For more than 100 years, cholecystectomy, especially laparoscopic cholecystectomy and mini cholecystectomy, which have been rapidly developed in the past 20 years, has been considered the “gold standard” for gallbladder stone treatment. However, with the continuous progress of medical technology and medical philosophy, various gallbladder stone removal procedures represented by mini cholecystolithotomy (MC) are gradually carried out in hospitals at all levels with better results, thus posing a strong challenge to traditional cholecystectomy.
At present, the debate about whether to adopt “bile preservation” or “cholecystectomy” for gallbladder stones is very intense. In this debate, patients are seeing a sense of responsibility and growing hope from surgeons regarding “bile preservation” or not.
The focus of the debate – stone recurrence
The traditional concept is that the cause of gallbladder stones is the result of multiple factors, such as the change of bile composition, gallbladder movement dysfunction, infection and mucin secretion, etc. Although the stones are temporarily removed after gallbladder incision and extraction, the hotbed of stone formation – “pathological gallbladder” – is retained. “. The adhesions around the gallbladder after cholecystotomy for stone extraction undoubtedly increase the obstacle of gallbladder movement and affect the emptying of the gallbladder, as well as increase the infection factor. Therefore, the recurrence rate of gallstones after incision and extraction is very high, resulting in high social cost of reoperation.
On the other hand, the recurrence of gallbladder stones on the “biliary” side is mainly due to the limited technical means in the early stage, and the old cholecystostomy is a blind stone extraction. The operator could not see the real situation inside the gallbladder, and inevitably the stone was crushed and the debris was missed, and when it grew slowly, the stone was mistakenly considered as “recurrence”, which was actually “intraoperative leftover” and “residual”. The stone is mistakenly thought to have “recurred” and is actually “left over” and “residual”.
However, “endoscopic minimally invasive choledocholithotomy” overcomes the blind spot of the old choledochostomy and avoids “stone leakage” during choledochostomy, which can achieve intraoperative stone removal and clear bile cyst duct patency, truly reducing the “stone recurrence rate” after fistulotomy. The “stone recurrence rate” (<10%) after fistula is really reduced. In addition, if the postoperative period is supplemented with a period of combined Chinese and Western, anti-inflammatory and biliary to promote inflammation subsidence and gallbladder function recovery, the chances of stone recurrence can be further reduced.
The recurrence rate of gallbladder stones after cholecystectomy varies widely, ranging from 0.78% to 44%. I personally believe that this may have a lot to do with the grasp of the indications for surgery, personal constitution, stone genesis and postoperative treatment and conditioning.
First of all, biliary preservation is a progress and improvement of philosophy. I believe that the “hotbed theory” and “pathological gallbladder” proposed 100 years ago have great historical limitations. Cholesterol stones or mixed stones are closely related to lifestyle habits, dietary structure, lipid levels and other systemic factors. In a sense, these gallbladder stones are a systemic disease. The gallbladder is not the culprit, but also the victim, and the cause cannot be blamed exclusively on the gallbladder itself.
This has something in common with urinary stones. Urological stones are often a systemic metabolic disorder, and the urinary tract is only vicariously involved, and the treatment is based on stone extraction and removal. Why, then, does the gallbladder have a different fate? Perhaps it has to do with the philosophy of surgeons for more than 100 years, who believe that stones are produced by the pathologically altered gallbladder and that there is no risk or danger in removing the gallbladder;
In clinical practice, they have been forcibly instilling in patients the false message that it is okay to have the gallbladder removed and that they will get used to it after a while, resulting in millions of gallbladders being removed every year. The gallbladder is an organ created during the evolution of human beings and has a strong digestive function. Many patients who have had their gallbladders removed have had their quality of life reduced to varying degrees, often suffering from bloating, loss of appetite and persistent diarrhea.
In my opinion, usable gallbladders, gallbladders confirmed to be free of deformities or malignant changes, such as those with contractile function, confirmed benign polyps, patent cystic ducts and normal gallbladder morphology are preservable gallbladders. Strictly grasp the indications, improve the living and eating habits, and supplement with intermittent application of cholestatic drugs can effectively reduce the recurrence after biliary lithotripsy.
The second point of contention – the size of trauma
Opponents of biliary preservation believe that cholecystectomy has a history of more than 100 years, and its benefits far outweigh the disadvantages in long-term clinical application. In particular, the widespread use of LC has made minimally invasive and safe treatment available to more than 95% of patients with gallbladder disease. Although, MC has the advantages of small incision, light trauma, short hospital stay, low cost and few complications. This is consistent with the advantages of LC, but LC is superior in terms of operation and operation time.
On the other hand, the “bile preservation” side believes that “bile preservation” really reduces the trauma and simplifies the surgery, and also preserves the functions of the gallbladder, such as bile storage, bile concentration, secretion and gallbladder-sphincter reflex function.
So, what is minimally invasive and what kind of trauma is considered less invasive? In my opinion, the concept of minimally invasive should not be defined by the size of the incision, and the only criterion to distinguish minimally invasive and major invasive should not be open surgery or closed perforation, but the key should be the degree of damage to the organ function for evaluation. Therefore, the true concept of minimally invasive should be to maintain the best stability of the internal environment and to exchange the best treatment effect with the least organ damage. Therefore, there is a world of difference between bile preservation and bile cutting in terms of trauma to the human body, and preserving the physiological function of the gallbladder is the real minimally invasive.
The gallbladder is the place where bile is stored in the human body, just like a reservoir, constantly storing and concentrating the bile secreted by the liver, and when eating, the gallbladder discharges the concentrated bile into the duodenum through its own contraction to help digest fat. After removal of the gallbladder, the physiological disorder caused by the lack of effective regulation of bile. At this time, bile will continue to enter the duodenum while not getting enough bile to help digestion when eating, thus leading to the appearance of indigestion symptoms, such as abdominal discomfort, bloating and diarrhea.
