Many famous biliary surgery scholars in China have mentioned that with such a large population and such a high incidence of gallstone disease, surgery alone cannot solve all the problems, especially in Western countries where biliary diseases are rarely as predominant as in China, where hepatobiliary stones are the most common. Therefore, we should develop a biliary surgery with Chinese characteristics, mainly gallstone disease, based on western modern medical methods. Chinese medicine has a long history of disease prevention and treatment, and has shown its unique advantages and roles in clinical practice and scientific research in the treatment of biliary diseases for thousands of years, especially in the last half century. Therefore, the combination of Chinese and Western medicine should become the development direction of gallstone disease prevention and treatment.
1.The status of Western medicine in the treatment of gallstone disease
Gallbladder stones are mainly treated by cholecystectomy in western medicine. With the development of endoscopic technology, people pursue the minimization of surgical injury and the optimization of treatment effect, the treatment of gallbladder stones, from traditional open surgery to small incision gallbladder stone extraction, to laparoscopic cholecystectomy, to endoscopic biliary stone extraction. This reflects not only the change in the understanding of the disease, but also the increasing humanization of surgical treatment.
Although, preserving organ function is the highest level of minimally invasive surgery, people still have doubts about biliary preservation surgery, mainly worrying about its recurrence. However, with the proficiency and experience of endoscopic biliary technology, the recurrence rate of biliary stone extraction will be reduced, and the procedure will be ideal both physiologically and psychologically due to the preservation of a functional gallbladder.
The classic principles of hepatobiliary stone treatment have always been “remove obstruction, drainage, stone extraction, and lesion removal” and “leave a back way” as proposed by Prof. Huang. So far, surgery is the most used treatment for hepatobiliary stone disease in clinical practice. Especially with the accumulation of clinical experience in liver surgery and the in-depth research on the anatomy, pathological anatomy and pathophysiology of liver surgery, many of the formerly considered forbidden areas of surgery have been broken through, and the surgical treatment of hepatobiliary stone disease has now reached a high level. The combination of advanced diagnostic tools, rational use of bile-intestinal anastomosis techniques, and active selection and implementation of regular hepatic lobectomy can lead to the radical treatment of limited intrahepatic bile duct stones.
In the past decade or so, the development and application of endoscopic and minimally invasive treatment techniques have greatly enhanced the ability to treat hepatobiliary stone disease, which has led to further improvement of clinical outcomes. The organic combination of percutaneous transhepatic bile duct, percutaneous transabdominal and transoral routes of endoscopic technology, making full use of the respective therapeutic features of choledochoscopy, laparoscopy and duodenoscopy, constitutes a minimally invasive surgical treatment system for biliary tract diseases mainly based on endoscopic technology. The anatomical structure of the biliary tract has proved to be suitable for minimally invasive treatment techniques.
However, due to many reasons such as the complexity and multiplicity of gallstone diseases, especially the stones affecting both intrahepatic bile ducts, and the ease of recurrence of stones in the residual chronic inflammatory hepatobiliary ducts after resection of the main lesions, a large number of cases are difficult to be completely cured. For these problems, it is obvious that the improvement of surgery, minimally invasive and interventional techniques alone is not yet a fundamental solution, and pharmacological treatment should be an important way to solve this series of problems. It is worth studying and discussing how to reasonably use TCM on the basis of surgery-based treatment [2].
2. Current status of Chinese medicine in the treatment of gallstone disease
In Chinese medicine, gallstone disease and the resulting acute biliary tract infection are considered to belong to the category of “dysthymia” and “jaundice”, and there are many classical prescriptions for this disease, such as Da Chai Hu Tang, Xiao Chai Hu Tang, and Yin Chen Artemisia Tang. In the past half a century, the Chinese medical science has been very active. In the past half century, Chinese and Western medical practitioners in China have been exploring and researching on the basis of the experience of their predecessors, and have done a lot of research on the dismantling, cutting and reorganization of classical prescriptions, and have made evidence and analysis from both experimental and clinical aspects, and have made many achievements, from basic research to clinical practice, proving the scientificity and effectiveness of Chinese medicine in treating this disease. So far, the main means of TCM treatment for this disease is the application of Chinese medicine.
Likewise, acupuncture and moxibustion, which are based on the principles of qi and blood and meridians in Chinese medicine, have been developed from thousands of years of experience and exploration. Clinical practice and experimental research have also proved that acupuncture treatment is effective in relieving smooth muscle spasm, regulating neurological and endocrine functions, and coordinating immune functions. With the development of modern technology, in the past two decades, many scholars have innovated and developed a series of physiotherapy devices and methods based on the principles of meridian acupuncture, making the implementation of this classical treatment method more scientific, controllable and effective.
The treatment of gallstone disease in TCM has always focused on “stone removal”, and hepatobiliary stones are more suitable for stone removal therapy than gallbladder stones. After decades of lithotripsy practice, it has been found that the effect of single Chinese medicine (or Chinese medicine compound) or acupuncture in lithotripsy treatment is relatively poor, and the improper selection of indications is a factor affecting the efficacy. Therefore, with the joint efforts of Chinese and Western medicine practitioners, “Total Attack Lithotripsy Therapy” was born.
