Since 1882, when lengenbuch pioneered cholecystectomy for the treatment of gallbladder stones, this procedure has become the standard of care for gallbladder stones in cholecystitis with its excellent therapeutic results. 37 years ago, Mouret first reported laparoscopic cholecystectomy (LC), which became the so-called “gold standard” for the treatment of gallbladder stones due to its strong advantages of minimal trauma and rapid recovery. “However, it is still a technical innovation of cholecystectomy, including the current robotic surgery, and is not a change of treatment principle. In the 7th edition of Huang Jia-Qiang’s Surgery, he states: “Except for choledochostomy for acute cholecystitis in emergency situations, the surgical treatment of gallbladder stones is the removal of the pathological gallbladder containing the stones and the appropriate management of extra-choledochal complications of the stones”. The principle of treatment for chronic calculous cholecystitis should be to remove the gallbladder lesions that have lost their normal function, which has long been a consensus at home and abroad. In 2011, the Biliary Surgery Group of the Chinese Medical Association, Chinese Medical Association, officially published the “Expert Consensus on Decision-making in the Treatment of Benign Gallbladder Diseases” (hereinafter referred to as the “2011 Consensus”), in which the basic principles for the treatment of benign gallbladder diseases are discussed, it is proposed that “cholecystectomy is the standard procedure for benign gallbladder diseases, and LC should be the standard procedure for benign gallbladder diseases. LC should be the first choice.” “The practical value of cholecystectomy needs to be further investigated, and at present it is only appropriate for emergency management under emergency conditions and not as a recommended procedure for elective surgery.” However, the flourishing of cholecystolithotomy (commonly known as “cholecystectomy”) in China in the past 10 years or so has posed a serious challenge to the traditional cholecystectomy. In some units, it has even become the procedure of choice. Many patients and physicians are confused by the controversy. With the growing desire to “remove the lesion while preserving the gallbladder” and the advent of new technologies and equipment, should the consensus principles of treatment for chronic cholecystitis and gallbladder stones be changed today? For such a common disease with a prevalence rate of 7% to 10% in China, should bile be preserved? Or should we cut the gallbladder? We reviewed 317 clinical studies on biliary stone extraction from four major medical scientific databases (CNKI, Wanfang, Vipshop, CMB) in China until March 2014 to investigate whether this procedure can replace cholecystectomy or also become one of the standard procedures for the treatment of gallbladder stones in chronic cholecystitis. In reviewing and analyzing the literature, the following major controversial issues have drawn the author’s particular attention. 1. whether biliary conservation surgery should be aggressively performed in asymptomatic patients with chronic cholecystitis gallbladder stones Academician Huang, when talking about the difficulties of biliary surgery in the 21st century, stated that the first difficulty, is that it seems easy [3]. The use of LC for gallbladder stones does seem easy, but this “ease” hides a great danger. Because of its “ease” and the surgical complications caused by its arbitrary implementation, biliary reoperation has become the most important abdominal surgical reoperation, and it happens that a seemingly anatomically simple operation results in adverse consequences such as patients not being allowed to undergo liver transplantation, disability, or even death. Therefore, many experts and scholars call for caution in performing cholecystectomy, especially for asymptomatic patients, and not to perform the procedure arbitrarily because it is easy to perform. For asymptomatic patients, the “2011 Consensus” specifically states in the “Basic Principles” that “asymptomatic gallbladder stones should not be removed indiscriminately, and those with non-specific gastrointestinal symptoms should be excluded first. Other diseases should be excluded”. This is in light of the fact that, “Based on follow-up of such patients for 20-30 years, 60% to 80% of patients are free of complications during the follow-up period.” The “2011 Consensus” also cites the literature that “patients with asymptomatic gallbladder stones are essentially a benign group with a mild course, and the need for prophylactic cholecystectomy should depend on an accurate assessment of the risk of prospective treatment.” It is proposed that “prophylactic resection or prospective treatment under regular follow-up can be performed for asymptomatic gallbladder stones, and prophylactic resection can avoid complications such as cholecystitis and pancreatitis secondary to stones, but at the same time