The third point of contention – surgical risks and post-operative complications.
In terms of surgical risks and post-operative complications, biliary preservation definitely has the absolute advantage. Opponents of biliary preservation emphasize that medical technology and surgical techniques have developed to the point where open or laparoscopic cholecystectomy is a breeze, and postoperative gallbladder function can be partially compensated by bile duct dilatation.
However, in practice, it is not uncommon to see serious conditions such as hemorrhage, bile duct injury, or even death during cholecystectomy surgery, and postoperative complications are numerous. After cholecystectomy, although the bile ducts are compensated by widening, can they compensate for the gallbladder’s functions of storage, concentration, and timely bile discharge? The answer is no. Moreover, the widened bile duct can cause disturbance of bile excretion kinetics, which can easily form vortex and reflux and repeatedly irritate the bile duct wall and form chronic inflammation, thus increasing the chance of developing bile duct stones.
Complications of cholecystectomy
1, indigestion, abdominal distension and diarrhea: the gallbladder has the functions of storage, concentration of bile, contraction, complex chemical function and immune function. Bile is secreted by hepatocytes through capillary bile ducts, small bile ducts, left and right bile ducts, common hepatic ducts, along the cystic duct, into the gallbladder for storage and concentration. The concentrated bile is 30 times more concentrated than hepatic bile and is reserved for high-fat meals before being discharged into the intestine to participate in digestion.
If the gallbladder has been removed, here the liver bile from the liver discharge can not be stored, regardless of whether the body needs, but continuously discharged into the intestinal tract; to go to the banquet to eat sorghum thick taste, the urgent need for a lot of bile to help consume, but unfortunately at this time the body has no “surplus bile” to help, the body has to tolerate indigestion, bloating diarrhea suffering.
2.Gastric reflux of duodenal fluid after cholecystectomy, reflux of gastric fluid esophagus: some patients have duodenal fluid reflux after cholecystectomy (DuodenogastricRelux, DGR) and gastric fluid reflux. The mechanism: loss of bile reserve function after cholecystectomy, resulting in intermittent and feeding-related excretion of bile into the duodenum on a continuous basis, which increases the chance of reflux into the stomach and produces DGR leading to bile reflux gastritis or esophagitis; the tone of the broad muscle at the lower end of the esophagus decreases significantly.
3. The incidence of colon cancer is significantly higher after cholecystectomy. It was found that the risk of colon cancer after cholecystectomy was 45 times higher than that of cases without cholecystectomy. It is generally believed that the mechanism of promoting colon cancer after cholecystectomy is that more bile circulation after cholecystectomy affects the degradation of bacteria, resulting in higher content and proportion of secondary bile acids in the liver salt pool. And secondary bile acids have carcinogenic or synergistic carcinogenic effects, and colon carcinogenesis occurs intentionally; while other studies believe that it is the change in the quality and quantity of bile after cholecystectomy that is the main cause of colon carcinogenesis.
4.Post cholecystectomy syndrome. In the past, this term was only a vague concept, but with the progress of modern diagnostic imaging technology, the diagnosis of residual stones and bile duct injury after biliary surgery has been excluded, and only the inflammation and dyskinesia of Oddi’s dilator muscle after biliary surgery can be called postoperative syndrome. The treatment of this symptom is very difficult clinically.
5. The incidence of common bile duct stones is increased 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 discharged from the gallbladder, and their shape and nature (cholesterol-based) are similar to gallbladder stones, pomegranate-like or mulberry-shaped, which are called secondary common bile duct stones; while in cases of common bile duct stones with gallbladder removal, the nature of the stones are mostly bile pigment stones, and their shapes are mostly cast, cylindrical, square, silt-like and bullet-shaped. The stones are mostly cast, cylindrical, square, silt-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 cushioning 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 theory for the formation of gallstones.
Therefore, cholecystectomy for gallbladder stones avoids the risk of “recurrence” of gallbladder stones after surgery, but invites the scourge of “growing common bile duct stones”.
6, gallbladder resection leads to bile duct damage. Due to the many variations of gallbladder triangle bile duct and blood vessels, and the influence of local tissue adhesions, injuries to the right hepatic artery, right hepatic duct, common bile duct, common hepatic duct and gastrointestinal are very common, especially bile duct injuries. Academician Huang Xiaoqiang once counted 2566 cases of common bile duct injury, 1933 cases were caused by cholecystectomy, accounting for 75% of stenosis cases.
China’s annual gallbladder removal more than a million cases, so that every year so that there will be thousands of cases of bile duct injury every year. The complication of bile duct injury is a very difficult problem in biliary surgery, and has a certain mortality rate. Professor Pan Cheng’en of the First Affiliated Hospital of Xi’an Jiaotong University has mentioned more than once that bile duct injuries can be catastrophic and cause “lifelong disability” to patients. Endoscopic bile stone extraction is performed inside the gallbladder cavity without separating the gallbladder triangle, so there are no complications as mentioned above.
Therefore, I believe that as a surgeon, we should update our knowledge and philosophy, put people first, and think more about the patients. For those who have negative fatty meal test of gallbladder, basically normal gallbladder morphology (no atrophy in size, no distortion in morphology, no stenosis or occlusion of gallbladder duct), and no stone embedded to form Mirizz syndrome, especially those who are younger (under 45 years old) I advocate gallbladder preservation and stone extraction. However, if the gallbladder is no longer functional (positive lipid meal test), the morphology of the gallbladder is obviously abnormal, and malignancy cannot be excluded, the gallbladder should be removed.