Gallbladder stones and gallbladder polyps are among the most common diseases in the world today, and the surgical treatment of gallbladder disease has been debated for hundreds of years. Due to the influence of Langenburch’s “hotbed doctrine”, cholecystectomy has been described as the gold standard for the treatment of these two diseases. With the development of laparoscopic techniques in the last decade or so, cholecystectomy has become a “breeze” and many physicians have expanded the indications for cholecystectomy. It is reported that 500,000 patients have their gallbladders removed each year in the United States, and as China is a large population, the number of gallbladder removal cases in China cannot be underestimated. Due to the side effects and complications after cholecystectomy and the further understanding of gallbladder function; due to the development of medical science and technology in the past two decades, the improvement of modern technology of gallbladder preservation surgery (hereinafter referred to as biliary surgery) and the reduction of stone recurrence rate after surgery; due to the minimally invasive endoscopic biliary stone removal (polyp removal) surgery compared with traditional cholecystectomy or laparoscopic cholecystectomy has the advantages of preserving the integrity of organs, The indications for cholecystectomy are being rewritten, and the scope of biliary preservation surgery is being redefined. However, there are no uniform standards at home or abroad. The authors discuss the indications for biliary conserving surgery and the selection of the procedure. Liu Yanmin, Department of Minimally Invasive General Surgery, The First Hospital of Guangzhou Medical University
I. Indications and contraindications for biliary surgery.
The majority of gallbladder stones and polyps are benign lesions. A reasonable operation or successful treatment should not only meet the requirements of removing stones and polyps, but also ensure the safety of patients, improve the function of the body and meet their higher quality of life requirements. The choice between biliary preservation and cholecystectomy depends on the nature and extent of the gallbladder lesion, on whether the stones can be removed from the gallbladder and whether the polyp-like lesion can be completely cleared; on whether the gallbladder is functional and whether the chosen treatment can bring more benefits to the patient. Biliary preservation surgery is less invasive than cholecystectomy, and the indications are significantly different from those for cholecystectomy. Biliary preservation emphasizes the function of the gallbladder, whereas the indications for cholecystectomy are the opposite; biliary preservation prevents the development of lesions and emphasizes early intervention to maintain gallbladder function. The indications for cholecystectomy require symptomatic, sufficiently large polyps and more severe lesions, while bile conservation is not mandatory. Biliary preservation is more effective in asymptomatic individuals with mild gallbladder lesions. The choice of treatment method also depends on the condition of the hospital and the skill of the physician. In primary care hospitals without rapid pathological diagnosis, bile preservation surgery to remove polyps is difficult. According to the above principles, the indications and contraindications of gallbladder stone and gallbladder polyp biliary surgery are as follows.
In the practice of cholecystectomy, we found that symptomatic gallbladder stones feel better than asymptomatic patients after surgery, but the opposite is true for biliary surgery, as symptomatic patients with gallbladder stones have certain effects on gallbladder function, and patients do not feel as good as asymptomatic patients after biliary surgery. For asymptomatic gallbladder with good function, removal of stones by minimally invasive methods has good postoperative effect and is more meaningful for maintaining the function of gallbladder. We support minimally invasive gallbladder stone removal surgery for asymptomatic gallbladder stone patients. (2) Good gallbladder function Ultrasound, oral cholecystography or isotope examination, and gallbladder contraction of more than 1/3 for 1 hour after a fatty meal (2 fried eggs in oil). If possible, gallbladder contraction and concentration function examination can be performed at the same time, and those with both functions have good surgical results. Gallbladder contraction function is divided into three levels, gallbladder contraction of 1/2 or more is good, 1/3 to 1/2 is good, and below 1/3 is poor. In practice, we see that sometimes the gallbladder contractile function test does not reflect the true functional status of the patient’s gallbladder because the quality and quantity of the fatty meal, the time of examination after the fatty meal is too early (e.g. <30 minutes) or too late (more than 2 hours) to observe the true contractile function of the gallbladder. In addition, too large or too many gallstones or inflammation of the gallbladder limit the contraction of the gallbladder, and the preoperative examination often shows poor gallbladder function, but for these patients, some doctors also perform biliary surgery at the request of the patient, and it has been shown that some of these patients have recovered their gallbladder function to varying degrees after surgery. However, we also find that most of these patients have difficulty in returning to normal gallbladder function and have a higher chance of stone recurrence after surgery. This situation must be explained to patients who insist on gallbladder preservation before surgery. (3) Gallbladder wall thickness <4mm If the gallbladder wall is thickened >4mm, it often indicates cholecystitis and gallbladder wall edema. Most of this gallbladder function is poor. Gallbladder surgery in this condition is prone to bleeding and infection, and the results of gallbladder preservation are poor. Biliary preservation is also contraindicated in cases of limited thickening of the gallbladder wall, where cancer cannot be excluded. (4) Patency of the cystic duct and common bile duct After intraoperative lithotripsy, observe the opening of the cystic duct for bile entry to prove whether the duct is patency. If the gallbladder fills rapidly within 3 minutes and the pressure of the gallbladder keeps increasing, it indicates that the common bile duct is not patent and must be confirmed by intraoperative bedside cholecystogram. (5) Informed consent of the patient and his or her family Biliary surgery is still controversial. Biliary stone extraction must be the patient’s wish and a strict indication for surgery, and long-term biliary care instructions from the physician are required after surgery.
