Long ago, bile cutting was the only option to save lives
The historical roots of bile-cutting logic go back to the pre-Langenbuch era.
Due to poor diagnostic techniques, gallbladder stones could only be detected when they caused complications, often fatal, with a very high mortality rate. Without efficient antimicrobial drugs and without the technology and conditions to deal with secondary internal environmental disturbances, removal of the diseased gallbladder was apparently the only means that might effectively save the patient’s life.
It was in this context that Dr. Langenbuch in Germany invented cholecystectomy, which was epoch-making in the history of surgery. Despite the conditions of the time, death still occurred. However, it was clearly a huge improvement over the previous practice of sitting on the sidelines.
Later, due to the continuous progress of overall medicine, this procedure was also improved and its results were also improved, and it naturally became the “gold standard” for the treatment of gallbladder stones. The logic of treating gallbladder stones at this time was simple: because the gallbladder produced stones, which in turn destroyed the gallbladder and endangered lives, removal was the only option.
Later, only symptomatic stones required gallbladder removal
Later, with the advent of technology, new diagnostic tools, especially ultrasound, allowed doctors to detect stones at or before the time when the patient developed clinical symptoms of gallbladder stones.
A 15-year follow-up found that only 20% of patients with gallbladder stones were symptomatic and 80% could remain asymptomatic for life.
Therefore, the idea that asymptomatic stones do not require treatment has been proposed and is accepted by a very large majority of scholars. However, for symptomatic stones, gallbladder removal is still advocated because there is no proven non-surgical treatment.
The logic at this point is that the gallbladder should be removed not only because there are stones in the gallbladder, but because the gallbladder is the “soil” where the stones are produced. This is the “hotbed doctrine” pointed out by the famous scholar Prof. Zhang Baoshan.
But some people say: no cutting, the gallbladder must be useful at birth!
The logic of gallbladder preservation is due to the fact that, first of all, the gallbladder is born and received by the parents and must have its own use. This is not just a hunch or a belief, but the diversity of gallbladder functions has been confirmed by medical science.
Secondly, biliary surgery, especially the new type of biliary surgery invented by Prof. Zhang Baoshan and others, has the advantages of surgical safety, easy operation, reliable efficacy and low recurrence rate, and it has also been proved that the recurrence of gallbladder stones is related to the incomplete removal of stones by the old type of biliary surgery.
Finally, mankind has shown the unlimited potential to recognize and prevent gallbladder stone formation.
To cut or not to cut is justified, what should I choose?
The debate over gallbladder preservation and cutting has been going on for a long time, with both doctors and patients being at a loss as to what to do.
The strong weapon of gallbladder preservationists is to emphasize the “will of God” or “purpose” of gallbladder production, and recently many evidences have been produced to show that the stones are not as prone to recurrence after removal as originally reported.
Of course, there is no shortage of “sins” blamed on gallbladder removal, such as surgical complications, a slightly higher probability of surgical colon cancer, bowel dysfunction, and so on.
Gallbladder cutters, on the other hand, believe that the complications of gallbladder stones are far more dangerous than the benefits of keeping the gallbladder, and that gallbladder removal does not have serious consequences, and that the body can fully compensate for the loss of the gallbladder, and that gallbladder removal is safe and reliable, with no risk of stone recurrence.
We tried gallbladder preservation treatment, but the stones recurred
I was a devout gallbladder conservator, and my doctoral project was a combination of lithotripsy and lithotripsy for the non-surgical treatment of gallbladder stones. At that time, in the second half of the 1980s, extracorporeal shock wave lithotripsy for gallbladder stones had not yet started in China, but it was generally favored and was gaining momentum.
However, fortunately, our predecessors in the surgical field, such as Huang Zhiqiang, Zhang Shengdao and Zhu Xueguang, were always at the forefront of academic development and correctly grasped the trend of academic development, promptly pointing out the potential problems of this new treatment and the many facts that needed to be further demonstrated.
At that time, he made the reasonable suggestion that “the indications for lithotripsy should be strictly controlled”. This would facilitate academic exploration without blindly expanding the potential adverse effects of an immature treatment method.
It was against this background that my project was carried out. This is because it was a common observation at that time that stones were not as easily eliminated after lithotripsy as one might think, and sometimes stones increased rather than decreased, and the occurrence of common bile duct stones increased, as did the occurrence of pancreatitis.
