1, about the high recurrence rate after biliary surgery – the hotbed theory For a long time, it was believed that the recurrence rate after biliary lithotripsy was high and this method was not desirable. The theory advocating bile cutting and stone extraction was created by Langenbuch, a famous German doctor, in 1882. In those days, when there was no endoscopic technology, Langenbuch believed that the old choledochostomy was not a complete treatment for gallbladder stones and that stones were prone to “recurrence (>90%)” after surgery; in addition, he was unable to detect asymptomatic large gallbladder stones and saw only a few cases when gallbladder stones had developed to the point of peritoneal irritation. Therefore, he proposed that “gallbladder removal is not only because the gallbladder contains stones, but also because it can grow stones”, and regarded the gallbladder as a breeding ground for the growth of gallbladder stones. Later people called it “hotbed doctrine” and regarded it as “gold standard”. Many scholars have been opposed to the idea that gallbladder stones should always be removed from the gallbladder; however, due to the inability to reduce the recurrence rate, it has been regarded as the “golden standard” for more than 120 years and has influenced generations! However, the main flaw of the warm-bed theory is that it ignores the importance of gallbladder function, which is inevitably missed due to the backward technical conditions and the inability to retrieve stones from the blind, and is not qualified to talk about the recurrence rate, which misrepresents and exaggerates the postoperative recurrence rate. Therefore, a wrong conclusion was made as mentioned above. Today, is the hotbed theory correct, is the recurrence rate of stones after cholecystectomy very high, and what is the quality of life of patients after cholecystectomy? What are the long-term drawbacks? These questions are not very clear to many surgeons. Over the past 19 years, we at Peking University Hospital and other units have seriously explored and researched this issue by applying the new high-tech technology, choledochoscopy. Under direct endoscopic vision, we are able to remove gallbladder stones completely, thoroughly and cleanly, and as a result, the recurrence rate of stones after surgery has been reduced to 2-10%. The recurrence rate after cholecystectomy was actually mostly due to intraoperative residuals, which should be the residual rate, and also revealed the various disadvantages after cholecystectomy. The new method reveals the limitations and errors of the “hotbed theory”. It is well known that the principle of gallbladder stone formation is mostly based on the Small’s triangle metabolic theory, which suggests that the cholesterol concentration in the gallbladder bile is oversaturated and solid cholesterol crystals are precipitated to form cholesterol stones. However, the mucosa of the gallbladder does not secrete cholesterol, and cholesterol is produced and secreted from the liver; therefore, the “hotbed” of stone formation is not in the gallbladder, but in the liver. Therefore, our predecessor in biliary surgery, Professor Ran Ruitu, believed that gallbladder stones originate from the liver and that the indications for cholecystectomy (gallbladder stones) should be modified. Therefore, the doctrine of Langenbuch misreported and exaggerated the recurrence rate after cholecystectomy, ignoring the importance of the existence of gallbladder function, and the hotbed doctrine is obsolete today and cannot be advocated! In the past, most doctors believed that the stimulation of stones in the gallbladder is often accompanied by chronic inflammation of the gallbladder, and the two are mutually causal, making it a stubborn lesion. Therefore, the only way to eliminate the problem is to remove it. However, the new method of bile preservation has reduced the recurrence rate after surgery, and since the stones have been removed, the inflammatory stimulus has disappeared, which is definitely beneficial to the inflammation of the gallbladder. Moreover, any inflammation in clinical practice should be reversible. In the follow-up of a group of post-biliary surgery cases with chronic cholecystitis in Beijing Hepingli Hospital, the gallbladder wall changed from thick to thin in 84% of the cases 1-2 years after gallbladder stone removal, and the contraction and contrast rate of gallbladder improved significantly, which shows that gallbladder inflammation is completely reversible and the inflammatory lesions can be eliminated, which cannot be used as a reason for gallbladder removal. 