Gallstone disease is a common and frequent disease in China and can occur in the biliary tree (intrahepatic bile duct? common hepatic duct? The gallbladder and common bile duct), and can occur either singly or in multiple locations, or in combination with multiple stones. Traditionally, it is usually treated by caesarean section, but due to the large trauma and slow recovery of the patient after surgery, the medical community has been studying minimally invasive treatment methods in recent years. After years of efforts, the current minimally invasive treatment method is endoscopic surgery based on flexible endoscopy (choledochoscopy, duodenoscopy) and laparoscopy (laparoscopy), also known as “triple mirror combination”, which is the research direction of minimally invasive treatment for gallstone disease. This paper discusses several controversial issues in the selection of treatment modalities, as the operators have different degrees of familiarity with the mirrors, and there are many combined modalities.
I. The “retention” of the gallbladder
Gallbladder stones are a very old disease, and epidemiological data show that the incidence of gallstone disease is higher in Western countries. For example, gallstone patients in the United States account for about 10% of the total population, while Germany is about 10%-15%. The overall detection rate of cholelithiasis in China is 6.6%, and the detection rate fluctuates between 3% and 11% in different regions, including 10.7% in Shanghai and 17.79% in Hefei, but this figure is somewhat lower than the 21.5% incidence of cholelithiasis in North American Indians.
It is such a high prevalence disease that has created the prevalence of laparoscopy today, but today, when laparoscopic cholecystectomy (LC) is commonly performed nationwide and even worldwide, there is a faint voice crying out: preserve the functioning gallbladder! This voice, though small, cannot help but cause us to think: should the gallbladder be preserved or not?
Reviewing numerous scientific literature, the treatment methods for gallbladder stones are summarized as the following six: ① open surgery to remove the gallbladder (OC); ② laparoscopic removal of the gallbladder (LC); ③ bile preservation and lithotripsy; ④ drug lithotripsy; ⑤ herbal lithotripsy; ⑥ herbal lithotripsy after shock wave lithotripsy? Among them, the only three procedures involving surgery are OC, LC and biliary lithotripsy. In essence, there is no difference between OC and LC, so obviously the “retention” of the gallbladder we are talking about is a game between “OC/LC” and “biliary lithotripsy”. It is clear that the “retention” of the gallbladder we are talking about is a game between “OC/LC” and “gallstone extraction”.
From the mainstream voice in China, there are more people who advocate “going” the gallbladder for many reasons, while fewer people advocate “staying” the gallbladder, but their advocacy is not without reason. What is the crux of the problem? The history of surgical treatment of gallbladder stones is important to understand.
In 1867, when Bobbos accidentally dissected the gallbladder to remove stones during the removal of an abdominal tumor with good results, gallbladder dissection and lithotripsy became rapidly popular, but the high recurrence rate of stones over the next decade or so eventually led to the elimination of the procedure. About 15 years later, Langenbuch (1882) successfully performed the first open cholecystectomy (OC), and the treatment of gallbladder stones entered a new period that continues to this day; the surgical approach and technique of OC remained unchanged during more than 100 years of clinical practice. However, in the 1980s, with the development of technology in other disciplines such as electronics, traditional cholecystectomy was challenged: Dr. Mouret first used laparoscopy to remove the gallbladder in 1987, Dbois was the first to perform cholecystectomy under televised laparoscopy in 1988, and Zuwu Xun et al. alone performed the first case of LC on the mainland in 1991. after nearly 20 years of development, the treatment of gallbladder stones entered a new period of minimally invasive treatment: the popular period of LC surgery.
During the above process, did anyone think of keeping the gallbladder? Yes. In China, Prof. Zhang Baoshan of Peking University proposed the procedure of “biliary stone extraction” in the hope of preserving the gallbladder. However, even though Professor Zhang has 15 years of research data, his voice is not loud enough in the industry, or at least not enough attention has been paid to it. In fact, I believe that the “retention” of the gallbladder reflects the surgeon’s return to the evidence-based treatment of gallbladder stones.
