The "one size fits all" battle for the gallbladder
China News Weekly reporter/Yuan Suwen intern/Yu Haoqing
Published in the 1036th issue of "China News Weekly" on March 21, 2022
In order to prevent gallbladder cancer, the king of cancer, can we directly abandon the gallbladder?
In the domestic medical community, doctors who support gallbladder cutting and gallbladder preservation have been debating.
Recently, a group of surgeons published an expert consensus in the name of the Chinese Medical Association, which for the first time explicitly opposed the operation of "cholecystectomy" and listed "cholecystolithiasis, whether symptomatic or not" as the primary indication for "cholecystectomy".
Roughly estimated, the incidence of gallbladder stones is 10%, which means that in China with a population of 1.4 billion, more than 100 million gallbladders need to be removed.
This is difficult for doctors who are mild-mannered, and it hurts the feelings of many patients.
Someone left a message online, calling the consensus "one size fits all".
The treatment of diseases in medicine is often embodied in the attitude towards probability.
In terms of gallbladder disease, although more than 100 million people in China have gallstones, the likelihood of actually developing gallbladder cancer is much lower.
At present, there is no nationwide data on epidemiology, but with reference to the existing data and the situation abroad, there may be no more than 10 people recruited for every 100,000 people.
But "prognosis is poor." Behind the veiled term by doctors is a brutal odds—only 5 percent of gallbladder cancer patients live another five years.
How to reduce the number of patients "hit" by gallbladder cancer?
Leading experts are ready to "sacrifice" all gallstones.
Existing studies have shown that gallstones are a high risk factor for gallbladder cancer. If the gallbladder with gallstones is removed, the incidence of gallbladder cancer will be significantly reduced.
In China, doctors are divided into two groups, one group advocates gallbladder removal, and the other group insists on exploring "preserving the gallbladder and removing stones".
Controversy over the pros and cons of secondary surgery
On Yang Xue's belly, there is an exclamation mark, a small cross, a lonely dot, and a dot hidden in the belly button.
These are the 5 scars left by her two gallbladder operations, a gallbladder preservation operation and a cholecystectomy after the recurrence of the stone.
She was deeply impressed by the two visits to the doctor. The first time, she appeared in the newspaper as the youngest local gallbladder patient, and the second time, the doctor rolled her eyes during the relapse consultation.
Baiyan was not aimed at Yang Xue, but her previous gallbladder-preserving surgery.
Yang Xue remembered that it was in February 2016 when she saw a doctor at the West China Hospital of Sichuan University.
When she mentioned that she had performed gallbladder-preserving lithotripsy surgery, the doctor did not agree.
"I feel like he doesn't approve of it at all." Yang Xue recalled that the doctor told her that the gallbladder-preserving surgery was not so miraculous and the recurrence rate was high. thing."
The first attack of Yang Xue's gallstones was in the autumn of 2000.
"The doctor gave two options: removing the gallbladder, or trying to preserve the gallbladder, but gallbladder preservation may lead to recurrence of stones." She recalled that when she was young and there was only one stone, her family decided to preserve the gallbladder.
Removing the stone required laparotomy, for which she spent three weeks in and out of the hospital.
After the operation, she thought she was cured, "I don't want to eat meat, I want to eat meat, I want to eat hot pot, I don't feel any discomfort." In 2016, when she was about 30 years old, the stone recurred.
After 16 years, medical concepts and technologies have been updated.
The doctor used laparoscopic technique to perform cholecystectomy for Yang Xue. She only stayed in the hospital for one day and went home with a "cross" and two "dots" attached with a large Band-Aid.
The effect of gallbladder removal made Yang Xue less efficient in digesting fat.
"The doctor reminded me to eat less fatty meat and foods with high cholesterol." Yang Xue said, apart from this, she didn't feel much discomfort, but she only suffered from bloating from time to time.
Nowadays, the high recurrence rate of gallbladder-preserving lithotripsy surgery has become a consensus in the industry, but in relevant domestic and foreign studies, the recurrence rate varies greatly.
