Since 1882, when lengenbuch pioneered cholecystectomy for the treatment of gallbladder stone disease, this procedure has become the standard treatment modality for gallbladder stones in cholecystitis with its good therapeutic results. 37 years ago Mouret first reported laparoscopic cholecystectomy (LC), and although it has rapidly gained popularity with its powerful advantages of minimal trauma and rapid recovery and has become the so-called “gold standard”, it is still essentially an innovation in the technical means of cholecystectomy, including the currently carried out robotic surgery, and is not a change in the principle of treatment. In the “Huang Jia Qiang Surgery” (7th edition), Academician Huang states that “except for the implementation of cholecystostomy for acute cholecystitis in emergency situations, the surgical treatment of gallbladder stones is the removal of the pathologic gallbladder containing stones and the appropriate management of extra-chollicular complications of 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 the “Expert Consensus on Decision-making in the Treatment of Benign Gallbladder Diseases” (hereinafter referred to as “2011 Consensus”), which was officially released by the Biliary Surgery Group of the Chinese Medical Association, the basic principles of treatment for benign gallbladder diseases are stated as follows: “Cholecystectomy is the standard procedure for benign gallbladder diseases. LC should be the first choice.” “The practical value of cholecystectomy needs to be further investigated, and it is currently only appropriate for emergency management under emergency conditions and not as a recommended procedure for elective surgery.” However, the flourishing gallbladder lithotripsy (commonly known as “cholecystectomy”) in China in the past 10 years or so has posed a serious challenge to 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? To this end, we reviewed 317 clinical studies on biliary stone preservation from four major medical scientific databases in China (CNKI, Wanfang, Wipu, and CMB) 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 special attention. 1. Should biliary conservation surgery be actively performed in asymptomatic patients with chronic cholecystitis gallbladder stones? When talking about the difficulties of biliary surgery in the 21st century, Academician C.K. Huang said that the first difficulty, is that it looks easy. The application of LC for the treatment of gallbladder stones does seem easy, but this “ease” hides a great danger. Because of its “ease” and surgical complications caused by arbitrary implementation, biliary reoperation has become the most important abdominal surgery reoperation, from a seemingly anatomically simple surgery, resulting in adverse consequences such as patients are not allowed to perform liver transplantation, disability, or even death, has occurred. 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 who present with non-specific gastrointestinal symptoms should be excluded first. Other diseases should be excluded”. This is in view of the fact that, “according to the results of the follow-up of such patients for 20-30 years, 60%-80% of the patients were 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 domestic literature on biliary lithotripsy the problem of arbitrary implementation of biliary lithotripsy. Many reports include “asymptomatic gallbladder stones” as an indication for surgery. Some of the indications reported in the literature are “various cases of gallbladder stones”, some of which are “only a feeling of fullness in the epigastrium after meals”, “detected by physical examination of the unit”, and “asymptomatic gallbladder stones”. In some cases, “the youngest age was 4 years and 3 months”, and they all underwent biliary stone extraction; in other cases, no indication was mentioned. Although the number of papers published as of March 2014 has reached 317 and the number of cases has reached 32,090, which are 5.87 times (317/54) and 7.20 times (32,090/4454) more than the data reported by Wang Huiqun et al. 4 years ago, i.e. in 2010, respectively, yet there are still many questions about the exact follow-up findings regarding stone recurrence rates from the analysis of the 317 papers (see later). It can be seen that many surgeons have performed the procedure arbitrarily because of the perceived simplicity and feasibility of the technique before knowing the exact results of the procedure. 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, digestive tract injury, and other surgical complications, and if the stone recurs, he/she also has to bear the risks of secondary surgery and the burden of health economics of paying more money. 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 will 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 take into account the evolution of the disease process 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. . The rise of endoscopic biliary lithotripsy technology has brought a boon to meet the patient’s wish of “eliminating the disease and 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 problems 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 enable fundamental control of the disease, while many domestic scholars propose biliary preservation as an alternative treatment option to LC. According to the analysis of the literature, the feasibility of the following cases, in particular, needs to be carefully considered. One of them is the inflammatory histological changes in the gallbladder wall. There are no adequate and substantiated studies to confirm 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 due to 