Therefore, we conceived whether we could use stone crushing to accelerate stone dissolution? The results of in vitro and animal experiments fully supported this idea.
Later, based on repeated animal experiments, we successfully completed 78 cases of “lithotripsy-lithotripsy” treatment in humans, and achieved exciting recent results. However, the follow-up results gave us a fatal blow. In just six months, about 25% of the patients had recurrence of stones, and all of them were multiple stones (most of the stones we had selected were single stones).
At the same time, our other group of 100 patients who had their stones removed by percutaneous cholangioscopy also had a recurrence of 10% (only 1 year). This gave us a very objective idea of the fundamental flaw of biliary preservation therapy – stone regeneration!
The birth of laparoscopy made bile cutting a matter of course
By the early 1990s, the success of the first laparoscopic cholecystectomy in China, in Qujing, Yunnan Province, gave new hope to a hundred helpless scholars.
As young people who were catching up with this great era, especially those who had just been hit by the failure of “stone regeneration”, they naturally soon joined the ranks of the first laparoscopic cholecystectomies in China without any hesitation.
Because of my optimism about the prospect of minimally invasive laparoscopic surgery, I left Ruijin Hospital at the end of 1993, where everyone was looking forward to, and came to a small town health center in Zhangjiagang, where I started the “road to gall bladder” and became a real “gall bladder slaughterer”.
During this period of time, as long as the gallbladder grows stones, it is a “crime that deserves to be cut”, because keeping the gallbladder means stone regeneration, which is sooner or later.
But then came the question: Is there no longer a reason for the gallbladder to exist?
As the gallbladder was being cut, I felt that it was becoming easier to cut, and that the gallbladder was looking better and better.
I thought to myself, these gallbladders must still be functional, can’t they be preserved for a while longer? Even for a very short time.
Is it possible that the past recurrence cases are the remnants of stone fragments? If we intervene with medication after stone extraction, or change the bad habits that were prone to stone production, is it possible that recurrence has changed? Is it true that the probability of recurrence is different for each type of gallbladder stone? What are the reasons for those that do not recur or recur only after a long time?
Will mankind never be able to solve the mystery of stone formation? Is there any point in studying the causes of gallbladder stones …… and so on.
In the pre-Langenbuch era, gallbladder stones were only detected when they caused complications and were often fatal, and removal of the diseased gallbladder was apparently the only means that might effectively save the patient’s life. However, with the continuous development of diagnostic and therapeutic techniques, the debate on gallbladder preservation and gallbladder cutting has intensified, and in the face of gallstone patients, whether to cut or preserve may be better to vary from person to person.
With these reasons in mind, my thinking has evolved. I admit that I am a rational biliary preservationist and started out carefully doing dozens of biliary preservation procedures with very satisfactory recent results.
Now, we have done more than 2000 cases and after 10-15 years of follow-up, the results are excellent and the probability of gallstone recurrence is about the same as the probability of a normal person developing gallstones, which is about 10%.
If you are eligible for gallbladder preservation, please give your gallbladder a chance to live
I am very fortunate to have experienced the gallbladder cholecystectomy and gallbladder preservation debate and clinical practice, and I have also experienced the evolution of my own thinking.
For every patient with gallbladder stones, we have the obligation to listen to his or her personal wishes and first see if there is a requirement to preserve the gallbladder. If so, then an objective examination should be used to understand the functional status of the gallbladder and the nature of the stones as a way to make a judgment about the value of gallbladder preservation and the possibility of recurrence.
Explain to the patient the pros and cons of gallbladder preservation for stone extraction. If the conditions for gallbladder preservation can be met, then the patient’s needs should be met as much as possible, and instructions should be given on ways to prevent stone regrowth.
However, surgical removal should be an option for patients whose gallbladder is no longer functional, or whose function is largely absent, or for patients with a very high likelihood of stone recurrence (e.g., multiple stones or mucoid stones), or who have had pancreatitis, or are suspected of having bile duct stones. Of course, the patient’s age, general condition and other medical conditions should also be taken into account.
In conclusion, the judgment of “cut” or “save” needs to be “humanized” and “individualized”, not One size does not fit all.
The physician should choose the method that he or she is best at, but should explain the facts to the patient before treatment, and should not make an unobjective assessment of the available methods because of his or her ability. We must be open-minded, accommodate all hopes, and welcome every ray of sunshine.