Treatment of gallstones “supermarket”

  In recent years, the incidence of gallstones has increased significantly. In the United States, the incidence of gallstones is 10% to 15%, and about 700,000 patients undergo cholecystectomy each year. The incidence of gallstones in China has reached 7% to 10%.
  There are many treatments for gallstones, and many patients are confused. Why do you have gallstones? Is the right upper abdominal pain caused by gallstones? What are the hazards of gallstones? Still dare to eat greasy? Are technologies such as gravel, dissolved stone and row of stones feasible? If you want to have surgery, can you do it? Can you minimally invasively remove the gallbladder? Does it affect digestion after surgery? Does the bile duct have a long stone? Is it easy to get colon cancer? and many more.
  Based on this, we list the treatments and indications related to gallstones. Patients can combine their indications according to their own wishes and choose a treatment plan reasonably. It is like shopping in the supermarket, choosing the most wanted and most suitable for themselves.
Conservative treatment or surgical treatment

  Choosing conservative or surgical treatment depends on the following factors:
  1. Symptoms: Some studies have shown that 70% of patients with gallstones have no symptoms, and only 25% of patients will develop symptoms in the next 10 years. However, asymptomatic does not mean no lesions. On the contrary, even if there are symptoms, it is necessary to identify whether it is caused by gallstones.
  2. With or without function: For gallbladder contraction function ≥ 50% can consider gallbladder surgery, for gallbladder contraction function <50%, if you have indications for gallbladder surgery, decisive removal of the gallbladder.   3. With or without inflammation: The presence or absence of inflammation and the severity of inflammation are important factors in determining the outcome and outcome of gallstone disease. Surgical treatment should be selected for patients with acute gallbladder inflammation secondary to gallbladder gangrene, perforation, or ineffective conservative treatment.   4. There are no complications: gallstones can be secondary to common bile duct stones, acute cholangitis, acute pancreatitis, Mirizzi syndrome, biliary fistula, stone intestinal obstruction and other complications.   5. Whether there is cancer or not: For patients with high risk of gallbladder cancer, active surgical intervention should be taken. For patients suspected of malignant transformation, the gallbladder should be carefully identified for the diagnosis or limited surgical resection of the lesion. Gallstone treatment "supermarket" Non-surgical treatment area   1. Non-surgical treatment indications:   1 young patients with initial onset cholecystitis;   2 patients with rapid relief after non-surgical treatment;   3 asymptomatic gallstones.   2. Expected treatment: no special medication is required, and a healthy lifestyle is recommended, including a balanced diet, breakfast, drinking water, regular physical examination, and symptomatic treatment.   3. Non-surgical intervention: drug dissolution, drug drainage, gravel treatment.   Drug dissolution therapy ①   acid drugs such as ursodeoxycholic acid, chenodeoxycholic acid may play a role in the dissolution of cholesterol gallstones. About 5% to 15% of patients with gallstones may be effective.   ② row of stone treatment   efficacy have gallbladder stone row of Chinese traditional medicine, such as herbal medicine, acupuncture, etc., have been used to treat gallstones, the specific effect is not obvious. And the stone-discharging process can cause serious complications such as secondary common bile duct stones, acute cholangitis, and biliary pancreatitis; repeated stone discharge can also cause serious consequences such as damage and stenosis of the bile duct sphincter.   ③ extracorporeal shock wave lithotripsy   ESWL served as a means of minimally invasive treatment of gallstone clinical application. For stones with a diameter <20mm, the effective rate can reach 60% to 80%, but about 1/3 of patients relapse within 2 years. The key is that gallstones in the gallbladder can not be fixed, so the effect of gravel is poor, even if it is cracked, its small stones are discharged into the bile duct, which may cause serious complications such as bile duct obstruction and acute pancreatitis.   In non-surgical interventions, it is recommended to try the treatment of dissolved stone drugs. It is not recommended for stone treatment and extracorporeal shock wave lithotripsy. Surgical treatment area   1. Cholecystectomy:   Cholecystectomy is the most effective method for the treatment of benign gallbladder disease, which can be performed by laparoscopic, open or small incision.   Surgical indications   1 symptomatic gallstones;   2 acute acalculous cholecystitis;   3 gallstones with gallbladder polyps;   4 magnetized gallbladder (chronic cholecystitis, gallbladder atrophy, wall thickness);   5 parts of asymptomatic gallstones can also choose Surgery, such as filled gallstones, gallstones with gallbladder polyps, gallstones with diabetes. In addition, patients older than 70 years with organ dysfunction, such as gallstones, are also recommended for surgery. Surgical indications   1 symptomatic gallstones;   2 acute acalculous cholecystitis;   3 gallstones with gallbladder polyps;   4 magnetized gallbladder (chronic cholecystitis, gallbladder atrophy, wall thickness);   5 parts of asymptomatic gallstones can also choose surgery, such as Filled with gallstones, gallstones with gallbladder polyps, gallstones with diabetes. In addition, patients older than 70 years with organ dysfunction, such as gallstones, are also recommended for surgery. Specific surgical method   Open cholecystectomy: for routine surgery, suitable for all types of cholecystectomy. The disadvantage is that it is more traumatic, suitable for abdominal adhesions, and cannot be remedied for laparoscopic surgery or laparoscopic surgery.   