Case: Lying on the operating table was a 52-year-old male patient with abdominal distension and pain for six months, which became more pronounced after eating. After ultrasound examination, several stones of 6-9 mm in size were found. After research, Director Bu Jianzhong recommended him to have a stone extraction surgery with preservation of the gallbladder. After the preoperative preparation, Director Bu cut two small holes in his abdomen to put in the endoscope. A special clamp “grabbed” the gallbladder, a small scalpel stabbed in, and a special small mesh basket fished out the stone. …… TV screen clearly “played” the whole procedure. The TV screen clearly “shows” the entire procedure. A while later, the stones were taken clean, director Bu after repeated observations to confirm that no other small stones sutured gallbladder, “the arms back to the warehouse”.
Does the gallbladder function?
Criteria for gallbladder preservation
This is a case of laparoscopic surgery combined with choledochoscopy, which is different from general surgery not only because of the more advanced technology, but more importantly because of the doctor’s advanced philosophy: if you have gallstones, you don’t have to do everything. In many people’s impression, the gallbladder is suffering from stones, hospitalized for a few days, remove the stone “nest”, simply, once and for all. But in the eyes of the general surgeon at the Public Security Hospital, if the gallbladder is still functional, the “old nest” should be preserved, because after all, the gallbladder is involved in many metabolic functions.
The way to know whether the gallbladder is functional is not complicated, ECT, ultrasound, gallbladder emptying test can understand its situation. Generally speaking, the gallbladder in the acute inflammatory phase is not suitable for biliary preservation surgery.
For patients with gallbladder stones of normal size, shape and function, the method of “endoscopic minimally invasive biliary stone extraction” should be used; for atrophied, non-functional gallbladder with thick wall (>0.5cm), suspected cancerous or cancerous gallbladder, the gallbladder should be removed.
At present, due to the maturity and development of biliary endoscopic technology, minimally invasive endoscopic techniques can be used: the operation is performed under epidural anesthesia, a small incision of 4cm~6cm is made in the right upper abdomen to enter the abdominal cavity, the bottom of the gallbladder is lifted and a small hole is cut under direct vision, the choledochoscope enters the cavity of the gallbladder, the stones are removed by applying a lithotripsy basket under direct vision, and the small hole at the bottom of the gallbladder is closed with absorbable sutures. The small incision in the abdominal wall does not need to be sutured, and can be fixed only with ligature tape.
This surgery reduces the difficulty of surgery, removes the stone, preserves the gallbladder, less pain, less trauma, shorter hospital stay, lower cost, more importantly, the surgery preserves the physiological function of the gallbladder, and the recurrence rate of stones is not high (1%-7%), the surgery is very safe, avoiding a series of complications after gallbladder removal; while the traditional surgery removes the gallbladder, which can cause a series of physiological disorders, although there is no the possibility of recurrence of gallbladder stones, but increases the incidence of common bile duct stones, which have a greater clinical risk than gallbladder stones.
Removal of the gallbladder
Can cause problems such as indigestion
In the past, the gallbladder was considered to be a storage organ for bile, except for its function of concentration and contraction, and was not taken seriously. With the development of modern medicine, there is a further understanding of this important digestive organ of the gallbladder. In addition to the role of concentration, contraction and regulation of buffering biliary pressure, it is also a complex organ of chemical and immune functions, so it should not be easily abolished!
1, indigestion, abdominal distension and diarrhea: after gallbladder removal, liver bile is discharged from the liver with nowhere to store, so it has to be continuously discharged into the intestine. When the body eats a greasy diet and urgently needs a lot of bile to help digestion, there is no extra bile in the body, and indigestion, bloating and diarrhea will occur.
2.Gastric reflux of duodenal fluid: The loss of bile reserve function after cholecystectomy causes bile to become continuously discharged into the duodenum from intermittent and feeding-related excretion, at which time the chance of reflux into the stomach increases, leading to bile reflux gastritis or esophagitis, which brings a lot of pain to patients.
3.Increased incidence of common bile duct stones: after gallbladder removal, it will cause compensatory dilation of common bile duct, and the bile flow in the common bile duct slows down and vortex or eddy flow occurs, forming common bile duct stones.
4. Currently, there are data showing that the incidence of colon cancer is 45 times higher in patients whose gallbladder has been removed compared with ordinary people.
Biliary colic is a typical manifestation
Biliary colic is the typical manifestation, or what we usually call “biliary pain”, which often occurs after a full meal, eating fatty food, or during sleep. The pain is located in the upper abdomen or right upper abdomen and is paroxysmal, radiating to the shoulder blades and back, and is often accompanied by nausea and vomiting. Another 20%-40% of patients with gallstones are asymptomatic throughout their lives and are found incidentally during physical examinations or other tests, called “resting gallbladder stones” or “asymptomatic gallbladder stones”. These patients often have normal gallbladder function, so it is especially important to preserve the gallbladder.
Long-term shoulder and back discomfort should be noted
As gallbladder stones can often radiate to the scapula and back, some patients have very obvious symptoms and are mistaken for frozen shoulder, and long-term treatment with physiotherapy, acupuncture, and sealants does not improve. The radiating pain to the back of the shoulder caused by gallbladder stones is characterized by vague and indeterminate pain location, does not affect the movement of the shoulder joint, and the symptoms disappear soon after local physiotherapy, etc. It is time to pay attention to your gallbladder and be sure to ultrasound your gallbladder!