Some surveys in the 1990s showed that the recurrence rate of gallbladder-preserving lithotomy can reach 50%, while in some domestic statistics in recent years, the recurrence rate is less than 10%. There are differences in statistical methods and techniques behind this. Contribution of progress to reduction in relapse rate.
Hu Hai is the director of the gallstone disease department of Shanghai Oriental Hospital, and has been researching gallstone preservation for more than 30 years.
He told China News Weekly that despite being a surgeon, he still believed that preserving organs would benefit patients more than cutting them out at will.
"Even if gallstones recur after gallbladder preservation, doesn't it make sense that we can extend the life of the gallbladder and make it work for you longer?"
The deputy chief physician of the hepatobiliary surgery department of a tertiary hospital in Qingdao basically agrees with the concept of gallbladder cutting.
However, he believes that for teenagers with only one stone and no change in thickness and roughness of the gallbladder wall, after a detailed evaluation, it may be possible to try to preserve the gallbladder.
However, Zhang Yongjie, chief physician of the Eastern Hepatobiliary Surgery Hospital of Naval Military Medical University, has a more distinct attitude towards this: the younger people are, the less able they are to protect their courage.
In this regard, he explained to "China News Weekly", "If a person develops gallstones after the age of 60, it may be related to many factors, but if a person develops gallstones before the age of 20, I have to ask why?" He It is believed that the more troubled the gallbladder is at a young age, the more susceptible the patient is to gallbladder disease. Since the pathogenesis of cancer is related to genes, the susceptible person should be extra careful.
Zhang Yongjie also admitted that although cholecystectomy is not a perfect method for rational treatment of benign gallbladder diseases, "but cholecystectomy is an effective and definite method to reduce the incidence of gallbladder cancer after more than 100 years of testing. This is a fact, it is Supported by Evidence-Based Medicine".
Gallstone-preserving surgery with "Chinese characteristics"
Although pioneered by foreign scholars, gallbladder-preserving stone extraction has now become an operation with "Chinese characteristics".
Zhang Yongjie remembers that before the outbreak of the epidemic, foreign gallbladder surgery experts often came to China to communicate. Whenever these foreigners heard that China was still carrying out gallbladder-preserving and stone removal surgery, they always had a puzzled face and asked a few "why?"
Zhang Yongjie introduced that around 1985, a British urologist used percutaneous nephroscopy to remove kidney stones, and the incision was only the size of a key hole, which set off a wave of minimally invasive surgery.
In 1988, a doctor used the same method to remove gallstones and developed percutaneous nephroscopic gallstone preservation. However, in the early 1990s, a follow-up study found that the recurrence rate of gallstones after gallstone preservation exceeded 40%. With the advent of endoscopic cholecystectomy (LC), cholecystectomy was abandoned internationally.
In 1991, "Chinese Journal of Surgery" also published the first domestic report on laparoscopic cholecystectomy.
But Chinese doctors are still exploring the possibility of preserving the gallbladder.
In 1987, drawing on the experience of using extracorporeal shock wave lithotripsy in urology, Shanghai Zhongshan Hospital introduced a lithotripsy machine from France and was the first to try extracorporeal shock wave (ESWL) in the treatment of gallstones in China.
In the same year, Hu Hai entered Ruijin Hospital for postgraduate studies and was taught by Professor Fu Peibin, the founder of surgery of the hospital, and his disciple Zhang Shengdao.
Hu Hai recalled that as a surgeon, Fu Peibin also agreed that tissues and organs could not be cut off casually, and Hu Hai also joined the research team using shock wave lithotripsy and other methods to dissolve stones in the treatment of gallbladder stones.
Shock wave gravel was once all the rage.
In January 1991, the Biliary Surgery Group of the Chinese Society of Surgery held the first national seminar on extracorporeal shock wave lithotripsy of the biliary tract, received 64 papers on shock wave lithotripsy, and reported a total of 6357 cases of lithotripsy.
But later, due to complications and other reasons, this therapy was less used in clinic.
