Today, the development of biliary surgery has become a hot topic of controversy in the industry as to whether gallbladder stones should be “bile-cut” or “bile-preserved”; the doctor’s decision will directly affect the patient’s postoperative career, so this issue is of great concern to patients. Therefore, this issue is of great concern to patients. 1 “Biliary preservation” research is not superfluous The surgical approach to the treatment of surgical disease has never been static. With the in-depth understanding of the physiology, pathology and pathophysiology of tissues, organs and organs, the surgical procedure may be improved accordingly to achieve the development of a procedure with less damage to the body, less impact on normal function and better results. In the case of gastric and duodenal ulcer disease, for example, surgeons try to remove the ulcer after ineffective medical treatment, but the recurrence rate of the ulcer after surgery is extremely high. When it was recognized that this was due to the unresolved problem of high gastric acid secretion, a subtotal (or major) gastric resection was performed instead. The recurrence of ulcers was reduced after subtotal gastrectomy, but the problem of insufficient gastric capacity became apparent again. What to do? Vagotomy, highly selected vagotomy with hemi-gastrectomy, and a series of other reforms followed. Of course it is better now, the further clarification of the pathogenesis of ulcer disease such as H. pylori, the development of effective and efficient drugs, the majority of patients with ulcer disease can be cured without surgery, which is what we hope for in the treatment of gallbladder stones. The same is true for biliary surgery diseases! Take bile duct cyst as an example, it has undergone improvements in drainage surgery such as external drainage of cyst, duodenal anastomosis of cyst and Roux-Y anastomosis of cystic jejunum, which basically solved the problems of biliary obstruction, bile loss and retrograde infection. However, it was later found that the development of bile duct cysts was related to congenital abnormalities of biliopancreatic duct coaptation, and although the drainage surgery solved the biliary obstruction, the pancreatic-biliary coaptation of pancreatic enzymes retrograde into the bile duct was activated by bile, and the bile ducts were continuously eroded and repaired, producing cancer over time. A living example prompted the creation and promotion of cystectomy surgery; cystectomy and bile duct jejunostomy Roux-Y anastomosis, cystectomy and interposition jejunal bile duct duodenal anastomosis and other different reconstruction methods came into being. Therefore, the study of “biliary preservation” is an attempt to improve the treatment of gallbladder stones, which is fully in line with the laws of scientific development. “Gallbladder cutting” was selected from various treatment methods (including gallbladder stone extraction) based on the knowledge of gallbladder stones and the medical conditions at that time. “Gallbladder cutting” removed the stones and the diseased gallbladder, which not only solved the pain caused by acute attacks, but also prevented the regeneration of stones and the resulting complications such as bile duct obstruction and biliary pancreatitis. However, “biliary excision” also has the shortcomings of physical trauma and possible complications, “biliary excision” is to weigh the pros and cons before there is no better treatment and choose the method that has more advantages than disadvantages to solve the problem. There is no doubt that “gallbladder cutting” has benefited millions of gallstone patients over the years. However, today we have a better understanding of gallstones, and science and technology are much more developed than back then, is it still necessary to “cut the gallbladder”? Especially with the development and application of new imaging tests such as ultrasound, many “quiet stones” can be detected, so should all gallbladders be removed? Therefore, the reintroduction of “bile preservation” is not “superfluous”. Over the years, many pioneers have done a lot of work for “bile preservation”, including: gallbladder lithotomy, oral lithotripsy, lithotripsy by perfusion, lithotripsy, and lithotripsy (including lithotripsy by combined Chinese and Western medicine). Therefore, “bile preservation” is not a “new concept” or “new thinking”. The Chinese People’s Liberation Army 45th Hospital started to use endoscopic gallbladder lithotripsy as early as 1990, and 632 cases have been followed up from 1990 to 1994, so the existing endoscopic gallbladder lithotripsy is not a “new high-tech technology”. Although “bile preservation” has a promising application, it should be soberly seen that there is a big gap between the current data and the large-scale promotion of “bile preservation”. “We have a long way to go. We need to study and work in depth according to the principles of evidence-based medicine. 