Under the guidance of laparoscopy, a small incision is made in the abdominal wall to pull out the gallbladder, cut open the bottom of the gallbladder, clean the gallbladder with a choledochoscope to remove stones or polyps, and then close the gallbladder to achieve the purpose of “keeping” the functional gallbladder. Obviously, choledochotomy was based on the widespread use of endoscopy and the surgeon’s extended field of vision before realizing that we could keep a functioning gallbladder.
Although many surgeons knew that removing the gallbladder to treat gallbladder stones was not physiologically correct, it was used as a last resort around the world in the absence of a good solution. Now, with new technologies such as choledochoscopy and laparoscopy, why not consider leaving the gallbladder in place? It’s not technically difficult! The treatment of gallbladder stones should be a “go and stay” situation. Philosophically, the development of things from one extreme to the other, and then back to the middle, is discriminatory and in line with the “middle way” of traditional Chinese culture.
While we accept that the gallbladder “goes and stays”, the recurrence rate of stones is indeed a problem that we must face. According to Prof. Zhang Baoshan’s experience, if the recurrence rate of stones can really be reduced from 80% in the early stage to less than 10% now, it will undoubtedly be a blessing for young patients who are eager to keep their gallbladders. Of course, under the premise of strict indications and standardized surgical requirements, further multicenter randomized controlled clinical studies in accordance with the requirements of evidence-based medicine is a task for the future period.
II. Choice of treatment modality for extrahepatic bile duct stones
Whether primary or secondary stones, extrahepatic bile duct stones account for up to 20.1% of gallstone disease. The repeated discharge of these stones may cause infection by obstructing the bile duct, or combined with papillary inflammatory stricture, or complicate with biliary pancreatitis, which is extremely harmful. For many years, clinicians have adopted open exploration to retrieve stones for treatment, which not only results in long hospital stay and great injury, but also easily leaves residual stones, and the incidence of residual stones is reported to be up to 10% in the literature. Although intraoperative cholangiography, postoperative T-tube angiography, and even choledochoscopy for repeated stone extraction have been adopted to reduce the incidence of residual stones, they are still very traumatic to patients, painful to patients, and do not conform to the principle of minimally invasive treatment. Therefore, clinicians have been looking for treatment methods to reduce the rate of residual stones and reduce trauma.
In recent years, due to the improvement of duodenoscopic Retrograde Cholecystectomy (ERCP) and Endoscopic Sphincterotomy (EST), as well as the development of related materials (lithotripsy basket, lithotripsy mesh, nasobiliary drainage tube, etc.), the combined use of the “triple scopes” has become a major factor. The combined use of “triple scopes” in the treatment of extrahepatic bile duct stones has received increasing attention. For extrahepatic bile duct stones, there are two types of minimally invasive treatment depending on the type of lumpectomy used: (1) Laparoscopic CommonBileDuctExploration (LCDE) with intraoperative choledochoscopic stone extraction, which is a combination of laparoscopy and choledochoscopy; (2) Duodenoscopic stone extraction (ERCP+). EST).
There are no rigorous controlled studies on the size of the trauma of the two modalities, but they should both be minimally invasive procedures, and operators often choose according to their preference and familiarity. In the author’s opinion, with the increasingly mature experience of therapeutic ERCP and the application of liquid electrolysis, hepatobiliary surgeons should consider using duodenum more often for extrahepatic bile duct stone removal.
III. Treatment options for gallbladder stones combined with common bile duct stones
In most cases, gallbladder stones combined with common bile duct stones are secondary stones. In the past, these patients were still treated by OC plus common bile duct exploration, but now there are two types of treatment for these patients: (1) LC+LCDE, in which the gallbladder is removed laparoscopically and the common bile duct stones are removed with the help of choledochoscope; (2) duodenoscopic extraction of common bile duct stones (ERCP+EST), followed by nasobiliary drainage (ENBD) after surgery, and then LC after 3 days.
