Wang Jingtao, Department of Surgery II (Hepatobiliary Surgery), Weifang Hospital of Traditional Chinese Medicine, Zhang Baoshan
Department of Surgery, Peking University Hospital, Beijing, China (100034)
[Keywords] Minimally invasive surgery, cholelithiasis, gallbladder, choledochoscopy and treatment, Classification No. R657.4+2
“Minimally invasive endoscopic choledocholithotomy is a new technology and a new concept: stone extraction and bile preservation is the goal, and endoscopic stone extraction is the means, which is completely different from the old-fashioned choledochostomy stone extraction. It is completely different from the old choledocholithotomy. Without choledochoscope, we can not complete the biliary stone extraction. In the past, the treatment of gallbladder stones was mainly surgical, and the removal of the gallbladder was unquestionable. This theory was developed by the famous German doctor Langenbuch (1882), who, in response to the disadvantage of the “recurrence” of stones after the old cholecystostomy, proposed that “the gallbladder is not removed because it contains stones, but because it can It is because the gallbladder can grow stones.” Therefore, only cholecystectomy can be performed. In a word, the recurrence rate of stones after cholecystostomy is too high, so this method cannot be used.
For more than 100 years, this has been regarded as the “goldenstandard” and never doubted. Therefore, for the treatment of gallbladder stones, surgeons do not hesitate to decide: gallbladder removal! But how does the patient live after the gallbladder removal? What is the discomfort? Are gallbladder stones not recurring; but increasing the chances of growing stones in the common bile duct? Is it noted that cholecystectomy causes far more bile duct damage than cholecystostomy? Does it increase the incidence of colorectal cancer? What is the reason for the high rate of stone “recurrence” after cholecystostomy? These are questions that many doctors do not ask carefully.
The rapid development of modern high-technology over the past 20 years [1, 2], together with advances in other fields of medicine, has led to the discovery of the disadvantages of cholecystectomy and the unlocking of the secret of the “high recurrence rate” after the old cholecystostomy.
New technology has revealed that the “high recurrence of stones” after cholecystostomy is an injustice, and that most cases are not postoperative recurrences but “surgical legacies”. So today, a hundred years after Langenbuch’s theory. His “gold standard” view is worthy of consideration.
1 The “secret” of easy recurrence after old cholecystostomy
For the treatment of gallbladder stones, the long-held view is that cholecystectomy is unquestionable, so for more than 100 years the “old cholecystostomy” has been rejected because of the high risk of stone “recurrence” after surgery. Why is the recurrence rate of this procedure so high? No one has asked why this procedure has a high recurrence rate. With the development and progress of endoscopic technology, endoscopy can directly see the internal situation of the biliary tract, which has played a huge role in the diagnosis and treatment of biliary tract diseases. 20 years of careful exploration and research in this field on the topic of “easy recurrence of stones after cholecystostomy” has uncovered the “easy recurrence of stones after cholecystostomy”. “The secret of the high recurrence rate of stones after cholecystostomy.
We found that the old-style cholecystostomy is a blind stone extraction. Because the operator cannot see the real situation inside the gallbladder directly; plus, the stone extraction process and the blind use of forceps clamps and scraping spoons scraping, inevitably the stones will be shattered, missing debris; and its criteria to determine whether the stones are taken or not, not by direct vision but by hand touch to determine the presence or absence of stones, extremely unreliable! This will definitely lead to the retention of stones after surgery; when the fine stones grow slowly, it will be mistaken as a “recurrence” of stones, which is actually caused by the doctor’s “intraoperative omission” and “residual”, resulting in years of This is the “key” to the ease of recurrence after choledochostomy. However, “endoscopic minimally invasive choledocholithotomy” overcomes the blind spot of the old choledochostomy, avoids “gallstone leakage” during choledochostomy, really reduces the “stone recurrence rate” after fistulotomy It also reduces the “stone recurrence rate” after fistula, and returns the “original face of biliary stone extraction”. “Endoscopic Minimally Invasive Biliary Stone Removal” is to enter the gallbladder with a soft (fiber) cholangioscope for examination and treatment, the fiber cholangioscope can be bent at will, and can be illuminated for observation, so that stones can be removed wherever there are stones, and stones can be completely and thoroughly removed. In addition, for patients with suspected intra- and extra-hepatic bile duct stones or other biliary tract diseases, fiberoptic choledochoscopy can be performed via the gallbladder duct [3].
