Biliary lithotripsy is a technique that has gradually emerged in the last decade. Since the beginning of its emergence, it has been widely and intensely debated in the academic community. The main focus has been on postoperative stone recurrence rates, indications for the procedure, and causes of stone recurrence. There is no high-level evidence-based medical evidence to give a clear answer to the “bile preservation” and “bile cutting” debate. It should be clear that “gallbladder preservation” is not only to preserve the gallbladder anatomically, but more importantly, to preserve the gallbladder functionally so that the preserved gallbladder can still perform its normal function. If the gallbladder loses its normal function, blind “gallbladder preservation” is bound to leave a legacy of recurrence of stones or other gallbladder diseases.
In 1882, Langenbuch, a German physician, performed the first cholecystectomy and proposed the famous “hotbed doctrine” for the treatment of gallbladder stones, which states that “the gallbladder is not removed because it contains stones, but because it can grow stones.” Since then, cholecystectomy has become the standard procedure for the treatment of gallbladder stones. After Eric Muhe performed the first laparoscopic cholecystectomy (LC) in 1985, LC became popular with patients worldwide for its minimal trauma and quick recovery. In the early 1990s, laparoscopic techniques were introduced to mainland China and soon flourished in China. According to the results of a nationwide survey organized by the Biliary Surgery Group of the Chinese Medical Association in 1994, patients with gallbladder stones accounted for 11.5% of general surgery inpatients during the same period. This shows that the volume of LC surgery in China is huge. While LC is developing rapidly, many patients with mild or even asymptomatic gallbladder stones have had their gallbladders removed, and medically induced biliary tract injuries caused by LC occur from time to time.
In recent years, some experts have proposed choledocholithotomy, with special emphasis on the use of fiberoptic choledochoscopy to remove gallbladder stones while avoiding some complications of cholecystectomy. This article briefly discusses several focal points of biliary lithotripsy for readers’ reference.
1.The development of biliary lithotripsy
Biliary lithotripsy is not a newly emerged technique. Early biliary lithotripsy was mainly used for patients with acute calculous cholecystitis who had poor general condition, high surgical risk, or expected serious complications such as biliary tract injury and bleeding due to cholecystectomy. In this group of patients, gallbladder incision and stone extraction can be used to simplify surgery and reduce trauma, which can also be considered as an early application of the concept of “damage control” in the surgical treatment of gallbladder stones.
In the past 10 years, with the gradual maturation and widespread use of endoscopic technology, some hospitals have started to adopt the “new” choledochoscopy-assisted stone extraction, which is gradually gaining the attention of the academic community. Some scholars believe that the early biliary lithotripsy was forced to adopt the method of gallbladder preservation because the patient was not suitable for cholecystectomy, so it is called “passive biliary surgery”; the present biliary lithotripsy is to remove the stones while preserving the function of gallbladder, so it can be called “active biliary surgery”. “In 1980, Burhenne reported the percutaneous removal of residual stones from the common bile duct via the T-tube sinus tract. Inspired by this technique, Kellett et al. reported eight cases of percutaneous cholecystolith extraction in 1988. This is considered to be the first “active biliary surgery”.
According to the different periods of development of the surgical technique, “active biliary surgery” can be divided into “old-style biliary stone extraction” and “minimally invasive endoscopic biliary stone extraction”. The difference lies in the fact that “old-style” surgery mostly uses instruments and equipment such as stone extraction forceps, scrapers and hard mirrors to extract stones; “endoscopic lithotripsy” emphasizes the use of fiberoptic choledochoscope to enter the gallbladder for examination and treatment, which to a certain extent avoids the need for “old-style” lithotripsy. The “endoscopic lithotripsy” emphasizes the use of fiberoptic cholangioscope to enter the gallbladder for examination and treatment, which avoids some of the disadvantages of the “old” lithotripsy technique to a certain extent.
In conclusion, “endoscopic minimally invasive biliary lithotripsy” is an improvement and development of traditional biliary lithotripsy, which is very different from the traditional procedure in concept and practice, but whether it can achieve the good wish of “treating the disease and protecting the function at the same time”, there are still a lot of controversial issues in the academic field. There are still extensive and intense controversies on many issues, and even the “biliary preservation school” and “biliary excision school” with opposing views have been formed.
2.The recurrence rate of stones in choledocholithotomy
Kellett et al. summarized the results of the follow-up of 2053 choledochostomy cases published in 23 papers over a 36-year period from 1 to 19 years, and the recurrence rate of stones ranged from 0 to 83%, with a total recurrence rate of 34.6%. Donald et al. reported the results of the follow-up of 6 to 48 months after percutaneous cholecystectomy, and the recurrence rate of stones ranged from 7% to 44%, with a total recurrence rate of 31.0%. The total recurrence rate was 31.0%. Zou et al. reported that the 10-year recurrence rate was 41.46% in 439 patients who underwent cholecystectomy. Chen Pei et al. reported that the recurrence rate of stones was 39.3% and 39.7% at 5 years and more in 1058 patients who underwent biliary lithotripsy in Shanghai. Liu Jingshan et al.
showed that the recurrence rate of stones was 10.1% at 10 and 15 years after surgery. Shi Jianzhong et al.
reported a 4-year stone recurrence rate of only 3.1% in 97 patients after biliary lithotripsy.
This shows that the results of stone recurrence rates reported by different authors are very different. Although these clinical studies are somewhat different in terms of the surgical techniques used and the indications for surgery, is there a bias of the authors? Is there any difference in the treatment of missing data? These questions need to be answered by multicenter, large-sample clinical trials under the premise of uniform research standards.
