In recent years, great progress has been made in the prevention and treatment of gallstone disease.
1. In terms of pathogenesis
While previous knowledge was limited to the physiological, biochemical and pathophysiological levels, the search for causes has now been conducted at a higher level, namely at the genetic level, to understand the essential changes in the evolutionary interactions with nature and lifestyle evolution in the genesis of stones in humans, in the hope of finding fundamental solutions for stone prevention. Although we have identified many genetic loci clearly associated with stone formation through genealogical analysis, little is known about how these loci trigger a series of subsequent chain reactions. Therefore, research in this area can only be said to be in the initial stage.
2. New epidemiological findings
The epidemiological characteristics of gallbladder stones are
(1) More females.
(2) More people older than 40 years old.
(3) More obese people.
(4) More breakfast fasters.
(5) More people with family history.
The authors’ survey of more than 30,000 gallbladder stone patients revealed some new features.
(1) The age of onset expanded to below 40 years old and there was no gender difference.
(2) Increased incidence of stones after rapid weight loss.
(3) Increased incidence of gallbladder stones with contraceptive use.
(4) Increased incidence of stones in people with fatty liver or a history of hepatitis.
(5) The incidence of gallbladder stones is also increased in those who sit for a long time or lack of exercise.
(6) The proportion of combined common bile duct stones increases significantly with age.
These findings provide the basis for my view, which has been proposed in recent years and widely accepted in the field.
3. Progress in diagnosis
Ultrasound is the best method to diagnose gallbladder stones or polyps, but for common bile duct stones, it is better to do MRI to show the whole length of the bile duct. If cancerous gallbladder polyps or gallbladder cancer is suspected, then it is better to do enhanced CT. nowadays, routine MRI is advocated for the elderly because some scholars found that the combined common bile duct stones were 30% for those with gallbladder stones at age 60 and increased to 60% at age 90.
MRI is performed in the following cases.
(1) Those with multiple stones of long duration.
(2) Advanced age.
(3) Previous history of jaundice or frequent back pain.
(4) Those with a history of pancreatitis, especially if it is recurrent.
(5) Frequent episodes of biliary colic, or with fever and jaundice.
(6) Those with ultrasound suggestive of dilated common bile duct.
In fact, the existing imaging examinations have their own merits, not the most expensive is the best, so both the physician and the patient should choose the examination means under the condition of clarifying the purpose of the examination.
4.Progress in treatment
For gallbladder stones, there are no more than three options for treatment. One is to wait and see; the second is to remove the gallbladder; the third is to preserve the gallbladder and remove the stone.
For asymptomatic stones, the vast majority currently advocate that no treatment is necessary. The rationale is that many patients are asymptomatic for life. In fact, there is no objective basis for this theory. I have been trying to find a convincing basis for this, but so far I have not been able to do so. On the contrary, my observations and investigations over the past 20 years have revealed that the so-called “symptom concept” of gallbladder stones is a long-standing misconception that “only the symptoms are known, but not the cause”. In the past, patients were considered to have gallbladder stone symptoms only when they had typical biliary colic, while non-specific symptoms such as vague pain in the upper abdomen, abdominal distension and dyspepsia were regarded as gastrointestinal symptoms. This was the understanding before the advent of ultrasound, because at that time we did not have the means to detect gallbladder stones in a timely and simple manner. Nowadays, more than 70% of patients with gallbladder stones are found because of “digestive tract” problems or because of routine physical examinations, when in fact the so-called “digestive tract symptoms” are atypical symptoms of cholecystitis. Therefore, the old view of defining gallbladder stone symptoms by the presence or absence of typical biliary colic symptoms needs to be re-examined, otherwise it will have an obstructive effect on the development of future gallstone treatment models.
Second, the gallbladder is removed, and as long as gallbladder stones cause biliary colic, then “everything is done”. This is the code of surgical gallbladder stone treatment and has ruled the surgical community for more than 100 years. The theory is that stones come from the gallbladder, that the gallbladder is a breeding ground for stones, and that removing the gallbladder will eliminate the problem forever. There is nothing wrong with the result: if the gallbladder is gone, gallbladder stones will naturally cease to exist. However, the gallbladder cannot simply be considered as an optional component of a living organism, especially the human body, and this has been challenged by basic medical research and advances in modern surgical treatment techniques.
The development of gallbladder stones is a process that goes through genetic, physiological and biochemical, physical, clinical symptoms and complications phases. The danger of gallbladder stones lies not only in the effects on the gallbladder itself, such as decreased contraction and concentration of the gallbladder and obstruction of the cystic duct, but more importantly in the complications caused by gallbladder stones, such as acute pancreatitis and common bile duct stones, the latter two being far more significant than the effects of the gallbladder itself. Since stones are the cause of these problems, prevention of stone production or elimination of stones is naturally the key to solving this problem.
The emergence of lithotripsy, lithotripsy, and lithotripsy in the mid-1980s was a great success, but ended 10 years later with inaccurate results and obvious side effects. During this period, small incisions for biliary stone extraction were introduced, but they were left in the cold because of the high recurrence rate. The advent of minimally invasive surgery has reinforced the belief of “cut it out” for the blind bile-cutting school, but for the other camp, the rational bile-preservation school, a humane solution has been found which is welcomed by the majority of patients, and this humane solution is based on personalization. Imagine removing stones from a functioning gallbladder with a very small, even imperceptible trauma, so that the gallbladder continues to work for you for a long time, or even 3-5 years, and you say it doesn’t make sense? One of my online surveys found that almost 100% of patients are willing to preserve their gallbladder first, and if the stones recur before cutting it, it is worth it for a functioning gallbladder.
The so-called rational gallbladder preservation for stone extraction should have.
(1 ) After explaining the advantages and disadvantages of biliary preservation, the patient has the requirement of biliary preservation.
(2 ) The gallbladder is clearly functional by impactological examination.
(3 ) The stone is not prone to recurrence or a preventive link is found after the analysis of stone removal.
(4 ) The treatment method is mild to the body.
The most commonly used methods are.
Small incision stone extraction, laparoscopic stone extraction. Although the small incision technique was once left out of the picture, there is a revival scene again due to the improvement of technology, and now most of the Beijing and Guangzhou take this technique. It has relatively low technical requirements, as long as there is a cholangioscope on the line, and can be promoted in primary care hospitals. The technical requirements for laparoscopic lithotripsy are relatively high, requiring not only good equipment in the hospital where it is performed, but also extensive experience in minimally invasive surgery, especially in choledochoscopic lithotripsy and minimally invasive suturing techniques. This technology has now started to radiate from Shanghai to the surrounding area.