increases the risk of the patient bearing the immediate and long-term complications associated with cholecystectomy.” However, we have observed in the national literature on biliary lithotripsy the problem of arbitrary implementation of biliary lithotripsy. Many reports include “asymptomatic gallbladder stones” as an indication for surgery. Some literature reported that the indications for surgery were “gallbladder stones in various conditions” [7], “only a feeling of fullness in the epigastrium after meals”, and “found on physical examination of the unit”, Some of them “had only postprandial epigastric distention”, “were found on unit physical examination”, and “were as young as 4 years and 3 months”, and all of them underwent biliary stone extraction; others did not mention any requirements regarding indications. Although the number of papers published up to March 2014 has reached 317 and the number of cases has reached 32090, which are 5.87 times (317/54) and 7.20 times (32090/4454) higher than the data reported by Wang Huiqun et al. 4 years ago in 2010, respectively, the exact follow-up conclusions regarding the recurrence rate of stones are still questionable from the analysis of the 317 papers (see later). It is evident that many surgeons have performed this procedure at their own discretion, without knowing the exact results of the procedure, because they believe that the technique is simple and feasible. In the opinion of these operators, because the technique of biliary stone retrieval is easy to master, it can be performed at will, and as long as there are stones it is an indication, even if there is a recurrence in the future, a short-term solution to some problems is possible. They do not take into account that surgery itself is an invasive procedure. When a surgeon considers the treatment strategy for a disease, the first thing to consider is whether the patient needs an invasive treatment like “surgery” to solve the problem, i.e., “why do it? The question of “why? Secondly, we should consider what kind of surgical option to choose in order to achieve the best treatment effect with the least trauma and the least cost, i.e., the question of “what to do”. Although gallbladder lithotripsy has its positive significance in preserving the gallbladder, it is still an invasive surgical technique, and the patient who undergoes the surgery also has to bear the risks of anesthesia accidents, bile leakage, gastrointestinal injuries, and other surgical complications. In this sense, it should be clear that patients who are asymptomatic and can be observed for a long time should not have their gallbladders blindly removed surgically; likewise, they should not have their gallstones removed arbitrarily. Whether for cholecystectomy or gallbladder lithotomy, it should be carefully selected and overtreatment should be guarded against. It should be a consensus and a basic principle for our surgeons to adopt any kind of surgical treatment for asymptomatic patients with benign diseases. As to whether long-term observation of asymptomatic gallbladder stones may cause delayed treatment of gallbladder carcinoma, this is another aspect of the problem. Our observation of gallbladder stone disease depends not only on the presence or absence of clinical symptoms, but also on regular dynamic observation of various biochemical and imaging diagnostic measures to consider the evolution of the disease and make timely decisions on whether surgery is necessary. This is not contradictory to the principle that “surgery should be performed cautiously for benign diseases”. 2. The question of whether the gallbladder should be removed and blind biliary preservation in patients with symptomatic chronic cholecystitis and gallbladder stones Gallbladder lithotomy is one of the treatment methods for symptomatic chronic cholecystitis and gallbladder stones, but its indications deserve our serious consideration. In fact, gallbladder lithotripsy is not an innovative technique, but has actually been tried for many years. After the discovery of the harm caused by gallbladder stones in cholecystitis, almost at the same time when cholecystectomy was applied to treat the disease, scholars were already exploring the possibility of eliminating stones and preserving the gallbladder by means of drug lithotripsy, lithotripsy, extracorporeal shock wave lithotripsy, etc., only to be gradually and naturally eliminated because of a large number of domestic and foreign randomized controlled studies confirming its poor therapeutic effect . The rise of endoscopic biliary lithotripsy technology has brought a boon to meet the patient’s wish of “eliminating the disease while preserving the gallbladder”, but this technology is still a technical improvement in the treatment of chronic cholecystitis and gallbladder stone disease by high technology means, and does not solve the fundamental problem of stone formation and future recurrence. This technique is currently used abroad mainly for