However, the practice of using endoscopy to "preserve the gallbladder and remove stones" has continued.
After searching on CNKI, the reporter found that relevant papers have been published since 1991.
The earliest article was published in the Journal of Practical Surgery on May 1, 1991, in which it wrote, “Nanjing First Hospital has used West German Storz percutaneous cholecystoscope since 1990 to remove stones after shock wave lithotripsy and perform ultrasonic lithotripsy. , the effect is satisfactory", "it can be regarded as a valuable diagnosis and treatment method".
The earliest study on minimally invasive gallbladder preservation and lithotripsy on CNKI was published in 1996 and carried out by the Department of General Surgery, Nanyang Hospital of Traditional Chinese Medicine, Henan Province.
In the 21st century, related practice and research have further increased.
In 2009, the Endoscopic Minimally Invasive Gallbladder Conservation Professional Committee of the Endoscopy Branch of the Chinese Medical Doctor Association was established, and since then the Expert Consensus on Endoscopic Minimally Invasive Gallbladder Conserving Surgery for the Treatment of Benign Gallbladder Diseases has been updated in real time every two years.
The industry related to gallbladder preservation and stone extraction is also developing. The reporter searched with "bile preservation" as a keyword and found that there are 158 patents related to gallbladder preservation devices registered.
Gallstone-preserving surgery used to be all the rage, but this surgery was mainly carried out in primary hospitals.
In 2010, some scholars analyzed 53 Chinese literatures published by 2009 on endoscopic gallbladder preservation and stone extraction, of which 12 were from 7 provincial and ministerial hospitals, reporting 1,620 patients; 33 were from 14 prefecture-level hospitals. 1968 patients were included; 8 were from county-level hospitals, involving 866 patients.
Prefectural and county-level hospitals reported nearly two-thirds of the number of cases.
The increase in surgery has also failed to address the high recurrence rate and hidden gallbladder problems.
In 2010, Zhang Yongjie published "Several Questions about the Advocacy of Preserving Gallbladder and Taking Stones at the Present Stage", in which he wrote that academic opinions must be supported by objective evidence, otherwise they will be unscientific and common sense mistakes.
In this article, he believes that gallbladder preservation and stone extraction are the starting point of focusing on the protection of the structure and function of the gallbladder, which is in line with the basic principles of medical activities.
However, there is still a "lack of evidence-based medical evidence" for the operation.
In 2011, the Biliary Surgery Group of the Surgery Branch of the Chinese Medical Association issued the "Expert Consensus on Treatment Decisions for Benign Gallbladder Diseases (2011 Edition)", which suggested that cholecystectomy is the standard treatment for benign gallbladder diseases and should be the first choice. The practical value of cholecystolithotomy needs further study.”
The status quo that gallbladder-preserving and stone extraction operations are concentrated in primary hospitals in China has not changed.
In the title of the paper, Zhang Yongjie searched CNKI documents from 2010 to 2021 with the keyword "protecting gallbladder and removing stones", and the number reached 1,430. The publishing units are still mainly primary hospitals.
In contrast, he searched with the keywords "cholecystectomy lithotomy" and "gallbladder preservation" in the title of his thesis in the foreign database Pubmed, and there were only 31 papers between 2010 and 2021, of which 23 were from China.
In 2021, Zhang Yongjie published "Recognition of the History and Current Situation of Gallbladder Preservation and Stone Removal", stating, "Unfortunately, the standardization of most domestic studies on Gallbladder preservation and stone extraction is not yet accurate, and there is a lack of long-term follow-up data to explore secondary cancers. risks of."
Cholecystectomy is written into the consensus of leading experts.
On September 26, 2021, "Chinese Journal of Surgery" released the "Expert Consensus on Surgical Treatment of Benign Gallbladder Diseases (2021 Edition)", in which "cholecystolithiasis, whether symptomatic or not" was listed as "cholecystectomy" for the first time. Indications for surgery, and ranked first.