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 occurrence of gallbladder cancer. At present, in some domestic units, there are “stones >3.6cm”, “atrophic cholecystitis”, “gallbladder full of stones, up to more than 823” (it is hard to imagine that such a gallbladder can function well, and there are no histopathological changes of atypical hyperplasia in the mucosal tissue), yet all of them were taken for bile preservation and stone extraction. Second, it is about the relationship between gallstone disease and metabolism, family history, and genetic inheritance. A joint study between Ruijin Hospital of Shanghai Jiaotong University School of Medicine and Karolinska Institute in Sweden 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. ATP binding cassette (ABC) G5/G8, liver X receptor α (LXRα), which regulates its expression, and scavenger receptor B type I (SRB1), which is a nuclear receptor increased. In the reports of 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 genes, family history, and abnormal cholesterol metabolism, the 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. It has been demonstrated that stone formation in the gallbladder is closely related to a decrease in the number of receptors for cholecystokinin (CCK), an important gastrointestinal hormone that regulates the motor function of the gallbladder, reduced receptor expression, and weakened signaling in the gallbladder wall. Therefore, it is no coincidence that the gallbladder becomes the end organ of gallbladder stone disease and that resection of the diseased gallbladder can achieve definitive therapeutic results. Third, there is the issue concerning 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 ultrasound” as indications, while others report no clear method of gallbladder function assessment and lack of objective assessment criteria for homogeneity, as methods vary. It is difficult to assess the reliability and authenticity of the “normal function” 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 the oral cholecystography method, which has been largely abandoned. The second is nuclear 99Te, ETC scan, which requires special equipment and is not yet popular in most primary care hospitals. The third is the ultrasound measurement method, which is currently the most commonly used method in hospitals at all levels. It should be clearly pointed out that the criteria for determining gallbladder contraction function according to Ultrasound Medicine are: “(1) Good gallbladder contraction function: gallbladder emptying or shrinking >2/3 within 2h after meal is normal. (2) poor gallbladder contraction function: gallbladder contraction <1/2 within 2h after meal is suspicious. (3) Poor gallbladder contraction function: Gallbladder contraction <1/3 within 2h after meal is abnormal. (4) No contractile function of gallbladder: 2h after meal, gallbladder size is the same as fasting, if fasting gallbladder < normal size, it mostly indicates serious lesion and loss of function, if gallbladder enlarges, it indicates obstruction below the gallbladder." . In the modified ultrasound three-dimensional gallbladder function detection and judgment criteria introduced by Jiang Zhaoyan et al [25], it is also specified that "the criteria for normal gallbladder function are two indicators: gallbladder contraction rate (≥75%) and gallbladder wall thickness (≤3 mm). If the contraction rate of the gallbladder is reduced or the wall of the gallbladder is thickened and either of the two indicators is not within the normal range, it means that the gallbladder function is not normal". In the literature of domestic biliary stone retrieval, many authors set "gallbladder contraction ≥30% 2h after lipid meal" and "gallbladder wall thickness <6mm" as the criteria of "good function", which is not accurate. 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 inclusion criteria, in practice, patients with chronic cholecystitis and gallbladder stones who do not have good gallbladder function are also included in the indication category of "gallbladder stone retrieval", which is The results of this study are not only the results of the study, but also the results of the study. < p=""> Fourth, the question of whether there is a risk of missing occult cystic ductal carcinoma after removal of gallbladder cervical stones is particularly worrisome. It is difficult to diagnose and treat occult gallbladder duct cancer at an early stage, and once the diagnosis is delayed and improperly treated, the prognosis is poor. The prognosis of gallbladder cancer itself is very poor, because its pathological characteristics are adenocarcinoma accounting for 89.4% of the incidence, of which only 5.7% are papillary adenocarcinoma with relatively good differentiation, and most of them are poorly differentiated adenocarcinoma and indolent cell carcinoma with poor prognosis. The prognosis is relatively poor if the tumor invades the cystic duct. lymph nodes), while lymph nodes in the abdominal trunk, paraduodenal, peripancreatic, and superior mesenteric artery were considered as distant metastases (N2). Shirai et al. injected dye into the lymphatic ducts of the gallbladder to show the lymphatic drainage pathways of the 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 gallbladder is the site where stones can easily stay, rub, and embed, and has the highest probability of mucosal epithelial damage and greater possibility of tumor development. 