Under the premise of scientific combination of Chinese and Western medicine and physiotherapy, and strict control of treatment indications, the effect of total attack lithotripsy for hepatobiliary stones has been greatly improved compared with the past. The “total attack lithotripsy” is the main comprehensive measure of non-surgical treatment of liver and bile duct stones with Chinese and Western medicine as the mainstay so far. However, during stone removal, some patients are in great pain, and there is a risk of complication of acute cholangitis.
Compared with modern Western medical treatment, Chinese medicine is still relatively primitive or in its infancy in the treatment of gallstone disease, especially hepatobiliary stones. However, the integrative and systemic coordinating potential of TCM in clinical practice has been gradually recognized.
Recent studies have revealed that TCM methods such as clearing away heat, activating blood circulation and removing blood stasis, and draining the liver and bile have considerable effects in controlling infection (including regulating systemic inflammation, protecting the mucosal barrier, immune regulation, etc.), protecting liver cells and promoting bile secretion to form intrahepatic bile duct flushing, changing the intrahepatic microenvironment, inhibiting fiber formation, reversing stone formation tendency, and preventing stone formation. This should be regarded as the advantage and potential of TCM, which needs to be practiced and explored in clinical and basic research.
3.The application of Chinese medicine and Western medicine minimally invasive techniques in the treatment of gallstone disease
The characteristics of the two treatment methods of Chinese and Western medicine. Let’s say that a piece of wood (liver) is moldy (stone), how would we deal with it? One is to remove the mold (stone removal) or remove the wood that has been partially decayed (partial removal of the liver); the second is to transfer the wood from a dark, damp environment to a dry environment, mold (stones) will naturally disappear. Western medicine currently treats gallstones like method one, and Chinese medicine treats gallstones like method two.
Obviously, a combination of both methods works best. Chinese medicine and Western medicine each have their own advantages in the treatment of gallstone disease. Western medicine has advantages in stone extraction and lithotripsy (treating the symptoms), while Chinese medicine has advantages in lithotripsy, lithotripsy and prevention of stone recurrence (treating the root of the problem), combining the advantages of both effectively (treating both the symptoms and the root of the problem) will greatly increase the cure rate of stone.
To sum up, in the treatment of gallstone disease, the advantages of Chinese medicine and Western medicine should be combined in a reasonable way, so as to make use of their respective advantages and complement each other’s shortcomings, thus improving the cure rate of gallstone disease. Therefore, we must focus on the following combinations:
①The combination of overall and local. We should realize that gallstone disease is a local manifestation of systemic disease, and grasp the adjustment of the systemic condition and the local treatment of hepatobiliary lesions, so as to correctly implement the diagnosis and treatment.
Combination of evidence and disease identification. Follow the different diagnosis and treatment rules and characteristics of Chinese medicine and Western medicine, fully utilize their respective advantages and complement each other’s shortcomings.
Combination of surgery and non-surgery. The combination of lithotripsy, lithotripsy, lithotripsy, and lithotripsy can be used to cure the disease with minimal trauma.
④The combination of treatment and prevention. The high recurrence of gallstone disease, especially intrahepatic bile duct stones, is limited to the current deficiency of Western medicine in the role of stone prevention and treatment. We should make use of the overall balancing and coordinating characteristics of TCM to explore the source to stop stone regeneration and disease recurrence.
In the application of Chinese medicine, we will choose different prescriptions and doses according to the patient’s different conditions and constitution (diagnosis and treatment), so as to achieve true individualized treatment, and firmly eliminate the phenomenon of one medicine for a thousand people and one medicine for ten thousand people. In this regard, we propose to choose different prescriptions according to the patient’s vitality and condition at the time: we do not recommend passive lithotripsy for patients with quiescent gallstones because it does not follow the trend of the human body, but should restore vitality and lithotripsy, highlighting the word “lithotripsy”. When the patient’s vital energy is restored, active stone discharge will occur.
After the stones are discharged or removed, we should continue to restore the level of vital energy and adjust the imbalance of the body to prevent the recurrence of gallstones. After the stones are discharged or removed, we should continue to restore the level of vital energy and adjust the imbalance of the body to prevent the recurrence of gallstones. In addition, it should be noted that for gallstones in the quiescent or draining stage, if we remove the gallstones through minimally invasive surgery, it will greatly reduce the consumption of gallstones on our body’s vital energy, which is very beneficial for us to restore our overall health level. Laparoscopic cholecystectomy should be preferred for gallbladder stones where the gallbladder has atrophied and where the gallbladder is no longer functional.
Based on the above points, we propose a stepwise program of minimally invasive treatment of gallstone disease by combining Chinese and Western medicine, which is summarized in 5 words: dissolve, drain, take, shatter and prevent, as follows.
This program still needs to be improved and developed in practice.