3. Causes of stone recurrence
Some scholars believe that the main reason for recurrence of gallbladder stones after biliary lithotripsy is “intraoperative leftover and residual stones”, which is also the drawback of the old lithotripsy method; the whole procedure of new biliary lithotripsy is operated under choledochoscope, which overcomes the blind spot of the old lithotripsy operation and takes many measures to prevent recurrence, using a special lithotripsy net, which can The new biliary stone retrieval procedure is performed under the choledochoscope.
The stone retrieval network can be used to completely and thoroughly remove stones. In this way, the recurrence rate of stones 5-10 years after surgery is reduced from 30%-40% to 2%-4% or less; combined with postoperative treatment such as cholestasis, the recurrence rate of stones may be further reduced.
On the other hand, some scholars believe that stone recurrence “cannot be explained by stone residual alone. The results of a case-control study of 720 biliary lithotripsy cases showed that the causes of stone recurrence included body mass index, family history of gallbladder stones, and incidence of gallbladder constriction. This result suggests that stone recurrence may be related to the etiology of gallbladder stones and the surgical indications for biliary lithotripsy. Theoretically, any factor that contributes to the development of gallstones may lead to stone recurrence after stone extraction, and the pathogenesis of gallstones will not be changed by gallbladder stone extraction. Therefore, research on the causes of stones should be emphasized, and we should not be stagnant in the treatment because the causes are unknown; nor should we be one-sided in emphasizing technology, while ignoring the systemic factors of stone recurrence, resulting in patients suffering from secondary surgery.
It is an indisputable fact in recent medicine that obesity and familial abnormalities of lipid metabolism belong to the category of metabolic syndrome. These two factors have been shown to be important in the recurrence of stones, and they confirm Langenbuch’s “hotbed theory” from an epidemiological point of view. Therefore, the “hotbed theory” is not completely obsolete today and is still one of the theoretical bases for the treatment of gallbladder stones. Han Tianquan et al.
In the view of reducing the recurrence rate, the indications for biliary stone extraction should be the absence of systemic factors leading to biliary cholesterol supersaturation, as well as the absence of nuclei in the gallbladder and factors leading to gallbladder bile stagnation.
4. Indications for choledocholithotomy
Elaine Lu summarized 317 clinical studies on biliary lithotripsy published in China as of March 2014, and found that the indications for surgery reported by each unit were very different. Many units listed “physical examination” and “asymptomatic gallbladder stones” as indications for biliary stone extraction. Other units believe that the indications for gallstone extraction should be: good gallbladder contraction and concentration function; smooth gallbladder wall with wall thickness <3 mm on preoperative ultrasound and CT examination<
span=””>; no atrophy of the gallbladder, etc. It is also considered to be an important factor in reducing the incidence of postoperative complications and stone recurrence rate. According to this indication, the 4-year recurrence rate of gallbladder stones reported in the literature was only 3.09%.
Some other scholars consider “filled gallbladder stones” as an indication for surgery, and have reported cases of 467 gallbladder stones being removed. In the literature, previous poorly contracted gallbladder is considered a contraindication. However, in some patients with poorly contracted gallbladder, intraoperative laparoscopic exploration shows that the inflammation of the gallbladder is not severe, and even if there are some adhesions, bile can still be preserved if the stones are removed and there is bile flow in the gallbladder duct after releasing the adhesions.
The above two categories of “indications” represent the two tendencies of the bile-preserving lithotripsy unit. For the first category of patients, is it possible to skip surgery and only follow up? This is a debatable question. For the second group of patients, is the evaluation of gallbladder systolic function strict? Is there regular follow-up and re-evaluation of gallbladder function after surgery? What are the results? Does it affect the recurrence of stones? All of these require further follow-up and careful analysis.
The ability to cure gallbladder disease with the preservation of the gallbladder is undoubtedly a great progress in medicine. However, it should be clear that “gallbladder preservation” is not only about preserving the gallbladder anatomically, but also about preserving the gallbladder functionally so that the preserved gallbladder can still perform its normal functions. If the gallbladder loses its normal function, blind “gallbladder preservation” is bound to leave a legacy of recurrence of stones or other gallbladder diseases.
5. Conclusion
For the treatment of gallbladder stones, the “Expert Consensus on Decision-making for the Treatment of Benign Gallbladder Diseases” officially released by the Biliary Surgery Group of the Chinese Medical Association Surgery Branch in 2011 has clearly pointed out that cholecystectomy is the standard procedure for benign gallbladder diseases, and LC should be the first choice. However, the increasingly widespread implementation of cholecystectomy in recent years has forced the academic community to make a scientific evaluation of this procedure. To summarize the above-mentioned issues, it is easy to see that there is a long-standing debate between the “biliary preservationists” and the “biliary excisionists”, and both sides are citing some literature in their favor to support their views. Since most of the existing clinical studies are retrospective empirical summaries with many confounding factors and biases, it is difficult to make an objective evaluation of this procedure. Even if there are some Meta-analysis articles, it is difficult to provide definite and reliable conclusions due to the low level of evidence of the original data. The Biliary Surgery Group of the Chinese Medical Association has initiated a multicenter prospective cohort study of laparoscopic gallbladder stone removal for the treatment of gallbladder stone disease, which is believed to provide a higher level of evidence than previous case reports.
In fact, whether or not the evidence from the “bile preservationists” is scientifically sound, it raises questions for the “bile cutters” to reflect upon. Are the indications for LC too broad, removing some functioning gallbladders? Is it possible that as the volume of LC procedures increases, there is a “slight” disregard for LC, resulting in medical bile duct injury? These questions are raised by the “bile preservationists” and are indeed a wake-up call for the “bile cutters”. Regardless of academic views, surgeons should strictly grasp the indications for surgery and implement the core values of minimally invasive surgery, i.e., removal of lesions, protection of function, and damage control, in a scientific manner.