Laparoscopic cholecystectomy: also known as "keyhole" surgery, with its obvious characteristics of small trauma and rapid recovery, has become the "gold standard" procedure for the treatment of gallbladder stones and benign diseases of the gallbladder. This procedure is divided into two methods, one is the three-hole cholecystectomy, which is a routine and traditional procedure for laparoscopic cholecystectomy. Under the right rib margin, three 5mm~10mm small holes were placed under the xiphoid and umbilicus, and the laparoscopic surgical instruments were placed. The cholecystectomy was performed under the direct vision of the laparoscopic monitor. The second is the reduction of cholecystectomy, which is divided into two-hole laparoscopic cholecystectomy and single-port laparoscopic cholecystectomy. Two-hole laparoscopic cholecystectomy On the basis of traditional three-hole laparoscopic cholecystectomy, the operation is performed under the xiphoid process and the two holes around the umbilical wheel. The intra-abdominal operation is the same as the traditional operation, but the incision is less and more beautiful. Single-port laparoscopic cholecystectomy, also known as concealed laparoscopic cholecystectomy, is performed by laparoscopic instruments only through the umbilicus. Surgical scars were not seen after surgery.   In particular, the reduction of laparoscopic cholecystectomy has a good cosmetic effect and is especially suitable for young female patients.   2. Gallbladder incision and stone removal (protective gallstone removal):   In recent years, the importance of gallbladder function has become more and more high, the surgical treatment of gallstones can not be all, but according to the specific conditions of gallstones, gallbladder Form and function, the patient's will to design a personalized and reasonable surgical approach. It is also a development trend to carry out gallbladder removal surgery for patients who meet the conditions of gallstone removal. Of course, the gallbladder stone has strict indications and must be used reasonably. There are two types of biliary stone removal methods: small incision biliary stone removal, laparoscopic biliary stone removal, laparoscopic choledochoscopy combined with gallstone removal.   1 The indications for gallbladder stone removal are normal and functional. The B-ultrasound examination shows that the gallbladder has a clear outline, normal position and size, gallbladder wall thickness <4mm, and good gallbladder contraction function (complication of gallbladder contraction ≥60% under gallbladder contraction test). Simple gallstones, small in number, moderate in size, without common bile duct stones, patients with no recent acute cholecystitis are also suitable for this approach. This is also the case for patients who have a clear willingness to fully understand the possibility of recurrence of stones.   2 double-mirror combined with gallbladder stone removal, combined with laparoscopic and electronic choledochoscopy, laparoscopic cholecystectomy, choledochoscopy for gallbladder, stone removal basket for one-time removal of stones.   3 hard mirror gallstone stone removal: the combination of laparoscopic and hard mirror (similar to ureter hard mirror) combined surgery. The advantage of the hard mirror is that for stones that are difficult to remove during surgery, it is possible to apply a pulse or the like to crush the stone and then take the stone again. The disadvantage is that the hard mirror cannot be bent, and it is impossible to probe the gallbladder cavity without dead angle and non-invasiveness to the fiber choledochoscope. Treatment area with secondary bile duct stones   Gallstones in the course of their development or due to improper treatment can cause stones to be discharged into the bile duct called secondary bile duct stones. Bile duct stones are easy to induce more serious diseases such as cholangitis and pancreatitis, which threaten the safety of patients. At present, minimally invasive treatment of gallstones with common bile duct stones has two main surgical methods, has been widely carried out and shows greater advantages than traditional open surgery:   1. LC + LCBDE (laparoscopic + fiber choledochoscopy combined with cholecystectomy + The operation method of bile duct incision and stone removal is to perform cholecystectomy after laparoscopic and fiber choledochoscopy combined with common bile duct incision, and T tube is placed in the common bile duct. Compared with traditional surgery, the surgical method has less trauma, the patient has less pain, quick recovery and clean stone. No need to cut the duodenal papillary sphincter, it can retain the integrity of its function, thus avoiding infection and stone recurrence caused by biliary tract reflux.   2. ERCP+EST+LC (laparoscopic cholecystectomy after ERCP+EST stone removal) is a staged operation. First, the duodenal papilla is cut in the gastroduodenal microscope, and the common bile duct stones are taken out by taking a stone basket. The nasal bile duct was placed and the patient underwent laparoscopic cholecystectomy after the patient's condition was stable (3 days). During the ERCP+EST stone removal process, the duodenal papilla needs to be cut, which may cause damage to the duodenal papilla and affect its "valve" function.   Therefore, patients with small bile duct stones and non-expanded bile ducts are recommended.