3. About the relationship between gallbladder stones and cancer. The relationship between gallbladder stones and gallbladder cancer has been reported somewhat misleadingly and sensationally in the past, but it is also one of the important reasons for gallbladder resection. However, the currently reported clinical incidence of gallbladder stones and cancer concomitantly is untrue, only referring to the incidence of gallbladder cancer in hospitalized patients, not the true incidence of gallbladder cancer in all gallstone patients or in the normal population! Recently, Professor Cai Duan in Shanghai reported that the real incidence of gallbladder cancer is 3/100,000 people; the fear of cancer should not be used as an excuse to kill people! Is it reasonable to kill 100,000 cases of benign gallbladder for the sake of preventing the occurrence of three cases of gallbladder cancer! Besides, after gallbladder lithotripsy, the stone factor that stimulates gallbladder cancer has been removed, the inflammation has subsided, and the cancer factor has also been removed, so isn’t gallbladder lithotripsy a good medicine to prevent cancer? For those gallbladder cancer prevention ideas, Academician Huang Zhiqiang has repeatedly stressed and questioned “Is the idea of LC to prevent gallbladder cancer right?” Undoubtedly, this theory is wrong. 4. The importance of preserving the gallbladder. In the past, surgeons did not know much about gallbladder function and did not pay much attention to it. They only pay attention to the healing of the incision after surgery, and put all the discomfort after cholecystectomy on the gastroenterologists. In this way, surgeons mistakenly believe that the gallbladder is dispensable, even if the gallbladder is removed, it is not a big problem, which is the biggest misunderstanding of biliary surgery. However, with the progress and development of science and technology in recent years, especially the exploration of various maladies after cholecystectomy, it is suggested that the gallbladder has extremely complex and important functions and is an important digestive and immune organ that is indispensable and irreplaceable. Because of this, post-cholecystectomy will bring many serious long-term side effects, which should be highly valued by the surgeon, and it directly affects the patient’s quality of life, and even endangers the patient’s life. However, this point is often overlooked by surgeons. Now the analysis is as follows: 4-1, dyspepsia and reflux gastritis. As far as is known, the gallbladder has at least the functions of storage, concentration and contraction. It also has, of course, complex chemical and immunological functions. The gallbladder can concentrate the dilute liver bile 30 times and store it in the gallbladder to be used when eating a high-fat diet before it is discharged into the intestine to participate in digestion. If the gallbladder has been removed, by the time the patient eats a fatty diet, there will be no high quality and sufficient bile to help, so the body will have to suffer from indigestion, bloating and diarrhea. However, such symptoms are often ignored by surgeons and pushed to the gastroenterology department, becoming a difficult “stubborn” disease in internal medicine. In addition, Duodenogastric Reflux DGR and gastric reflux after cholecystectomy have been widely reported in recent years, and Walsh et al. also confirmed in a controlled study that all markers refluxed into the gastroesophagus after cholecystectomy with a significant decrease in lower esophageal sphincter tone; Chen MF et al. also pointed out that the cause of DGR was the loss of bile reserve function after cholecystectomy. The loss of bile reserve function causes bile to change from intermittent excretion caused by feeding to continuous excretion into the duodenum, and bile is retained in the bulb of the 12 fingers within 24 hours, at which time the chance of reflux into gastritis certainly increases, producing DGR. 4-2. The problem of bile duct injury caused by cholecystectomy As we all know, there is always a certain probability of bile duct injury occurring after cholecystectomy (bile duct injury: 0.18~2.3%); and there is a certain mortality rate, which is 5~8% in the early stage; at present, there are still 0.17%, including: bile duct injury, liver duct injury, vascular injury, gastrointestinal injury and so on. In the bile duct injury cases, caused by cholecystectomy is 75%; in the United States, for example, each year to do about 500,000 cases of cholecystectomy, China has about 3 million cases each year; so there will be thousands of cases of bile duct injury each year; especially there is a certain mortality rate, if you seriously calculate the harm caused by cholecystectomy, will certainly shudder! China’s biliary surgery master Huang Zhiqiang academician shouted: bile duct injury is the biliary surgeon “forever pain”! As a general surgeon; you will not be able to avoid the problem of bile duct injury! You will never be able to forget the desperate and painful faces of patients with bile duct injury! Therefore, compared with cholecystectomy, biliary stone extraction simply cannot hurt the organs around the gallbladder; this point must be the biggest flaw of cholecystectomy, the Achilles’ heel of cholecystectomy! In addition, considering the physiological defects and the effects of cholecystectomy on service free function, it would be prudent to choose cholecystectomy for gallbladder stones. 