emergency treatment of high-risk patients in emergency situations, followed by elective cholecystectomy to remove the lesion and bring the disease under control, while many scholars in China propose biliary preservation as an alternative to LC. According to the analysis of the literature, the feasibility of the following cases in particular needs to be carefully considered. One is the inflammatory histological changes in the gallbladder wall. There are no well-documented studies confirming that the mucosa of the gallbladder, which has developed significant inflammatory proliferative histological changes, can be completely normalized by stone removal; however, there are numerous studies confirming that chronic inflammation of the gallbladder tissue with atypical mucosal epithelial hyperplasia and long-term compression of the gallbladder mucosa by stones >3 cm in diameter may lead to carcinogenesis. Atrophic cholecystitis is a high-risk factor for the development of gallbladder cancer. In some units in China, there are “stones >3.6 cm”, “atrophic cholecystitis” and “gallbladder full of stones, more than 823” (it is difficult to imagine that such gallbladder can It is difficult to imagine that such a gallbladder can function well without histopathological changes of atypical hyperplasia of mucosal tissue), yet all of them were treated with bile preservation and stone extraction. The second is about the relationship between gallstone disease and metabolism, family history, and genetic inheritance. A joint study by Ruijin Hospital of Shanghai Jiaotong University School of Medicine and Karolins- ka Institute, Sweden [17] showed that cholesterol stone disease belongs to the category of metabolic syndrome and that abnormal lipid metabolism in the enterohepatic axis, including the hepatobiliary and small intestine systems, is an important part of stone pathogenesis, characterized by genes related to lipid metabolism (e.g., cholesterol transport protein-adenosine triphosphate binding cassette (ATP-binding cassette) in the lateral membrane of bile ducts). binding cassette (ABC) G5/G8, liver X receptor alpha (LXRα), which regulates its expression, and scavenger receptor B type I (SRB1), which is a nuclear receptor. In several clinical studies on gallstone preservation, there is a lack of detailed information on the presence or absence of family history of stone patients, as well as biochemical indexes such as lipid and cholesterol metabolism testing and whether metabolic function is abnormal. Some scholars who advocate gallbladder preservation believe that stone formation has nothing to do with the gallbladder and should be preserved, but do not take into account that in patients with gallbladder stones related to genetic and family history, abnormal cholesterol metabolism, etc., stones occur precisely because of abnormal cholesterol metabolism. Therefore, removing the stones from the gallbladder does not address the metabolic and other etiological issues, and the stones are still prone to recurrence. Therefore, these cases are not suitable for biliary preservation surgery. The formation of stones in the gallbladder has been shown to be associated with a decrease in the number of receptors for cholecystokinin (CCK), an important gastrointestinal hormone that regulates the motility of the gallbladder, as well as reduced receptor expression and signaling in the gallbladder wall. Therefore, it is not a coincidence that the gallbladder is the end organ of gallbladder stone disease and that resection of the diseased gallbladder can achieve definite therapeutic results. The third issue is the standardization of preoperative gallbladder function assessment. The preoperative assessment of gallbladder function is an important basis for the choice of treatment strategy for gallbladder stones in chronic cholecystitis. Most of the literature reports on biliary stone extraction include “good gallbladder function” and “gallbladder systolic function ≥ 30%-40% by B-ultrasound” as indications, while others report no clear method of gallbladder function assessment, lack of objective assessment criteria for homogeneity, and varying methods. It is difficult to assess the reliability and authenticity of “normal function” as described by the authors because of different methods and even sensory estimation. Currently, there are three main methods used to assess the systolic function of the gallbladder, one is oral cholecystography, which has been largely abandoned. The second is the nuclear 99Te and ETC scan, which requires special equipment and is not yet available in most primary care hospitals. The third is B-ultrasound, which is currently the most common method used in hospitals at all levels. It should be clearly pointed out that the criteria for determining gallbladder systolic function according to Ultrasound Medicine are: “(1) Good gallbladder systolic function: gallbladder emptying or shrinking >2/3 within 2 h after meal is normal. (2) Poor gallbladder