For the doctor group, the "expert consensus" is not as effective as the "clinical diagnosis and treatment guidelines", but it is also an authoritative point of view.
This article is signed "Biliary Tract Surgery Group of the Chinese Medical Association Surgery Branch" and "Biliary Tract Surgeons Committee of the Chinese Medical Doctor Association Surgeons Branch". Among the members of the editorial committee, 27 surgeons are signed, and the group leader Quan Zhiwei He is a national committee member of the Surgery Branch of the Chinese Medical Association, and many of the other members are surgical experts who have practiced surgery for decades.
Among them, it is the first time to "oppose the implementation of gallbladder-preserving lithotripsy surgery for benign gallbladder diseases", and it is not recommended to use drug dissolution, stone removal and extracorporeal shock wave lithotripsy and other treatment methods; cholecystectomy is the only curative method for benign gallbladder diseases.
The "one-size-fits-all" wording has sparked a backlash from doctors who are still carrying out gallbladder-preserving surgery.
After half a year of debate, on March 3, 2022, the Chinese Journal of Surgery published the Interpretation of <Expert Consensus on Surgical Treatment of Benign Gallbladder Diseases (2021 Edition)>, proposing that gallbladder-preserving surgery can neither change the cause of gallstones, nor The risk of gallbladder cancer cannot be avoided, and the gallbladder after gallbladder preservation surgery is a risk factor for gallbladder cancer.
Cancers that may be prevented
If you want to choose the king of cancer, gallbladder cancer is the top "seed".
This sac is located in the middle and right of the human body and is hidden at the lower edge of the liver. It is 8 cm long and 3 cm wide. It acts as a warehouse. The bile secreted by the liver flows into it through the common bile duct, where it is stored and concentrated, and then "exited" as needed. Library", flows into the small intestine to digest fat.
The gallbladder is a low-key "warehouse", next to other organs, so once cancer cells grow in it, they can quickly circulate and invade everywhere.
When people notice it, it is often in the middle and late stages.
Yongjie Zhang is a member of the consensus editorial committee.
He recalled that during the consensus writing process, when it was suggested that asymptomatic gallstones should also be included in the indication for cholecystectomy, there was also some debate within the editorial board.
"In the end, the only reason to put this sentence in it is that there are too many chaos in the treatment of gallstones in the country. Preserving the gallbladder and taking the stone may delay the timely prevention of gallbladder cancer for many patients."
As an expert in gallbladder surgery for more than 30 years, Zhang Yongjie encounters new cases of gallbladder cancer every week, "and more than one", of which the youngest is only 18 years old.
In textbooks, the incidence of gallbladder cancer is 2/100,000, but this is not the actual incidence in China.
Studies have shown that the incidence of gallbladder cancer (GBC) has great geographic differences. Globally, Chile has the highest incidence, reaching 9.7/100,000 in 2014, while it is relatively rare in Europe.
This phenomenon may be related to the preventive status of risk factors, and at the genetic level, the expression level of C-reactive protein (CRP), which is an indicator of chronic inflammation.
According to the statistics of 339 tumor registries nationwide in 2014, it was estimated that the prevalence of gallbladder cancer in China was 2.37/100,000, and the mortality rate was 1.71/100,000.
However, Zhang Yongjie believes that there is still a lack of comprehensive and effective investigations of domestic medical institutions at all levels, so the actual occurrence of gallbladder cancer is unknown, and there is also a lack of reliable research on the actual survival status of gallbladder cancer with and without treatment.
At present, some retrospective studies on gallbladder cancer patients are being carried out in China, but a complete report has not been released yet.
According to Zhang Yongjie, a retrospective study involving more than 3,000 Chinese patients with gallbladder cancer showed that more than 50% of the patients were initially diagnosed with stage 4 disease. If stage 3 patients were included, the proportion would reach about 80%.
This fully shows the secret and rapid development of gallbladder cancer in the early stage, and most people have reached the middle and late stages when they are discovered.
Of the 3,000 patients in the above study, more than 1,500 underwent surgery, and only 40% of them were able to achieve radical resection, that is, to remove all tumor masses.