Some elderly or high-risk patients with gallbladder stones who cannot tolerate cholecystectomy can be treated with minimally invasive lithotomy to preserve the gallbladder even if the gallbladder is dysfunctional, but the method is different. After the patient’s condition improves, resection or inactivation of the gallbladder will be performed.
Contraindications
(1) non-functioning or dysfunctional gallbladder, such as porcelain gallbladder, atrophic gallbladder, septic gangrenous cholecystitis; (2) combined or unexcluded gallbladder cancer; (3) obstruction of the cystic duct or/and common bile duct that cannot be released in time; (4) malformed gallbladder, such as double gallbladder, septal gallbladder and small gallbladder; (5) gallbladder after gastrectomy with mostly gastrojejunostomy (6) Biliary preservation surgery should be cautious in patients with poor liver function and diabetes mellitus.
2. Indications for gallbladder polyp biliary surgery
Gallbladder polyps, also known as gallbladder polyp-like lesions, have a variety of pathological diagnoses: cholesterol polyps, inflammatory polyps, adenomas, adenomyoma, adenomatous hyperplasia, inflammatory polyps, smooth muscle tumors, hemangiomas, gallbladder cancer, adenoma carcinoma, etc. Since the application of ultrasound in clinical practice, the diagnosis rate of gallbladder polyps has increased significantly. Since a few gallbladder polyps may be early-stage gallbladder cancer or may become cancerous, and the nature of polyps could not be determined by non-cholecystectomy surgery in the past, a large number of patients with gallbladder polyps were forced to have their gallbladder removed. Although textbook guidelines for cholecystectomy in patients with gallbladder polyps are based on a diameter of >1 cm, the literature reports that there are cancerous cases even at <1 cm, so many patients are reluctant to wait for cancer before surgery. In the literature, most of the gallbladder polyps that underwent cholecystectomy for gallbladder polyps were 5-10 mm in diameter, and the postoperative pathology confirmed that most of these polyps were benign polyps, and most of them were cholesterol polyps that did not become cancerous. Most patients with gallbladder polyps have no significant impairment of gallbladder function, while gallbladder removal brings them different degrees of side effects, which affects the quality of life of patients. The traditional treatment of gallbladder polyps by one method of gallbladder removal is unscientific. Gallbladder removal surgery makes most people suffer from unreasonable super-needed treatment and brings excessive trauma and undue loss to patients. Due to modern advances in television endoscopic techniques and rapid pathological diagnosis, it is now possible to remove the lesion and obtain a correct diagnosis without removing the gallbladder, and thus the removal of polyps and preservation of the gallbladder is recommended. The indications and contraindications are as follows.
Single or multiple gallbladder polyps meeting the following conditions: (1) diameter >5mm; (2) good gallbladder function and ≥1/3 reduction of gallbladder area or volume after fatty meal (two fried eggs); (3) benign polyps with inactive cell proliferation confirmed by rapid pathological examination; (4) no bleeding from the trauma in the gallbladder after polyp removal.
Contraindications
(1) Poor gallbladder function, no significant reduction in gallbladder area on ultrasound examination after fatty meal or no significant contraction on oral cholecystography. (2) Bile duct obstruction or combined jaundice. (3) Rapid pathological examination of polyps with malignant changes or active cell proliferation, without excluding cancer. (4) Bleeding in the gallbladder with difficulty in stopping the bleeding. (5) The polyp base is too wide to be completely removed.