contraction function: Gallbladder contraction <1/2 within 2 h after meal is considered suspicious. (3) Poor gallbladder contraction function: Gallbladder contraction <1/3 within 2 h after meal is abnormal. (4) No contractile function of gallbladder: 2 h after meal, gallbladder size is the same as fasting, if fasting gallbladder is < normal size, it mostly indicates severe lesion and loss of function, if gallbladder is enlarged, it indicates obstruction below the gallbladder." . In the modified B ultrasound 3D gallbladder function test and judgment criteria introduced by Jiang Zhaoyan et al, it is also stated that "the criteria for normal gallbladder function are gallbladder contraction rate (≥ 75%) and gallbladder wall thickness (≤ 3 mm). A decrease in gallbladder contraction rate or thickening of the gallbladder wall, either of which is not within the normal range, indicates abnormal gallbladder function". In the domestic literature on biliary stone extraction, many authors define "gallbladder contraction ≥ 30% 2 h after lipid meal" and "gallbladder wall thickness < 6 mm" as the criteria of "good function", which is inaccurate. It is inaccurate. In fact, they should belong to the category of "poor gallbladder function". In other words, although many units have listed "good gallbladder contraction" as an indication criterion in the enrollment criteria, the actual operation is to include patients with chronic cholecystitis and gallbladder stones who do not have good gallbladder function into the indication category of "gallbladder stone retrieval", which is This is not rigorous and incorrect. Fourthly, the issue of whether or not there will be missed detection of occult cystic duct cancer after removal of stones is particularly worrying. Occult cystic duct cancer is difficult to diagnose and treat early, and once the diagnosis is delayed and the treatment is not appropriate, the prognosis is poor. One of the important updates in the 7th edition of AJCC is the classification of cystic ductal carcinoma as gallbladder cancer. The prognosis of cholangiocarcinoma is relatively poor if the tumor invades the cystic duct. The AJCC 7th edition divided the lymph node metastasis of gallbladder cancer into two stations, N1 and N2. N1 is the lymph nodes in the hilar region (including common bile duct, hepatic artery, portal vein and cystic duct lymph nodes), while the lymph nodes in the celiac trunk, paraduodenal, peri-pancreatic and superior mesenteric artery are considered as distant metastasis (N2). Shirai et al. injected dye into the lymphatic duct of gallbladder to show the lymphatic drainage pathway of gallbladder and found that the lymphatic drainage around the common bile duct at station N1 could directly converge into the lymph nodes around the abdominal aorta and inferior vena cava at station M1, thus rapidly causing systemic spread and metastasis and turning the disease into stage IIIB and IVB. This is the pathological basis for the rapid development, high malignancy and difficulty of treatment of gallbladder cancer, especially bile duct cancer. The narrow cervical duct of the gallbladder is the site where stones can easily stay, rub, and become lodged, and has the highest probability of mucosal epithelial damage, which makes tumor development more likely. We should be vigilant when performing cholecystectomy, if the cervical duct is left too long, it is easy for the tissues that have already developed cancer to remain and metastasize rapidly along the lymphatic tract. Special attention should be paid to the pathological observation of the gallbladder neck tissue after surgery for early detection and implementation of remedial radical surgery. In the case of biliary stone extraction for stones embedded in the cervical duct of the gallbladder, it is impossible to obtain objective results of pathological examination after surgery, which will lose the opportunity of early detection and timely treatment. Therefore, for those who have stones embedded in the neck of gallbladder, we should not only focus on "seeing the flow of bile from the cystic duct" after stone extraction to confirm whether the cystic duct is open after surgery, but more importantly, we should be alert to and prevent the delayed diagnosis and timely treatment of gallbladder duct cancer. For example, it was reported that "16 cases of gallbladder cervical duct stones were embedded for a long period of time and the gallbladder was removed so that gallbladder stones could be removed. In the author's opinion, this type of treatment choice is against the principle. If the stone is embedded in the cervical duct of gallbladder, regardless of whether the bile can be seen to flow out from the bile duct after the stone is removed, biliary surgery should be contraindicated to prevent the leakage of gallbladder cervical duct cancer, which is a principle issue in treatment choice. 