What are the treatment methods of cholecystolithiasis?

First, the surgical treatment of gallbladder stones:

In recent years, there have been many non-surgical treatments for gallstones, some of which were popular for a while, but they failed to pass the test of practice. Such as oral medicine lithotripsy, contact lithotripsy, extracorporeal shock wave lithotripsy, etc. The purpose of some interventional treatments is to remove stones and preserve gallbladder, such as percutaneous choledochoscope ultrasonic lithotripsy, lithotomy and small incision cholecystectomy. Its disadvantage is that the recurrence rate of stones is high, because they keep the hotbed of stone formation-pathological gallbladder. The so-called small incision cholecystectomy needs to establish a series of fine working procedures to get better results, rather than simply making the incision smaller. After years of practice, surgical treatment is still the first choice to treat symptomatic gallstones. Minimally invasive surgery is the current development trend of surgery, and laparoscopic cholecystectomy conforms to the current development trend.

1. Indications of open cholecystectomy for gallstones

(1) Cholecystolithiasis with acute cholecystitis, with definite surgical indications (suppurative, gangrenous and obstructive) within 72 hours.

(2) Chronic cholecystitis recurred, and non-surgical treatment was ineffective, and the gallbladder wall was thickened by ultrasound.

(3) Symptomatic gallstones, especially small stones that are easy to cause incarceration.

(4) The gallbladder atrophy has no function.

(5) Internal and external fistula of gallbladder, especially mucinous fistula after cholecystostomy.

(6) Gallbladder stones in diabetic patients.

2. Contraindications of open cholecystectomy for cholecystolithiasis

(1) Chronic pain in the right upper abdomen, which can't be explained by gallbladder lesions. No gallbladder abnormality was found by ultrasound and cholecystography.

(2) Before the cause of obstructive jaundice is clear, the gallbladder should not be removed blindly.

(3) Patients with severe heart, lung, liver and renal insufficiency or other serious medical diseases who cannot tolerate cholecystectomy.

3. Precautions:

For patients with acute cholecystitis who meet the following conditions, non-surgical treatment can be adopted first, and surgery can be selected after the acute stage.

(1) Young patients with mild initial symptoms.

(2) Patients with rapid remission after conservative treatment.

(3) The clinical symptoms are not typical.

(4) Patients who have been ill for more than 3 days, have no indications for emergency operation, and have been relieved by conservative treatment.

4. Common surgical methods include open cholecystectomy and laparoscopic cholecystectomy. Traditional open surgery is divided into anterograde resection and retrograde resection. In the case of abnormal anatomy of the gallbladder triangle or inflammation, edema and severe adhesion, the gallbladder can also be removed in combination with forward and backward directions.

(1) Anterograde cholecystectomy:

① Expose and treat cystic duct: cut the left peritoneum of the gallbladder neck along the outer edge of the hepatoduodenal ligament, carefully separate the cystic duct, and clamp the cystic duct 0.5cm away from the common bile duct for ligation.

② Treatment of gallbladder artery: dissect the gallbladder triangle, find the gallbladder artery, pay attention to its relationship with the right hepatic artery, and after confirming its distribution to the gallbladder, clamp, cut off and ligate it near the gallbladder, and double ligation at the proximal end. If the local anatomical relationship can be clearly defined, the gallbladder artery can be ligated and cut off before the cystic duct is treated. This way, the surgical field is clean and there is less bleeding. It can safely pull the cystic duct, straighten the twisted spiral cystic duct, and easily recognize the relationship with the common bile duct. If the gallbladder artery is not cut or ligated, it is likely to tear or break the gallbladder artery when pulling the gallbladder, resulting in massive bleeding.

③ Gallbladder stripping: The serosa of gallbladder was cut under the serosa on both sides of gallbladder, at a distance of 1 ~ 1.5 cm from the edge of liver. If you have acute inflammation recently, you can use your fingers or gauze balls to separate along the loose space under the serosa. If the gallbladder wall is thickened and difficult to peel off when it adheres to surrounding tissues, a small amount of sterile saline or 0.25% procaine can be injected under the serosa of the gallbladder for separation. When the gallbladder is separated, it can meet from the bottom of the gallbladder and both ends of the gallbladder neck to the middle, and the gallbladder can be removed. If there are communicating vessels and abnormal bile ducts between gallbladder and liver, they should be ligated and cut off to avoid postoperative bleeding or bile leakage.

