In recent years, great progress has been made in the research on the prevention and treatment of gallstone disease.
1. In terms of pathogenesis
While previous understanding was limited to the physiological, biochemical, and pathophysiological levels, the search for causes has 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 cause 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 described as being in its infancy. It is believed that basic research in the next 5-10 years will provide a clearer “roadmap” for stone formation.
2. New discoveries in epidemiology
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.
From a survey of more than 30,000 gallbladder stone patients, some new features were found.
(1) the age of onset extends to less than 40 years old and there is 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) Increased incidence of gallbladder stones in those who work in a sedentary position or lack exercise.
(6) The proportion of combined common bile duct stones increases significantly with age
These findings provide the basis for a view that has been proposed and widely accepted in the field in recent years.
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 MRCP to show the entire length of the bile duct. If cancerous gallbladder polyps or gallbladder cancer is suspected, then it is better to do enhanced CT. nowadays, routine MRCP is advocated for the elderly because it has been found that the combined common bile duct stones are 30% for gallbladder stones at age 60 and increase to 60% at age 90. In view of the national situation, we recommend MRI for the following conditions.
(1) Those with multiple stones of long duration.
(2) Those of advanced age.
(3) Those with a 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 are different, 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. And in this regard, the physician is the main responsibility!
4.Progress in treatment
For gallbladder stones, there are no more than three options for treatment. One is wait and see; the other is resection; the third is bile preservation and stone extraction.
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, after more than 10 years of observation and investigation, I found that the so-called “symptomatic concept” of gallbladder stones is a long-standing misunderstanding of “what is known but not what is known”. In the past, when patients had typical biliary colic, they were considered to have gallbladder stone symptoms, while non-specific symptoms such as vague pain in the upper abdomen, abdominal distension and indigestion 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. (the patient instinctively stops breathing). Nowadays, more than 70% of patients with gallbladder stones are found because of “digestive” problems or because of routine physical examinations, in fact, the so-called “digestive 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 the era of minimally invasive surgery, for the radical school, blind bile-cutting school of thought, has strengthened the belief that “everything is done”, but for the other camp of moderate school of thought, rational bile preservation school of thought, has found a humane solution that is welcomed by the majority of patients, and this humane 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 very long time, or even 3-5 years, and you say it doesn’t make sense? An online survey of mine found that almost 100% of patients are willing to preserve their gallbladder first, even if the stones recur within a year and then cut the gallbladder again, it is worth it for a well-functioning gallbladder, at least it gives another chance.
The so-called rational biliary preservation for stone extraction should have.
(1) A patient’s request for gallbladder preservation after explaining the advantages and disadvantages of gallbladder preservation.
(2) Clearly functional gallbladder by imaging.
(3) Analysis that the stones are not prone to recurrence after removal or that a prevention link has been found (e.g., single stones, or large stones but of similar size; knowledge of obvious stone prone factors that can be corrected, such as not eating in the morning, adding food at night, working in a sedentary position for a long time, rapid weight loss, long-term use of birth control pills, etc.)
(4) The treatment method is mild to the individual.
The most commonly used methods are.
Small incision lithotripsy; laparoscopic lithotripsy. Although the small incision technique was once left out of the picture, it has seen a resurgence due to improvements in technology and is now mostly adopted in Beijing and Wuhan. 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 of laparoscopic lithotripsy are relatively high, requiring not only good equipment in the hospital where it is performed, but also, and more crucially, extensive experience in minimally invasive surgery and timely updating of surgical concepts, especially in laparoscopic lithotripsy and minimally invasive suturing techniques.