But excision does not mean cure.
After resection, patients often have to undergo comprehensive treatment, chemotherapy, radiotherapy, and even immunotherapy and targeted therapy, and enter a long anti-cancer road.
Zhang Yongjie told reporters that in the National Cancer Institute's "surveillance, epidemiology and results" database search, the five-year survival rate data of gallbladder cancer could not be found.
As far as he knows, there are relatively few patients with malignant tumors of the biliary tract system in the United States, because the treatment of gallbladder stones in the United States has the "four regardless" principle, that is, regardless of age, gender, race, and symptoms, resection is always recommended.
Therefore, the incidence of gallbladder cancer in the United States is about 2/100,000.
Prophylactic resection has a significant effect on reducing the incidence of gallbladder cancer.
The latest evidence is that Chile, once the country with the highest incidence of gallbladder cancer, incorporated the gallbladder stone treatment plan into the cancer prevention system. After the gallbladder was removed, the cancer incidence was reduced by 30%.
Severe excision recommendations stem from the dangers of gallbladder cancer.
"In the field of cancer, everyone likes to be the king and hegemony. Some people say that liver cancer is the king of cancer, and some people say that pancreatic cancer is the king of cancer, but I often tell students in class that no matter what other cancers are, gallbladder cancer must be the king of cancer. King." Zhang Yongjie said.
He explained that, like cholangiocarcinoma and liver cancer, after radical resection, the 5-year survival rate may exceed 50%.
Even in the more dangerous form of pancreatic cancer, as the research progresses, the survival status after treatment is also greatly improved.
As for gallbladder cancer, domestic research is currently lagging behind, and due to the concept of preventive resection internationally, the incidence is not high, so there is not a lot of research resources invested. "Currently, the treatment of gallbladder cancer is still following the example of pancreatic cancer."
Among the high-risk factors for gallbladder cancer, the first one is gallstones.
Zhang Yongjie said that he found in clinical practice that the proportion of gallbladder cancer combined with gallbladder stones is about 90%.
The correlation between gallstones, cholecystitis and gallbladder cancer was 90%, surpassing the correlation of hepatitis, cirrhosis and liver cancer, which was about 80%.
The gallbladder is located deep in the internal organs, and after canceration, it may invade the bile duct, liver, hepatoduodenal ligament, stomach, and even down to the colon and inferior vena cava.
"How big can a so-called radical resection of gallbladder cancer be?" Zhang Yongjie said. He once had an operation that included part of the liver, half of the stomach, half of the pancreas, and twelve parts of the gallbladder. The duodenum, the entire extrahepatic bile duct, plus the right colon.
Such serious consequences can be prevented in advance.
"Originally a small gallbladder removal can solve it, why wait until then?" He and his colleagues have encountered almost all patients who did not listen to the advice. When I went to see a doctor, it was already in the advanced stage of gallbladder cancer, "it's already jaundiced and has metastasized, which is a pity."
Behind the disagreements among doctors
Zhang Yongjie believes that not only patients, but also medical workers should be more vigilant when dealing with gallbladder cancer.
During his consultation, many patients with gallbladder cancer will tell the history of gallbladder stones. Whenever he asks, "Why didn't you remove the gallbladder sooner?" The patient usually has two answers. ”, but when he was “uncomfortable”, he was diagnosed with advanced gallbladder cancer.
That's why he recommends cholecystectomy for patients with asymptomatic gallstones -- "symptoms" are subjective and can be tolerated differently by different patients.
Another answer is, "I have consulted an internal medicine or traditional Chinese medicine, ultrasound doctor, and the other party said that gallstones are very common, and you can ignore it if you have no symptoms."
"Many doctors have never seen gallbladder cancer and don't know the risk of cancer." Zhang Yongjie said that he has repeatedly called for multidisciplinary discussions on gallbladder cancer at national academic conferences. What it looks like, how dangerous its invasion is, how bad its recovery is, how painful the patient is, I believe they will no longer despise their opponents."