3, for the controversy of the treatment decision of gallbladder polyps whether gallbladder polyps are suitable for biliary preservation, it is worth to think carefully. In 1991, Wang Qiusheng classified gallbladder polyps detected by preoperative B-ultrasound into three categories based on the pathological findings of 100 surgically treated gallbladder polyps [28], and "2011 Consensus" provided clear instructions on the treatment decision of gallbladder polyps [2]. In the author's opinion, these recommendations based on long-term clinical studies are scientific, and biliary preservation should be performed with caution, given that the pathological nature of gallbladder polyps is difficult to determine preoperatively according to the current state of technology. There is a long-standing consensus on the standardization of technical operation regarding the surgical operation of cholecystectomy. In particular, the anatomy of the gallbladder triangle, the variation of bile ducts and blood vessels, especially when combined with portal hypertension, rich collateral circulation and large number of abnormal blood vessels in the hepatoportal area, the exposure of the LC operative field, the treatment of abnormal blood vessels, the electrothermal damage of various new surgical instruments and other series of problems should be paid special attention to avoid the serious side injuries caused by this inadvertence. There are still some technical details of biliary lithotripsy that deserve our close attention. Some authors have described the use of a pulling net to drag the gallbladder wall or even the neck of the gallbladder back and forth to retrieve stones. Other authors reported that the gallbladder neck is cut open to remove the stone and then sutured closed, will this operation invite stenosis of the gallbladder neck duct in the future? In some cases, if the stones are embedded in the neck of the gallbladder and cannot be moved, the stones are removed after lithotripsy with a pneumatic ballistic lithotripsy device, not to mention whether the stones are embedded in the neck of the gallbladder for a long period of time, which may lead to missed detection of possible carcinoma of the cystic duct. Will this escalate the problem that could be solved by LC to the need for additional bile duct exploration and extraction? There are also reports of "double gallbladder" after biliary lithotripsy (one case was also admitted to our hospital), the exact cause of which is unknown. The author believes that, from the perspective of the "precision surgery" concept actively advocated at present, the improper selection of indications for such cases is bound to be followed by improper technical operation and the potential risk of complications, which is not in line with the overall principle of obtaining the best results for patients with the least trauma and should be taken seriously for improvement. 4, the standardization of postoperative treatment The recurrence of stones is the most controversial issue in the prognosis of biliary lithotripsy. In Zhongshan Hospital of Fudan University, 792 patients whose stones disappeared after conservative treatment were followed up, and the recurrence rates were 11.6%, 22.3%, 24.5%, 36.4%, 39.3% and 39.6% for 1, 2, 3, 4, 5 and more than 5 years, respectively. Of the 67 studies with recurrence rates reported in 317 studies, 6519 cases were followed up and only 446 cases were found to have recurrence of stones. In the case of "white bile" and "pus accumulation in the gallbladder", biliary lithotripsy was forced to be performed. The "contraindications to surgery" listed in a "biliary lithotripsy protocol" stated that "stones in the gallbladder duct cannot be removed and are not expected to be removed after surgery"; the implication seems to be that as long as stones can be seen, the patient should be treated with biliary lithotripsy. In the present study, 59.0% (187/317) of the 317 papers reported no follow-up on stone recurrence rate, i.e., this important indicator for prognosis was missed; 19.9% (63/317) reported a recurrence rate of 0, and the follow-up period was less than 4 years. Only 21.1% (67/317) reported recurrence rate, which ranged from 2.8% to 36.5%, and 82.1% (55/67) had a follow-up period of less than 5 years. "Only one article used the life table method to calculate the postoperative recurrence rate. In general, the data on the prevention and treatment of stone recurrence and follow-up studies have many problems such as short follow-up time, incomplete data, large number of missed tests, different follow-up methods, and unreasonable statistical methods, and the overall true stone recurrence rate is difficult to estimate, which will be reported in detail in a separate article. These results suggest that although biliary lithotripsy has flourished in China in recent years, the issue of stone recurrence rate, which most affects its sustainability, has not been seriously studied and addressed, and the available literature shows a clear lack of scientific validity of the relevant studies. The exact efficacy of