2.1 To clarify the indications for “bile preservation” The author believes that it is no longer appropriate to “cut” all gallbladder stones, and it is also wrong to “preserve” all gallbladder stones. For example, should we preserve small gallbladders with thick and shrunken walls or gallbladders with internal fistula formation? The materialistic dialectic cautions people to study the time, place, and conditions of everything, and to individualize the appropriate surgical approach to the condition. The author reviewed the authoritative literature on “bile preservation” and could not find any indication for “bile preservation”, which is easily misleading and causes adverse consequences. If the primary stage of the study did not differentiate the conditions and expanded the test subjects, then the reports of more than a thousand cases should summarize the lessons learned, which types are indications and which types are contraindications, for the readers to learn from. 2.2 Careful observation should be made to distinguish the pathology of cases suitable for “bile preservation”, such as the size of the gallbladder, the thickness of the wall, the degree of concentration and contraction, the size, number, type and location of stones, the presence or absence and number of acute attacks, the general condition, and so on…. …etc., should be observed and recorded in detail for future research and analysis. 2.3 To record in detail the operation process and the postoperative situation in order to summarize whether a particular detail is related to the prognosis. This is the key to the promotion of “bile preservation” and the degree of promotion. Nowadays, all large and small cities in China are in the process of development, and the household registration changes frequently, so it is really difficult to follow up. But the follow-up rate of 66.32% is too low! The opportunity to objectively reflect the efficacy of the treatment should not be lost because “it is very difficult to cooperate with multiple hospitals and complete follow-up”. The follow-up rate of 84.2% in one participating unit should not be used as the result of the whole group, which will bring side effects. 3 to objectively analyze the problem, step by step 3.1 to objectively analyze the problem Things often exist in two sides, surgery is no exception. We have to be objective and comprehensive when analyzing a specific operation. Too much emphasis will be misrepresented. For example: (1) the data of a hospital in Beijing said that 84% of the gallbladder wall from thick to thin, the gallbladder contraction and apparently improved recovery from 1 to 2 years of follow-up. In this regard, it was concluded that “clinically any inflammation should be reversible”. The implication is that irrespective of the degree of inflammation of the gallbladder, any inflammation can be preserved. I wonder how convincing such a view can be. One has to ask: even if any inflammation is reversible, how far can it be reversed? Can 84% of the diseased gallbladder be restored, but what about the remaining 16%? Can they be identified at the time of first treatment so that they are not treated after serious consequences have occurred? (2) The high incidence of common bile duct stones after cholecystectomy was emphasized based on the fact that 425 gallbladders were removed and 370 gallbladders were not removed in 795 patients with common bile duct stones treated by ERCP and EPT. ERCP and EPT only treat part of the common bile duct stones, and this percentage cannot represent the whole picture of common bile duct stones; there are many methods of minimally invasive treatment of gallbladder stones with common bile duct stones, including pure laparoscopic treatment, LC + ERCP and EPT treatment, and the latter can be solved at the same time and in stages. There are many methods of laparoscopic treatment, LC + ERCP and EPT, the latter of which can be solved at the same time and staged. If staged, the case of ERCP first will be included in the group of unincised gallbladder, and the case of LC first will be included in the group of incised gallbladder, which shows the unscientific nature of such statistics; some gallbladder stones have been partially drained into the common bile duct before surgery, and the so-called residual stones were not detected during cholecystectomy, which will be incorrectly included in the group of incised gallbladder once they develop later; most of gallbladder stones are cholesterol-based, while most of bile duct stones are bile pigment-based. Most of the gallbladder stones are cholesterol-based, while most of the bile duct stones are bile pigment-based, and the pathogenesis of the two types of stones are related but basically different. It is difficult to explain from the analysis of the pathogenesis of gallstones; the promoters also mentioned the problem of vortex, which is a secondary theory in the formation of gallbladder stones, saying that bile enters the sudden wide cystic cavity through the narrow cystic duct and forms a vortex, and that