Zhang Yongjie's vigilance could not convince Hu Hai.
Hu Hai feels that experts sometimes become overly vigilant, "thinking that if you see gallbladder stones, it will be gallbladder cancer." He insists that the incidence of gallbladder cancer is only a small number in the population, and it is "good" to remove most of them for a small probability of the gallbladder, "lack of a dialectical materialist view".
Hu Hai believes that gallbladder cancer can be prevented.
"The probability of gallbladder cancer in patients with gallstones is less than 1 in 1,000." He said that after gallstone preservation, dynamic observation and follow-up can avoid risks.
In fact, Hu Hai's view contradicts some studies.
Foreign scientists have found that because gallbladder cancer is elusive, it is difficult to effectively reduce the incidence of cancer during follow-up.
Zhang Yongjie pointed out that there is still a lack of reliable and sensitive means for diagnosing early-stage gallbladder cancer, and now we can only be vigilant.
In addition, those with a family history of clustered tumors, long-term gallbladder disease, or changes in the characteristics of gallbladder pain are also high-risk groups.
When dangerous signs are found, further examinations should be actively carried out. In addition to B-ultrasound, hidden dangers can be screened by CT, MRI, and blood testing for tumor markers.
Still, even with the means described above, it's still possible for cunning gallbladder cancers to escape.
Zhang Yongjie suggested that more accurate screening methods for gallbladder cancer are still being explored. For example, his team is studying bile obtained by puncture and analyzing tumor markers in bile.
However, this invasive inspection method is difficult to implement on a large scale and is still in the research stage.
The Chinese people pay attention to the integrity of the body, which is one of the factors that make the bile stone extraction have a market in China.
However, Zhang Yongjie reminded that the gallbladder retained by surgical removal of stones is already a deteriorated gallbladder.
According to existing research, gallbladder lithogenesis is linked to the environment, the body, genetics, metabolism, inflammation, functional structure, and immunity.
Removing the stones does not change the hotbed of lesions.
Gallbladder-preserving surgery is facing a situation of being completely denied.
This makes Hu Hai unacceptable. He believes that no matter what era, protecting organs is a worthwhile endeavor.
Now in Hu Hai's department, gallbladder preservation also tends to be rational, "Two-thirds of the patients who come to us have their gallbladder removed, and only about one-third will try to preserve it. Our patients have been followed up. , the overall recurrence rate is 5.6%, and if patients were more carefully selected, the recurrence rate would be lower, right?"
Hu Hai believes that rational gallbladder preservation should meet two conditions. First, to maintain useful gallbladder, use the "poached egg experiment" to detect the response of the gallbladder after ingesting high cholesterol. The contraction function of the gallbladder needs to reach more than 50%; secondly, to preserve After the gallbladder is removed, it is necessary to continue to use drugs to improve the bile composition and prevent the recurrence of stones.
Without scientific research as a basis, any debate is like a castle built on sand.
Zhang Yongjie admitted that there is still a lack of the most basic scientific research on gallbladder cancer, which is also the root cause of the endless debate.
"When I was young, as a surgeon, I only performed operations and rarely studied the causes of diseases." Now that he is over sixty years old, he is leading a team to study genes or markers that may be related to gallbladder cancer. Helping to screen out who is more susceptible is a small contribution."
In the interview, he mentioned several times the American actress Angelina Jolie, who had both breasts removed when she was still healthy because of the presence of a breast cancer susceptibility gene.
"This is a very extreme case, but probably the easiest and most effective way to address her individual problems."
Zhang Yongjie acknowledged the "arbitrary" wording of the expert consensus.
He also emphasized that this is only an expert consensus, not a treatment guideline. "Guidelines require very strict high-level evidence, but we don't have these research results now." He said that the "expert consensus" approach is used to spread what everyone agrees. Viewpoint, "It does not violate scientific principles, because this is the personal experience and experience of experts, and it is also one of the evidences, but the level of evidence is slightly lower."
"China News Weekly" 2022 Issue 10
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