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, they reported “16 cases of long-term embedment of gallbladder cervical duct stones with white bile in the gallbladder” and “pus accumulation in the gallbladder”, but they forced to perform biliary lithotripsy. In the “contraindications to surgery” listed in a “specification for biliary stone extraction”, it is stated that “stones in the gallbladder duct cannot be removed, and it is expected that they cannot be removed after surgery”; the implication seems to be that as long as stones can be removed, biliary stone extraction can be performed. It seems that as long as the stone can be removed, biliary stone extraction can be performed. In the author’s opinion, this type of treatment choice is against the principle. If a stone is embedded in the cervical duct of the gallbladder, whether or not bile can be seen flowing from the bile duct after stone removal, biliary surgery should be contraindicated to prevent leakage of gallbladder cervical duct cancer, which is a matter of principle in treatment choice. 3, the controversy of the treatment decision for gallbladder polyps Whether gallbladder polyps are suitable for biliary preservation deserves careful consideration. In 1991, Wang Qiusheng divided the gallbladder polyps found by ultrasound into three categories according to the pathological findings of 100 cases of surgically treated gallbladder polyps in 1991, and the “2011 Consensus” gave clear instructions on the treatment decision of gallbladder polyps. In the author’s opinion, these recommendations based on long-term clinical research are scientific. Given that the pathological nature of gallbladder polyps is difficult to determine preoperatively according to the current technology, biliary preservation should be performed with caution. 4.The standardization of technical operation There has long been a consensus on the surgical operation standard of cholecystectomy. In particular, when combined with portal hypertension, rich collateral circulation and large number of abnormal blood vessels in the hepatoportal area, the exposure of the surgical field of view of LC operation, 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 pneumatic ballistic lithotripsy equipment, 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 cancer of the cystic duct. Will it escalate the problem that can 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 current actively advocated “precision surgery” concept, such cases are inappropriate selection of indications, followed by inevitable improper technical operation, there is a potential risk of complications, not in line with the overall principle of obtaining the best results for patients with minimal trauma, should be paid attention to improve. 5, 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 years, and more than 5 years, respectively. Of the 317 studies with recurrence rates reported in 67 papers, 6519 cases were followed up and only 446 cases were found to have recurrence. Is it because the current treatment effect of biliary lithotripsy in China has really improved, or is it because the follow-up survey is not meticulous that recurrence of stones is missed? A careful analysis showed that among the 317 papers in this study, 59.0% (187/317) reported no follow-up on stone recurrence rate, which means that this important indicator for prognosis was missed; 19.9% (63/317) reported a recurrence rate of 0, and their follow-up time was less than 4 years. Only 21.1% (67/317) reported a recurrence rate, which ranged from 2.8% to 36.5%, and 82.1% (55/67) had a follow-up time of less than 5 years. “Only one article used the life table method to calculate the postoperative recurrence rate. Overall, the data on the prevention and treatment of stone recurrence and follow-up studies had 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 was 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 effectiveness of ursodeoxycholic acid or other methods to prevent stone recurrence has yet to be confirmed in prospective, multicenter, large-case cohort studies or RCTs with more rigorous technical routes and longer follow-up periods. The development of their normative measures cannot yet be determined 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 still needed to return the patient to a functioning gallbladder. In conclusion, the author believes that the treatment principles proposed by Academician Huang Zhiqiang are not yet obsolete and should still be our consensus philosophy for understanding this problem when choosing treatment strategies for patients with chronic cholecystitis and gallbladder stones. Biliary preservation or excision is only a different treatment method according to the different stages of the patient’s disease development and the different specific conditions involved, and its treatment principles should not be easily changed. For 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, one is 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. 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 it as accurately as possible preoperatively by corresponding 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 biliary preservation, but from my many conversations with them, I have the impression that they attach importance to the preservation of a functioning gallbladder without obvious histopathological changes, rather than advocating the preservation of all diseased gallbladders. Recently, when listening to our literature research report, academician Huang Zhiqiang cautiously proposed: “We should pay attention to the indications! . We hope that this point will be given great attention 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, so as to relieve patients’ pain to the maximum extent with the least trauma, the best treatment strategy and the least economic cost, which is our aim. 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.