④ Treatment of liver: After cholecystectomy, a small amount of oozing blood in gallbladder fossa can be compressed with hot saline gauze pad for 3-5 minutes to stop bleeding. Active bleeding point should be ligated or sutured to stop bleeding. After hemostasis, the serosa on both sides of gallbladder fossa was sutured intermittently with silk thread to prevent bleeding or adhesion. However, if the gallbladder fossa is wide and there is less serosa, suture is not necessary.

(2) Retrograde cholecystectomy:

① Serotomy at the bottom of gallbladder: clamp the bottom of gallbladder with oval pliers for traction, inject a small amount of normal saline under the serosa at the position around gallbladder 65438±0cm away from the liver boundary to make serosa edema float, and cut serosa at this position.

② separation of gallbladder: from the bottom of gallbladder, the gallbladder is separated from the body in the subserous space of gallbladder. Ligation and amputation in the separation process must be carried out near the gallbladder wall. If the adhesion is tight and it is difficult to separate, the bottom of the gallbladder can be cut, and the left index finger can be inserted into the gallbladder for guidance, and sharp separation can be carried out at the periphery of the gallbladder wall.

③ Expose and ligate the gallbladder artery: when reaching the neck of gallbladder, find the upper gallbladder artery, clamp, cut off and ligate the artery near the gallbladder wall, and double ligation at the proximal end.

④ Separation and ligation of cystic duct: clamp the neck of gallbladder and pull it outward, separate the covered serosa, find cystic duct, and trace it to the junction with common bile duct. See the relationship between them clearly, and clamp and cut off the gallbladder 0.5cm away from the common bile duct. Ligate the stump of cystic duct with middle silk thread, and then suture it.

(3) Laparoscopic cholecystectomy:

Laparoscopic cholecystectomy has become a mature surgical technique, which is accepted by the majority of patients because of its characteristics of less trauma, less pain and quick recovery. From 65438 to 0992, the Biliary Surgery Group of Surgery Branch of Chinese Medical Association investigated 3986 cases of laparoscopic cholecystectomy in China. Complications are slightly higher than those of open cholecystectomy, so we should strictly grasp the indications and contraindications of operation and strengthen technical training.

① indications:

A. symptomatic gallbladder stones. Chronic cholecystitis with symptoms. C. diameter >; 3cm gallstone. D. Gallbladder stones are full. Symptomatic and surgically demonstrated gallbladder protuberant lesions. F The symptoms of acute cholecystitis were relieved after treatment, and there were indications for operation. It is estimated that the patient has a good tolerance for surgery.

② Contraindications:

A. Relative contraindications are: A. Acute attack of calculous cholecystitis. Chronic atrophic calculous cholecystitis. Secondary common bile duct stones. Have a history of upper abdominal surgery. E. obesity External abdominal hernia.

B. Absolute contraindications: A. Acute cholecystitis with serious complications, such as gallbladder empyema, gangrene, perforation, etc. Acute biliary pancreatitis. Suffering from acute cholangitis. Primary common bile duct stones and intrahepatic bile duct stones. E. obstructive jaundice. F. gallbladder cancer. G. gallbladder protuberance lesions are suspected of canceration. H. portal hypertension caused by cirrhosis. First, the second and third trimesters. Abdominal infection and peritonitis. Others have chronic atrophic cholecystitis, the gallbladder is less than 4.5cm× 1.5cm, and the wall thickness is >; 0.5cm (ultrasonic measurement). Accompanied by hemorrhagic diseases and coagulation dysfunction. The dysfunction of important organs makes it difficult to tolerate surgery, anesthesia and pacemakers (electrocoagulation and electrocision are prohibited). Diaphragmatic hernia caused by elderly patients with poor general condition, unsuitable for operation or no strong indications for cholecystectomy.