ursodeoxycholic acid or other methods to prevent stone recurrence has yet to be confirmed by prospective, multicenter, large-case cohort studies or RCTs with more rigorous technical routes and longer follow-up periods. The development of normative measures cannot be determined at this time and is an important issue for further in-depth study. If drugs such as ursodeoxycholic acid can prevent recurrence of stones, then the desire to interrupt gallbladder stone production could be realized and either cholecystectomy or biliary surgery could be retired, just as the use of H2 receptor inhibitors has made peptic ulcer a largely curable disease now with medical therapy. However, the drug has been manufactured and used for many years, and the exact effects expected as described above have not been fully confirmed in large RCTs, or even in the literature, and do not provide clinical relief. Therefore, a lot of intensive work is needed to return the patient to a functioning gallbladder. In conclusion, I believe that the treatment principles proposed by Academician Huang Zhiqiang are not yet obsolete and should still be the consensus concept in our understanding of this problem when choosing the treatment strategy for chronic cholecystitis and gallbladder stone disease. Biliary preservation or excision is only a different treatment method according to the different stages of the patient's disease development and the related specific conditions, and the treatment principles should not be easily changed. In the case of asymptomatic gallbladder stones, observation and prospective treatment should be carried out mainly under regular follow-up conditions, while appropriate therapeutic measures with the potential to control stone growth should be given. For patients with recurrent cholecystitis, stones >3 cm in diameter, gallbladder wall thickness ≥ 4 mm, filled gallbladder stones, atrophic cholecystitis, gallbladder neck duct stones, and chronic calculous cholecystitis with complications and malignant tendency, they should be firmly treated by cholecystectomy. From the analysis of the current literature and evidence-based medical requirements, domestic cholecystectomy lithotomy still lacks standardized criteria for indications and technical operation, and is still in the exploratory stage of “crossing the river by feeling the stones”, and should not be promoted as a standard procedure. In the absence of a large number of long-term prospective studies to confirm the exact efficacy of cholecystectomy, it should be tried in two stages of gallbladder stone disease, first, for patients with mild symptoms and histopathological changes, good gallbladder function, small size and number of stones, no family history, metabolic syndrome, and a strong personal will to preserve gallbladder, postoperative treatment should be supplemented with effective anti-stone recurrence therapy, and should be prepared for recurrence and then The patient should be prepared for surgical removal of the gallbladder after recurrence. Second, for the elderly and high-risk groups with acute attacks of cholecystitis, more coexisting diseases, and who cannot tolerate cholecystectomy, as an emergency temporary surgery to relieve the difficult to control clinical symptoms, after the remission of the disease, elective cholecystectomy should still be performed if possible to remove the underlying problem. As for the determination of the degree of progression of chronic calculous cholecystitis, in today’s highly developed biomedical and digital medicine, it should be possible to determine as accurately as possible preoperatively through appropriate technical means, supplemented by decision-making. At this stage, the “2011 consensus”, which is supported by a large body of literature, should still be adhered to, rather than blindly preserving the gallbladder. Academicians Qiu Fazu and Huang Zhiqiang are indeed very concerned about the issue of gallbladder preservation, but from my many conversations with them, I deeply feel that they attach importance to how to preserve gallbladders that function well and have no obvious histopathological changes, rather than advocating the preservation of all pathological gallbladders. Recently, when listening to our literature research report, academician Huang Zhiqiang cautiously proposed: “We should pay attention to the indications! This point, hopefully, will be brought to our attention. We hope that this point will be taken seriously by our biliary surgery colleagues. We should strive to apply the concept of precision surgery and strengthen the technical management of chronic cholecystitis and gallbladder stone disease, in order to provide maximum relief to patients with minimal trauma, optimal treatment strategy and minimal economic cost. And strengthening relevant basic and clinical research to fundamentally address the causative mechanisms and inhibitory modalities of chronic cholecystitis gallbladder stones is the direction of our future efforts.