In order to ensure that no residual stone will be missed after the “endoscopic minimally invasive biliary stone extraction”, we also stipulate that the endoscope must be a soft choledochoscope, and the hard choledochoscope cannot be bent, which cannot guarantee the removal of net stones; when removing stones, no clamps are allowed, and no scrapers are allowed to be used to avoid stone fragmentation and leakage of debris; only the lithotripsy basket is allowed to be used, like a “midwife”. “If there is bile mud on the surface of the gallbladder mucosa, the wall of the gallbladder can be scrubbed with a choledochoscope cell brush and washed with saline. After such treatment, if the stone grows again, it can be called “stone recurrence”.
What should be emphasized here is that “the recurrence rate of gallbladder stones after surgery must be called on the basis of ensuring that the stones are removed during surgery. Otherwise, it is not clear whether it is residual or recurrence. According to the above strict scientific regulations and high-tech stone extraction methods and tests, the real recurrence rate of 895 cases of “endoscopic minimally invasive cholecystectomy” in three hospitals in Beijing Hepingli was 2.7%~4.1% after 1~6 years of follow-up after cholecystectomy, which really reduced the recurrence rate of “cholecystostomy”. This result is real and reliable, and has returned the true face of biliary stone extraction, and won the Beijing Science and Technology Progress Award.
Clinical practice proves that the recurrence rate of gallbladder stones after “endoscopic cholecystectomy” with the application of modern technology is not as high and serious as it used to be, and gallbladder removal is not necessary. Of course, more time is needed to observe the follow-up of endoscopic minimally invasive cholecystectomy, and more cases are needed to practice it, but at least this surgical method brings hope and light to patients’ desire to preserve their gallbladder.
2 The importance of gallbladder preservation
In the past, the function of the gallbladder was not well understood, except for its function of concentration and contraction, it was only a storage organ for bile, which was not valued or even considered dispensable. Therefore, gallbladder removal was not a matter of debate.
With the progress and development of science and technology in recent years, a large number of clinical reports on various maladies after cholecystectomy have revealed that the gallbladder has complex and extremely important functions that are indispensable and irreplaceable. It is well known that the side effects or disadvantages after cholecystectomy should be highly valued by the operator, which directly affects the patient’s quality of life and even crises the patient’s life. But unfortunately this point is ignored by most surgeons and the craze of laparoscopic cholecystectomy.
Long-term side effects after cholecystectomy include the following directions.
2.1 Dyspepsia, bloating and diarrhea
As far as is known, the gallbladder has at least a storage, concentration and contraction function. It also has, of course, complex chemical and immunological functions. Bile is secreted by hepatocytes through the capillary bile ducts, the small bile ducts, the right and left bile ducts, the common bile duct, along the cystic duct, and into the gallbladder for storage and concentration. The concentrated bile is 30 times more concentrated than hepatic bile and is discharged into the intestine to participate in digestion when a high-fat meal is eaten. If the gallbladder has been removed, here the bile is discharged from the liver and there is no place to store it, regardless of whether the body needs it or not, it has to be continuously discharged into the intestine; when it comes to feasting on thick and fatty food, a lot of bile is urgently needed to help digestion, but unfortunately, there is no “spare food” in the body to help, so the body has to suffer from indigestion, abdominal distension and diarrhea.
2.2 Gastric reflux of duodenal fluid and reflux of gastric fluid esophagus after cholecystectomy
In recent years, there have been many reports on duodenogastric refluxDGR and gastric reflux after cholecystectomy.Walsh et al. also confirmed in a controlled study that all markers refluxed to the gastroesophagus after cholecystectomy and were accompanied by a significant decrease in lower esophageal sphincter tone; ChenMF et al. also pointed out that the cause of DGR was post-cholecystectomy The loss of bile reserve function causes bile to change from intermittent and feeding-related excretion to continuous excretion into the duodenum, at which time, the chance of reflux into the stomach increases, producing DGR. leading to bile reflux gastritis or esophagitis, which brings a lot of pain to patients [4-6].