this vortex is conducive to the formation of stones by the precipitation of supersaturated bile. The common bile duct may be compensated for widening after cholecystectomy, but how can a vortex be formed when there is no stenosis on its proximal side? Pigmented stones are associated with biliary tract infections, and there is no correlation with supersaturated bile in patients with cystic duct stones. In short, this is a controversial statement that is still inconclusive, and it is important to be objective and comprehensive when analyzing the problem. (3) Whether the incidence of colorectal cancer increases after cholecystectomy is also a question that has not yet been decided. Theoretically, the hepatic and intestinal circulation of bile increases after cholecystectomy, and the contact between bile acids and intestinal bacteria is frequent, and 7α-dehydroxylation is enhanced, which leads to a decrease in the proportion of primary bile acids (CA, CDA) and an increase in the proportion of secondary bile acids (DCA, LCA); LCA is a trigger for colorectal cancer, and DCA can become methylcholanthrene when ketobiliary acid increases, which is a powerful carcinogen. In recent years, the carcinogenicity of secondary bile acids has been described. But is it really so serious in clinical practice? Some data reflect that the incidence of colorectal cancer is already high in patients with gallbladder stones before cholecystectomy, and Yifu Zou reported that among 10 cases of colorectal cancer combined with gallbladder stones, only one case of colorectal cancer occurred after cholecystectomy, and the remaining nine cases had unresected gallbladder; Turnen reported that among 108 cases of combined diseases, 32 cases (29.6%) of colorectal cancer occurred after cholecystectomy, but as many as 76 cases (70.4%) occurred without resection. Monnes reported 30 cases of combined disease, with 9 cases (30%) of colorectal cancer occurring after cholecystectomy and 21 cases (70%) of unresected gallbladder. Among 246 cases of colorectal cancer from 1980 to 1990, 34 cases were confirmed to have gallbladder stones, among which 8 cases (23.5%) occurred after cholecystectomy and 26 cases (76.5%) occurred in the course of gallbladder stones. The high incidence of colorectal cancer in patients with gallbladder stones may be due to the presence of common pathogenic factors in both diseases. A high-fat, high-protein, low-fiber diet is one of the causes of both colorectal cancer and gallbladder stones. Refined carbohydrates increase the saturation of cholesterol in the bile and make it easy to form stones. Low-fiber diet can prolong the residence time of intestinal contents in the intestine and increase bacterial degradation of primary bile acids into secondary bile acids, DCA is both a lithogenic bile acid and carcinogenic to the colonic mucosa. All these and so on suggest that we do not need to choke if “bile cutting” is indicated. 3.2 We should not be in a hurry and proceed step by step. “Gallbladder cutting” has a history of more than 100 years, based on its efficacy not only accepted by everyone, but also regarded as the gold standard for the treatment of gallbladder stones. With the evolution of history and the progress of the times, the shortcomings of “bile cutting” have become more and more obvious. It is absolutely correct that knowledgeable people are trying to study and promote “bile conservation”. However, the promotion of new technologies and the change of concepts should be a process, which can never be solved by holding several national conferences and issuing a few more articles; we should refrain from submitting two drafts, otherwise the effect will be counterproductive; we should do it in a practical manner and speak with evidence-based medical data; we should first comprehend the spirit of the authoritative views of experts and introduce their sources, otherwise who knows it is not taken out of context? Even if there is a 50% recurrence rate, it is still cost effective to save the other 50% of the gallbladder. One cannot help but ask, among the 50% that cannot be saved, some need to have their gallbladders removed again, can the process be as easy and convenient as the article describes? Some people have recurrent attacks that drag their bodies across; some people have recurrence that requires another surgery to cut the gallbladder; some people have become old and frail when they operate again, which increases the risk of surgery; some people have gallbladder cancer. Do you think it is still a good deal? Therefore, the study of “bile preservation” should not be impatient and measured step by step, it is not yet appropriate to promote a large area, otherwise its effect is counterproductive. It is best to organize a research-based unit to implement it in a planned manner. At the same time, the advantages and disadvantages should be presented to patients in detail and filed with the relevant leaders. Because the current medical environment also cannot be ignored.