Both of these procedures are also minimally invasive, and the latter is mostly used in the hospital where the author works. Of the nearly 100 cases of stone extraction performed in 2007, only one case was forced to undergo a dissection of the common bile duct for the purpose of treatment, and the average length of hospital stay was within 7-10 d. The response was good. In the actual operation, there was a controversy in China whether to perform ERCP or LC first. However, from our experience, the essence of the problem is the mastery and familiarity of duodenoscopic techniques. If one is more confident in the management of stones in the common bile duct, this issue need not be a special concern. However, the author still recommends that ERCP be done first, and if the stone cannot be successfully removed, laparoscopic common bile duct exploration or surgical exploration can also be performed; after all, patients are not willing to go to the operating table twice.
Among them, our experience with the LCDE procedure is that for cases with a common bile duct diameter greater than 10 mm and clear stones, the therapeutic effect after surgery is ideal; for cases with a common bile duct diameter of about 15 mm, after the stones are removed by choledochoscopic exploration, those who can indeed exclude residual stones are repaired with absorbable sutures in a single visit to the bile duct, which also eliminates the pain of placing a T-tube in the patient. However, in cases with multiple gallbladder stones, changes in the diameter of the common bile duct (suggested by ultrasound) of about 6 to 10 mm, recurrent biliary colic or transient jaundice, and suspicious stones on imaging, the following situations may occur if the LCDE procedure is used: (1) the diameter of the common bile duct is too small, causing biliary tract injury during surgery and postoperative biliary tract stricture; (2) the T-tube is placed for a long time (at least 3 months) to prevent biliary tract stricture after surgery. (3) it is difficult to enter the lower end of the choledochus, which is relatively narrow, and it is easy to cause irregular contusions of the biliary mucosa and sphincter muscle; (4) the choledochoscope cannot enter the lower end of the choledochus, and the basket cannot be opened to retrieve the embedded stone, and too violent operation may cause stellate tearing of the duodenal papilla, bleeding or The choledochoscope cannot access the lower end of the common bile duct to retrieve the embedded stone, and too violent operation may cause serious surgical complications such as stellate tear of the duodenal papilla, bleeding or duodenal perforation. The use of ERCP+EST can avoid these embarrassments and risks, especially in patients with residual or simple common bile duct stones after OC or LC, and can be considered as a minimally invasive endoscopic surgical treatment based on “ERCP+EST”, which is a further broadening of the indications for exploratory choledochal surgery. In addition, the endoscopic surgical management of papillary lesions caused by microcrystallization of bile is more reasonable. Of course, a randomized controlled clinical study with a large number of cases is needed to further evaluate the advantages and disadvantages of “laparoscopy + choledochoscopy” versus “laparoscopy + duodenoscopy” in patients with gallbladder stones combined with common bile duct stones.
IV. Choice of three scopes in the treatment of intrahepatic bile duct stones
Intrahepatic bile duct stones are stones that occur proximal to the confluence of the left and right hepatic ducts, and their clinical manifestations vary depending on the location of the stone and the comorbidities. in the first half of the 20th century, this disease was common in Asia, accounting for approximately 4% to 50% of gallstone patients in that region. It is common in young and middle-aged men between 30 and 50 years of age, and its development may be related to parasitic infections (biliary roundworms or liver flukes) and secondary biliary inflammation. In contrast, in Western countries, it is more often associated with Caroli syndrome, biliary strictures of various causes, biliary stasis or infectious diseases. Stones often occur in the left outer lobe, right posterior lobe, unilaterally or bilaterally. If the stone is not discharged, although mild patients may be asymptomatic for a period of time or feel only dullness and vague pain in the affected liver area, or manifestations of limited cholangitis, but as the stone grows and expands, or when the stone discharge causes larger bile duct obstruction, manifestations such as obvious cholangitis and siltation upstream intrahepatic infection may appear, similar to extrahepatic bile duct stones. If the stone fills and casts in the bile duct for a long time, it will lead to liver abscess, fibrosis or atrophy of liver tissue, and thus develop into biliary cirrhosis, in addition to limited bile duct stenosis and proximal bile duct dilatation due to siltation and repeated inflammation. The choice of treatment for this group of patients is slightly different from that for extrahepatic bile duct stones. According to the experience of Academician Huang Zhiqiang, the “16-word policy” should be followed (remove the lesion, remove the stone, correct the stricture, and clear the drainage), and of course, the measure of “prevention of recurrence” should be added.