2.3 Effect of cholecystectomy on the incidence of colorectal cancer
In recent years, many European scholars have found a phenomenon and doubt that many of the cases suffering from colon cancer have a history of cholecystectomy. In Moorehead’s analysis of 100 cases of cholecystectomy over 60 years old, 12 cases of colon cancer were found; while in another 100 cases without cholecystectomy, there were only 3 cases of colon cancer patients [7]. It has been pointed out that the risk of colon cancer after cholecystectomy is 45 times higher than that of non-cholecystectomized cases (DionigiLorusso) [8]. contribute to the development of carcinogenesis [10].
Vernivk et al. suggested that the qualitative and quantitative changes in bile after cholecystectomy are the main causes of colorectal carcinogenesis [11]. The pathophysiological changes are mainly: the origin of secondary bile acids: bile acids secreted from the hepatic bile ducts are primary bile acids, which enter the intestine and come into contact with bacteria, and 7a carboxylation increases, thus leading to an increase in the amount of secondary bile acids; after cholecystectomy, the gallbladder function is lost, and primary bile acids continuously flow into the intestine and come into contact with bacteria for 24 h, thus producing a large amount of secondary bile acids; while in normal gallbladder function it only occurs when eating In contrast, when the gallbladder function is normal, it only occurs during feeding, so the contact time with bacteria is obviously longer in the former than in the latter, and thus the amount of secondary bile acids is increased; because the concentration of secondary bile acids in the proximal colon is higher and the absorption of secondary bile acids in the right hemicolectomy is greater than that in the left hemicolectomy, the cancer after cholecystectomy is more likely to occur in the right hemicolectomy.
Therefore, it is generally believed that the mechanism of promoting colon cancer after cholecystectomy is that more bile circulation after cholecystectomy affects bacterial degradation, resulting in higher content and proportion of secondary bile acids in the bile salt pool, and secondary bile acids have carcinogenic or synergistic carcinogenic effects, so that colon carcinogenesis is likely to occur.
2.4 Problems leading to bile duct damage after cholecystectomy
It is well known that during the surgical procedure of cholecystectomy, due to the importance of Calot’s triangle and the influence of local tissue adhesions, the comorbidities brought about by cholecystectomy are inevitable and there is always a certain probability (bile duct injury 0.18%-2.3%); and there is a certain mortality rate, which is 5%-8% in the early stage; it is still 0.17% [12]. These include: bile duct injury, hepatic duct injury, vascular injury, gastrointestinal injury, etc. It is especially worth emphasizing that the vast majority of bile duct injury records are caused by cholecystectomy. Huang Xiaoqiang statistics 2566 cases of CBD injury, 1933 cases were caused by cholecystectomy, accounting for 75% of the stenosis cases.
In the United States, for example, about 500,000 cholecystectomies are performed each year; so that there will be thousands of cases of bile duct injury occurring each year; China has a large population and the cases of gallbladder stones should be above the United States; and the complications of bile duct injury is a very difficult subject for biliary surgery. In particular, there is a certain mortality rate, and endoscopic biliary stone extraction is performed in the gallbladder cavity, and it is impossible to injure the organs around the gallbladder; this must be the biggest drawback of cholecystectomy. In addition, considering the physiological defects and immune function brought about by cholecystectomy, it should be considered carefully if cholecystectomy is hastily chosen to treat gallbladder stones.
2.5 Post-cholecystectomy syndrome
In the past, the term “postcholecystectomy syndrome” was a vague concept; with the advancement of modern diagnostic imaging technology, the diagnosis of postcholecystectomy residual stones and bile duct injury has been excluded, and only the inflammation and dyskinesia of the sphincter of Oddi that occurred after biliary surgery can be called “postoperative syndrome”. The treatment of this symptom is very difficult clinically.
