The gallbladder is an important digestive organ in the human body because of its role in storing, concentrating and draining bile and regulating biliary pressure, as well as its complex chemical and immunological functions. The gallbladder has often been removed for gallstones over the last 100 years, and the rapid popularity of laparoscopic cholecystectomy has made this technique the “gold standard” for the treatment of gallbladder stones. However, after cholecystectomy, some patients may experience various adverse complications such as gastric reflux of duodenal fluid and gastric esophageal reflux, dyspeptic diarrhea, post-cholecystectomy syndrome, and increased incidence of common bile duct stones, prompting clinicians to rethink cholecystectomy. In contrast to cholecystectomy, cholecystectomy is also a treatment for gallbladder stones; however, the mainstream opinion does not recommend it due to its high recurrence rate of postoperative gallbladder stones.
The theory advocating cholecystectomy for stone extraction was created by Langenbuch, a famous German doctor of the generation, in 1882. In the backward condition of no endoscopic technology at that time, he believed that the treatment of gallbladder stones by the old choledochostomy was incomplete and easy to recur after surgery (>90%); therefore, he put forward the theory that “gallbladder removal is not only due to the presence of stones in the gallbladder, but also because it can grow stones”, which is the famous ” hotbed doctrine”.
There have been many scholars who have opposed the idea of gallbladder resection for gallbladder stones, but the recurrence rate could not be lowered, so it has been used as the gold standard for more than 120 years and has influenced several generations. The main flaw of the hotbed doctrine is that it ignores the importance of gallbladder function and misreports and exaggerates the postoperative recurrence rate. The above conclusions were made because he was unable to remove the stones under the then backward technological conditions and lack of endoscopic techniques, much less qualified to talk about the recurrence rate.
Langenbuch believed that the cholesterol concentration in the bile of the gallbladder is oversaturated and solid cholesterol crystals are precipitated to form cholesterol stones. However, cholesterol is secreted by the liver, so the “hotbed” of stone formation is not in the gallbladder, but in the liver. Therefore, our predecessor in biliary surgery, Professor Ran Ruitu, believed that gallbladder stones originate from the liver and the indications for cholecystectomy (gallbladder stones) should be revised. Therefore, the modern view is that the warm-bed doctrine is obsolete today and cannot be advocated.
Many scholars have reintroduced the procedure of biliary stone retrieval because today there are laparoscopic and choledochoscopic help to achieve the requirement of minimally invasive and clean stone retrieval.
However, it is still not the mainstream view. The Society of Endoscopists has developed some technical specifications for biliary stone extraction surgery.
I. Indications for surgery.
1. Diagnosis of gallbladder stones by ultrasound or other imaging tests;
2. The gallbladder is visualized by Te99ECT or oral cholecystography and is functioning well;
3. Although Te99ECT or oral cholecystography does not reveal the gallbladder, the stones can be removed intraoperatively to confirm the patency of the gallbladder duct.
II. Contraindications to surgery.
1.Gallbladder atrophy and disappearance of gallbladder cavity;
2.Stones in the gallbladder duct cannot be removed, and it is expected that they will not be removed after surgery;
3.The obstruction of the gallbladder duct is confirmed by intraoperative imaging;
4.Stones in the cystic duct can be seen by intraoperative ultrasound or imaging, but cannot be detected by intraoperative cholangioscopy;
5.In case of combined total bile duct stones, the total bile duct stones should be treated before the biliary surgery.
Some other indications for choledocholithiasis surgery suggest that the treatment target must meet all of the following conditions.
1. Symptomatic gallbladder stones;
2, single stones of 20 mm or less in diameter;
3, X-ray translucent stones;
4, smooth gallbladder mucosal membrane and normal wall thickness;
5, normal gallbladder concentration and contraction function;
6, no family history of gallbladder stones;
7, no hyperlipidemia, coronary heart disease, diabetes, fatty liver, liver cirrhosis and other diseases.
At present, it is indeed debatable that all gallbladder stone patients take gallbladder removal, and some gallbladder stone patients may be suitable for cholecystectomy; for surgeons, it is important to carry out related work to find scientific screening criteria and develop more scientific cholecystectomy program.