sees stones in the gallbladder duct, which cannot be detected by intraoperative cholangioscopy.
Principles of endoscopic minimally invasive biliary preservation surgery.
1. removal of stones (polyps).
2.correct treatment of gallbladder wall lesions.
3.Ensure the patency of the gallbladder duct.