2.6 Increased incidence of common bile duct stones after cholecystectomy
In the treatment of common bile duct stones, it is easy to see that: in cases of common bile duct stones without gallbladder removal, the stones are mostly excreted from the gallbladder, and their symptoms and nature (cholesterol-based) are similar to those of gallbladder stones, which are garnet-like or mulberry-shaped, i.e. secondary common bile duct stones; whereas in cases of common bile duct stones with gallbladder removal, the nature of the stones is mostly bile pigment stones, and their shape is mostly cast, cylindrical, square, silt-like and bullet-like. square, mud-like and bullet-shaped, which are called primary common bile duct stones. When analyzing the causes of primary stones, one of the most important doctrines is the principle of “hydrodynamics”. After removal of the gallbladder, the gallbladder loses its buffering effect on the fluid pressure in the bile duct, resulting in an increase in pressure in the common bile duct, causing compensatory dilation of the common bile duct, which in turn slows down the bile flow in the common bile duct and causes vortex or eddy flow, the latter being an important doctrine for the formation of gallstones. In 795 cases of common bile duct stones in our institution (confirmed by ERCP and EPT), the group of resected gallbladder cases was significantly higher than the group of unresected gallbladder (425:370). In this way, cholecystectomy for gallbladder stones avoids the risk of “recurrence” of gallbladder stones after surgery, but invites the scourge of “growing common bile duct stones”; which stones are the most dangerous? It is self-evident which is more important.
To sum up, there is a world of difference between bile preservation and bile cutting in the treatment of gallbladder stones, and the physiological function of the gallbladder is preserved by bile preservation in the inner realm; bile cutting loses the gallbladder and its physiological function, which can cause a series of physiological disorders and even the possibility of colon cancer; the recurrence rate of gallbladder stones after bile preservation surgery is not high, which has been revealed and confirmed by modern clinical practice ( 2%~7%). The cholecystectomy procedure is very safe, and it is impossible to have those comorbidities of cholecystectomy, and so far there is no mortality. After removal of the gallbladder, of course, there is no possibility of recurrence of gallbladder stones; however, it raises the risk of increased incidence of common bile duct stones; however, the clinical risk of common bile duct stones is much higher than that of gallbladder stones, so which one is cost-effective? With the development of modern medical science and technology, there is a better understanding of the gallbladder as an important digestive organ, which is a complex organ with chemical and immunological functions, in addition to its role in concentrating, contracting and regulating the pressure of the bile duct. It is not a dispensable gallbladder, but a very important digestive organ, so it should not be easily abolished! Of course, for those who have an atrophied gallbladder, whose gallbladder is no longer functional, or whose gallbladder is suspected to be cancerous, the gallbladder should undoubtedly be removed to remove the lesion.
In conclusion, in the 21st century, when science and technology are highly developed, and 100 years after the gallbladder removal theory proposed by Langenbuch, it is worth seriously debating to re-conceptualize “this theory”, if by analogy with this theory, should any organ with stones be removed? Today, such a proposition seems too cruel, too pessimistic, too foolish and too simple. Does it mean that if there is a stone in the kidney, the kidney should be removed and if there is a stone in the bladder, the bladder should be removed? Obviously not. It is true that we should not blame the old Langenbuch 100 years ago, the old theory was undoubtedly limited by the technological conditions of the time, and there is no denying it. However, it is unbelievable that our modern doctors are still not asking why and insisting on the old views as late as the 21st century. China’s famous biliary surgery master Huang Zhiqiang academician far-sighted, recently the Journal of Gastrointestinal Surgery “gastrointestinal surgery to meet the 21st century” in the editorial pointed out [13]: “surgical culture” of “myopia The “myopia” of “surgical culture” is the “knife-onlyism” of surgery; “rejection of endoscopic realm”; “rejection of interventional medicine”, etc.; and calls for. “a traditional surgeon in the face of the new tide of medical revolution, whether to hold fast to the position or to a conceptual change”? “Of course, a conceptual shift must bring some sense of loss”. This is an important question to welcome the arrival of the 21st century, and I think the answer should be the latter.