B. Biliary Surgery Procedures There are several minimally invasive endoscopic biliary surgery procedures, mainly small incision endoscopic biliary stone extraction (or polyp removal), laparoscopic assisted small incision endoscopic biliary stone extraction (or polyp removal) and complete laparoscopic endoscopic biliary stone extraction (or polyp removal). The choice of biliary preservation procedure is based on individual, medical and technical conditions. In order to ensure the surgical results, the surgical procedures of gallbladder incision, stone extraction and gallbladder incision repair should incorporate the concept of minimally invasive and the principle of maintaining and restoring the gallbladder function, or at least not destroying or weakening its function. Any surgical method that affects the function of the gallbladder is avoided, such as cholecystostomy drainage modern biliary lithotomy has been abandoned because it leads to adhesions in and around the base of the gallbladder and affects the contraction of the gallbladder. In addition, rough lithotripsy, which destroys the mucosa of the gallbladder and can easily cause bleeding in the gallbladder, should also be avoided. The modern biliary preservation procedure also requires ensuring the biliary pathway is unobstructed, ensuring the safety of the operation, ensuring the removal of the stone (or polyp), and the standard of not seeing any fragment of biliary sand on microscopic examination.
1. Small incision biliary stone extraction (polyp removal) is suitable for patients whose gallbladder floor is located under the costal arch and whose abdominal wall is relatively thin. This is the most used procedure in China with the longest history. This procedure requires ultrasound to determine the location of the gallbladder floor, continuous epidural anesthesia, and an incision in the abdominal wall under the rib cage to lift the gallbladder floor to the abdominal wall incision to remove stones or polyps under direct vision. The operation is convenient, quick, less fluid accumulation in the abdominal cavity, and less costly. However, if the liver and gallbladder are located high and the gallbladder floor is located in the rib cage, it is difficult to operate. The incision is large, and there are many injuries to the patient. Sometimes excessive stretching can cause bleeding from tearing of the gallbladder bed.
2. Laparoscopic assisted small incision biliary lithotripsy is applicable as above, but preoperative ultrasound localization of the gallbladder base is not necessary. The gallbladder is located laparoscopically and the abdominal wall projection and entrance to the gallbladder floor are determined and operated as above. The advantage is that once the gallbladder floor is found to be high and within the costal arch, the procedure can be converted to a full laparoscopic endoscopic biliary lithotripsy. The disadvantage is that the patient requires pneumoperitoneum and general anesthesia, which increases the cost slightly.
Postoperative incision after laparoscopic assisted small incision biliary lithotripsy
Complete laparoscopic cholecystectomy is a new advancement in cholecystectomy and is suitable for any location of the gallbladder, regardless of the size and number of stones, with the widest range of adaptation. All operations are performed laparoscopically, through a 5mm sheath, with a rigid lumpectomy and minimal abdominal wall wound. The stones are removed from the concealed umbilical fossa wound with the best cosmetic results. However, it requires high laparoscopic skills of the surgeon and requires microscopic suturing to repair the gallbladder incision. General anesthesia is required and the cost is the highest.
Postoperative surgical incision after complete laparoscopic cholecystectomy
Third, pay attention to the “bile care project” after biliary surgery
Removal of stones and polyps is a small part of gallbladder preservation, to really preserve the gallbladder, we must prevent the recurrence of stones or polyps, and postoperative protection of gallbladder function and promotion of gallbladder function recovery (referred to as gallbladder protection) is an important measure to avoid the recurrence of stones and polyps after surgery, which is a systematic project that needs to be persisted for a long time. The causes of stone formation are complex, and the pathological nature of polyps varies. Doctors must assess the possible causes of stone formation in different individuals based on their medical knowledge and different patients’ medical history, living and eating habits, the nature of stone composition, patients’ blood lipids, blood sugar and liver function, and instruct patients on postoperative gallbladder care, including changing preoperative poor living habits and dietary structure, giving medication and physiotherapy when necessary, improving The patients will be guided to take care of their gallbladder after surgery, including changing their preoperative habits and diet, and giving medication and physical therapy if necessary to improve the function of the gallbladder and avoid stone recurrence.
The gallbladder is a useful organ in the human body, and the study of preserving the gallbladder is beneficial to human health, and efforts to protect the function of the gallbladder and reduce the recurrence rate are the main tasks and research hotspots we face.
(This article has been published in Chinese Journal of General Surgery (Electronic Version),2008,2(3):259-262)