With the development of technology, the indications of laparoscopic surgery are also expanding. Some diseases that were once relatively contraindications for surgery have also been tried to be completed by laparoscopy. For example, secondary common bile duct stones can be partially solved by laparoscopic surgery. After gaining the necessary experience, more diseases will be treated by laparoscopic surgery.

③ Surgical steps:

A. making pneumoperitoneum: make an arc incision along the lower edge of the umbilical fossa, about 10mm long. If the lower abdomen has been operated, you can cut the skin on the upper edge of the navel to avoid the scar left by the original operation. The surgeon and the first assistant lift the abdominal wall from both sides of the umbilical fossa with cloth towel pliers. The operator holds the pneumoperitoneum needle (Veress needle) with the thumb and forefinger of his right hand, and forces his wrist to puncture the abdominal cavity vertically or slightly obliquely to the pelvic cavity. There are two kinds of breakthrough feelings when the needle pierces fascia and peritoneum; Determine whether the needle tip has entered the abdominal cavity. It can be connected to a syringe pumped with normal saline, and shows negative pressure when the needle tip is in the abdominal cavity. Connect the blower. If the inflation pressure does not exceed 1.73kPa, it means that the pneumoperitoneum needle is in the abdominal cavity. When starting to inflate, it should not be too fast, but low flow rate, 1 ~ 2l/min. At the same time, observe the intra-abdominal pressure on the pneumoperitoneum machine. When inflating, the pressure should not exceed 1.73kPa. If it is too high, it means that the position of pneumoperitoneum needle is incorrect or the anesthesia is too shallow, and the muscles are not relaxed enough, so it should be adjusted appropriately. When the abdomen begins to bulge and the voiced boundary of the liver disappears, it can be changed to large-flow automatic inflation until it reaches the predetermined value (1.73 ~ 2.00 kPa). At this time, the patient's abdomen is completely raised, and the operation can be started.

Lift the abdominal wall with towel tongs at the umbilical pneumoperitoneum needle, and puncture it with 10mm trocar. 1 Puncture is a dangerous step in laparoscopic surgery, so be extra careful. Turn the trocar slowly and apply force evenly. When entering the abdominal cavity, there is a feeling that the resistance suddenly disappears. The closed air valve opens and the gas escapes, indicating that the puncture was successful. Connect the insufflator to keep the pressure in the abdominal cavity constant. Then put the laparoscope in and puncture at various points under the supervision of the laparoscope. Generally, puncture 2cm below xiphoid process, put in 10mm cannula, and prepare discharge hook, clip applicator and other instruments; Puncture 2cm below the rib edge of the right clavicle midline or 2cm below the rib edge of rectus abdominis and the axillary front line with a 5mm trocar, so as to put the irrigator and gallbladder fixing forceps in. At this point, artificial pneumoperitoneum and preparation work have been completed.

Because making pneumoperitoneum and 1 trocar puncture will accidentally injure the large blood vessels and intestines in abdominal cavity, it is not easy to find them during operation. Recently, many people have made a small incision on the navel to find the peritoneum, and directly put the trocar into the abdominal cavity to inflate.

After successful pneumoperitoneum, the operation began. Different hospitals have different habits in the division of operation. The General Hospital of the People's Liberation Army is in charge of all operations by the operators who master the gallbladder fixing forceps and electrocoagulation hooks. The first assistant grabs the irrigator, which is responsible for irrigation and suction, and assists the exposure of the surgical field; The second assistant is proficient in laparoscopy, so the surgical field of vision is always displayed in the center of the TV screen.

B. anatomy of B.Calot triangle: clamp the neck of gallbladder or Hartmann's capsule with grasping forceps and pull it to the upper right. It is best to draw the cystic duct perpendicular to the common bile duct, so as to distinguish it clearly, but be careful not to draw the common bile duct at an angle. The serosa on the cystic duct was cut by electrocoagulation hook, and the cystic duct and the gallbladder artery were blunted to distinguish the common bile duct from the common hepatic duct. Because it is close to the common bile duct, electrocoagulation should be used as little as possible to avoid accidental injury to the common bile duct. Use electrocoagulation hook to free cystic duct up and down. And see clearly the relationship between cystic duct and common bile duct. Place the titanium clip as close as possible to the neck of the gallbladder. There should be enough distance between the two titanium clips, and the titanium clips should be at least 0.5cm away from the common bile duct. Use scissors to cut between the two titanium clips. Do not use electric cutting or electrocoagulation to prevent heat conduction from damaging the common bile duct. Then find the gallbladder artery behind it and cut it with a titanium clip. After cutting off the gallbladder artery, don't pull hard to avoid breaking the gallbladder artery. Pay attention to the posterior branch of the gallbladder. Carefully peel off the gallbladder, electrocoagulation or titanium clip to stop bleeding.