4-3 Increased incidence of common bile duct stones after cholecystectomy. The incidence of common bile duct stones is more common in clinical cases with a history of gallbladder removal, and the incidence of common bile duct stones is 2:1 in the comparison of gallbladder removal than non-cholecystectomy cases in Peking University Hospital, which is the most reasonable explanation by the principle of “hydrodynamics” when analyzing the causes of stone formation. After removal of the gallbladder, the gallbladder loses its cushioning effect on the fluid pressure in the common bile duct, resulting in an increase in pressure in the common bile duct, which causes compensatory dilatation of the common bile duct, thus causing a vortex or eddy flow in the common bile duct, the latter being an important theory for the formation of gallstones. In this way, cholecystectomy avoids the risk of “recurrence” of gallbladder stones after surgery, but invites the scourge of “growing common bile duct stones”; which stones are the most dangerous? It is self-evident which is more important. 4-4. The effect of cholecystectomy on the incidence of colorectal cancer. In recent years, many European scholars engaged in colon cancer research found a phenomenon and suspicion that many cases of colon cancer have a history of cholecystectomy, which has attracted attention. in Moorehead’s analysis of 100 cases of cholecystectomy over 60 years of age, 12 cases of colon cancer were found; while in another 100 cases without cholecystectomy, there were only 3 cases of colon cancer patients. Regarding the relationship between cholecystectomy and colon cancer, Morvay pointed out through animal experiments that: bile acid secreted from the liver is primary bile acid, which interacts with Escherichia coli in the colon to produce secondary bile acid; secondary bile acid increases greatly after cholecystectomy, and this substance can stimulate the tendency of mitotic enhancement in the colonic mucosa, which increases the incidence of colon cancer, especially in the ascending colon. 4-5.Post-cholecystectomy syndrome. In the past, “post-cholecystectomy syndrome” was a vague concept; with the advancement of modern diagnostic techniques of ERCP and MRCP imaging, misdiagnosis such as residual stones and bile duct injury after biliary surgery has been excluded, and only the inflammation and dyskinesia of Oddi`s sphincter occurring after biliary surgery can be called “postoperative syndrome”. “postoperative syndrome”, and the treatment of this symptom is clinically very difficult. 5. Regarding the choice of endoscopic bile-preserving lithotripsy modality and method. As mentioned earlier, endoscopic biliary stone extraction can be divided into three methods: simple right upper abdominal small incision choledochoscopic biliary stone extraction; choledochoscopic biliary stone extraction under laparoscopic surveillance and purely laparoscopic choledochoscopic biliary stone extraction. All of these methods are known as sunglasses (3 to 4 cm). The advantages of the second method are that it is extremely easy to find the gallbladder, the incision is small, and it is suitable for cosmetic purposes; however, the laparoscopic pneumoperitoneum is unfavorable for the elderly and cardiovascular patients as its disadvantage. The third method is complex, with many inconveniences associated with suturing the gallbladder and choledochoscopic lithotripsy, and does not have many advantages. The authors advocate the first two procedures. In summary, great progress has been made over the past 19 years in exploring the subject of endoscopic minimally invasive biliary lithotripsy. The new biliary lithotripsy has reduced the so-called recurrence rate after langenbuch biliary surgery and has uncovered the secret of the very high “recurrence rate”. At the same time, it also reminds people to go beyond the misconception of recurrence rate of biliary stone extraction. Because any kind of disease has the possibility of recurrence, why not allow the recurrence of biliary lithotripsy? Even if there is a 50% recurrence rate, it is still cost effective to save the other 50% of the gallbladder (Prof. Shengdao Zhang). Even if there is a risk of stone recurrence, it certainly seems insignificant compared to the complications of cholecystectomy. In cases of recurrence after cholecystectomy, no serious adhesions are found during the reoperation, and it is very easy to remove the stones again with cholecystectomy. Therefore, there is no need to make a fuss about it, and it is not a reason to cut the gallbladder. In conclusion, for the treatment of gallbladder stones, there should be a change in the concept of human-centeredness, both to remove the stones and to protect the existence of gallbladder function. For gallbladder disorders, doctors should first consider protecting the function of the human organ and maintaining the balance of the internal environment, and then consider gallbladder removal if necessary. Do not remove the gallbladder for no reason on the pretext of “prevention” or “incidental”. This is the correct perspective for the treatment of gallbladder disease.