Gallbladder Stones
To operate or not
1.Asymptomatic gallbladder stones
Also called quiet gallbladder stones, some do not have attacks for life. This part of the patient has no pain, will not feel discomfort, has no impact on work life, and does not need treatment. However, ultrasound should be done once every six months to observe whether the stones have increased, whether the gallbladder wall has thickened, whether the gallbladder has shrunk, etc. This is because some patients with gallstones will have cancerous gallbladder, so we still need to pay attention to this aspect of the problem.
2.Symptomatic gallbladder stones
This part of the patient often has acute cholecystitis, which manifests as severe pain in the right upper abdomen radiating to the back of the right shoulder, sometimes accompanied by fever and jaundice. The presence of jaundice indicates that gallbladder stones have fallen into the common bile duct. This part of the patient needs to be treated immediately at the hospital. If the patient’s pain is relieved after non-surgical treatment such as anti-inflammatory and biliary treatment, surgery can be avoided immediately. If the pain is not relieved, or if the gallbladder becomes large, surgery is needed. Some patients with acute cholecystitis become chronic cholecystitis without severe pain, but with frequent discomfort and vague pain in the right upper abdomen. If you experience recurrent right upper abdominal discomfort, surgery is still recommended.
Pre-operative preparation for biliary surgery
1. Control the inflammation of gallbladder for two weeks. The gallbladder wall is congested and edematous during acute inflammation of the gallbladder, with unclear anatomy and brittle tissue. The surgery has great damage, bleeding, risk, slow postoperative recovery and complications. Therefore, it is recommended to control the inflammation of gallbladder for two weeks before elective surgery.
2. Pre-operative routine blood, electrolyte, liver and kidney function, lung function, electrocardiogram and other routine examinations are performed. To understand the patient’s physical condition and assess the risk of surgery.
3.A low-fat diet is required 3 days before surgery, fasting 12 hours before surgery and water fasting 6 hours before surgery. If necessary, Valium sedation treatment can be taken the night before surgery.
Precautions after surgery
1.Monitor the vital signs and administer oxygen.
2.Give symptomatic treatment such as anti-inflammatory and biliary, pain relief and hemostasis.
3.Supplement the energy required for physiology and maintain water and electrolyte balance.
4.Patients with cholecystostomy need to observe the drainage situation.
5.The first day after surgery, you can eat low-fat semi-liquid diet and get out of bed.
6.The patient may be discharged to rest on the 2nd-3rd day after surgery.
After the new endoscopic biliary surgery patients are discharged from the hospital, some patients may still have slight incision pain, indigestion, loose stools, weakness and other symptoms, these symptoms will slowly disappear, so there is no need to worry. However, after discharge from the hospital, the following problems should be noted.
First, pay attention to dietary regimen
Eat more vitamin-rich food, such as green leafy vegetables, carrots, etc., more fruits; eat some lean meat, eggs, fish and shrimp and soy products and other high-protein foods, do not eat cholesterol-rich foods, such as animal offal, fish roe, crab yolk, etc., do not eat high-fat foods such as fatty meat, fried foods and pastries containing oil, do not eat spicy and stimulating condiments such as chili, do not smoke, do not drink alcohol and coffee, if necessary, eat something that can promote If necessary, eat foods that promote bile secretion and relax the biliary sphincter, such as hawthorn, umeboshi, corn husk (brewed water for tea).
Two, keep the bowels open
Eat appropriate coarse fiber food to increase intestinal peristalsis to unblock the stool. If the stool is not solved for 2-3 days, you can take some laxatives such as marijuana pills, poo stop, fruit guide tablets, etc.
Three, regular life
To do regular living, to ensure adequate sleep, moody, optimistic and cheerful, no depression and worry; tolerance and generosity, not calculating. Optimism can promote the body’s metabolism, improve the ability to resist disease; bitterness is easy to depression and anger liver, so that the bile duct tension, affecting the secretion and excretion of bile, is not conducive to post-operative physical recovery.
Fourth, adhere to the exercise body
Such as walking, practicing qigong, playing tai chi, etc., in the disease in the body has a hundred benefits and no harm. One can move the body, circulation of Qi and blood, enhance physical fitness; the second can avoid sitting still all day without activity. But also pay attention to the combination of work and rest, do not overexert yourself.
Five, adhere to the medication
Generally, we should take cholestatic drugs continuously after surgery, such as anti-inflammatory cholestatic tablets, cholestatic combination, sodium cholate, cholinesterase, etc. After 3 months, stop taking the drugs for 1 month for observation, if there is no special discomfort, you can take them again after 2-6 months. If you still have symptoms such as chest tightness, fullness, abdominal pain and indigestion after stopping the medication, you should continue to take cholestatic drugs.
Sixth, annual review
After the removal of gallbladder stones and polyps, there is a certain recurrence rate, about 2%-7%. After the new minimally invasive endoscopic biliary stone removal and polyp removal, patients are recommended to review the ultrasound once a year, if there is recurrence, timely treatment is needed.