Due to the complexity of intrahepatic bile duct stones, especially certain complex stones, more stones inside and outside the liver can easily lead to acute obstructive suppurative cholangitis (AOSC), which threatens patients’ lives. There are three key aspects in which triple scopes can intervene: (1) regarding yellowing reduction and bile duct drainage patency; (2) lithotripsy; and (3) stricture correction.
Regarding the reduction of yellowness, some authors advocate that emergency PTBD (Percutaneoustranshepaticbiliarydrainage) is preferred over emergency laparoscopic exploration or ERCP, on the grounds that ENBD under emergency biliary exploration or ERCP often results in incomplete bile duct decompression without complete treatment. However, in the author’s opinion, ERCP and ENBD should be preferred, and with the assistance of skillful guidewire guidance techniques, any area that can be reached by the guidewire can be effectively drained. Regarding nasobiliary duct drainage, Li Wen of Tianjin People’s Hospital and Gong Biao of Shanghai Ruijin Hospital have good clinical exploration in the modification and shaping of nasobiliary ducts produced by Boston, and their experience in the management of complex intrahepatic bile duct stones and strictures after liver transplantation can be used as a reference. The attempt of Yuan Xinggui et al [7] to perform EST in laparoscopy for the treatment of cholelithiasis and choledocholithiasis has the same effect as the intraoperative LC and common bile duct stone extraction that we had performed in our hospital. Such a combination of two scopes can be done under a single anesthesia and can effectively drain patients with jaundice caused by stone obstruction, which is worth further exploration.
For intrahepatic bile duct stone extraction, percutaneous transhepatic choledochoscopy is very difficult due to the restriction of the PTBD sinus tract and the often accompanying biliary strictures. If adequate drainage of the bile duct is performed first and the cholangitis is effectively controlled, we advocate laparoscopic biliary exploration with an indwelling T-tube to establish choledochoscopic access for late choledochoscopic fluid electrolysis. The author has performed nearly 20 similar procedures, and almost all stones in grade 2 to 3 bile ducts were effectively removed. However, the prerequisite is that a large papillary sphincter dissection is performed during ERCP drainage to ensure patency of the common bile duct opening and to facilitate the discharge of small stones after lithotripsy. Therefore, the order of the triple-scope combination should be duodenoscopy, laparoscopy, and choledochoscopy.
As for the strictures present in certain intrahepatic bile ducts throughout the treatment, if they are relative strictures, hydrocystic dilatation can be performed under duodenoscopy or choledochoscopy, and multiple plastic stents can be placed to support them after dilatation. However, this treatment is controversial and requires further study because it can also lead to local obstruction and biliary sludge accumulation. The reason why most hepatobiliary surgeons believe that intrahepatic bile duct stones require open surgery is also related to the lack of effective correction of strictures, which requires flexibility. In actual clinical work, we believe that open surgery should be performed when intrahepatic bile duct stones are associated with the following conditions: (1) stones with hepatic segmental or lobe atrophy; (2) stones with bile duct cancer; (3) stones with multiple stenosis or cystic dilatation of the peripheral intrahepatic bile ducts, which cannot be treated by endoscopic or radiologically mediated methods.
In conclusion, triple scopes are the three key technologies for minimally invasive treatment of cholelithiasis. Despite the sequential development of the three scopes, their varying levels, and the fact that for a long time they worked separately, after nearly 40 years of integration, especially driven by the demand for minimally invasive treatment of gallstone patients and the gradual deepening of the understanding of the specific pathophysiology of gallstone disease, the three scopes have become a whole, and their effective combined use has greatly improved the level of minimally invasive treatment of gallstone disease and made gallstone disease It has become the most promising disease for minimally invasive treatment, and one day no more open surgery. In our underdeveloped western region, the degree of mastery of triple-scope technology may be uneven for a particular hospital, and for a particular patient, the location of the stones and the patient’s general condition may also vary greatly, so there is a problem of rational selection of triple-scope. Rationality involves both the measurement of one’s own technique and the comprehensive consideration of the patient’s condition. In conclusion, minimally invasive is a trend, and triple scopes are worth trying and expanding, as minimally invasive treatment requires “no minimum, only minimum” trauma.