C. Cholecystectomy: Hold the neck of the gallbladder and pull it upward, and carefully peel it off along the gallbladder wall. The assistant should assist in pulling, so that the gallbladder and liver bed have a certain tension. Remove the gallbladder completely and put it on the upper right side of the liver. Use electrocoagulation to stop bleeding, carefully rinse with normal saline, and check for bleeding and bile leakage (place a piece of gauze at the hilum of the liver, and check for bile staining after taking it out). After the ascites in the abdominal cavity is exhausted, the laparoscope is switched to the lower sleeve of xiphoid process, and the umbilical incision is loosened. The gallbladder with stones larger than 1cm can be taken out from the umbilical incision with loose structure and easy expansion, and if the stones are smaller, it can also be taken out from the puncture hole under xiphoid process.

D, taking out the gallbladder: the tooth claw forceps are sent to the abdominal cavity from the umbilical cannula, and the stump of the cystic duct is grasped under supervision, and the gallbladder is slowly dragged into the cannula sheath and pulled out together with the cannula sheath. When grasping the gallbladder, you should pay attention to putting the gallbladder on the liver to avoid sharp forceps teeth from accidentally injuring the intestine. If the stone is large or the gallbladder tension is high, it must not be forcibly pulled out to avoid gallbladder rupture and stone and bile leaking into the abdominal cavity. At this time, the incision can be enlarged and taken out with vascular forceps, or the incision can be enlarged to 2.0cm with dilator. If the stone is too large, the incision can be extended. If bile leaks into the abdominal cavity, wet gauze should be used to enter through the umbilical incision to suck the bile clean. When the stones are too big to be taken out from the incision, you can also open the gallbladder first, suck out the bile in the gallbladder with an aspirator, and take them out one by one after crushing the stones. If stones are found to have fallen into the abdominal cavity, they should be taken out.

After checking that there is no hematocele and fluid in the abdominal cavity, pull out the laparoscope, open the valve of the cannula, exhaust the carbon dioxide gas in the abdominal cavity, and then pull out the cannula. At the incision where the 10mm cannula was placed, the fascia layer was sutured with thin thread, and 1 ~ 2 stitches were stitched, and each incision was closed with sterile adhesive film.

④ Precautions during operation:

A. Precautions when making pneumoperitoneum: When abdominal puncture is performed on obese patients, the sense of two breakthroughs is not obvious. In order to confirm that the needle tip is really in the abdominal cavity, a syringe filled with normal saline can be connected to the pneumoperitoneum needle. If the normal saline in the syringe naturally flows into the abdominal cavity under the action of gravity, it means that the puncture needle has entered the abdominal cavity at this time. Keep an eye on the gas flowmeter when inflating, and the pressure should not exceed 1.73kPa at 4L/min. When inflated, the abdomen bulges evenly and the boundary of liver dullness disappears.

After pneumoperitoneum is established, in order to further confirm whether there is intestinal adhesion in umbilical region, Palmer aspiration test can be done: connect a 10ml syringe pumped with normal saline to a needle number. 18, penetrating into abdominal cavity through umbilical region. At this time, the carbon dioxide gas in the abdominal cavity pushes the normal saline of the syringe outward, and only the gas enters the needle tube, indicating that there is no intestinal adhesion here. If blood or fluid is not drawn out, it means there is local adhesion, if intestinal fluid is drawn out, it means there is.

B. Precautions in the use of high-frequency electrosurgical excision procedure: The accidental injury of common bile duct and intestine caused by electrosurgical excision procedure is the most common organ injury in laparoscopy, which should be paid attention to.

The insulating layer of laparoscopic instruments such as electrocoagulation hook should be complete, and it should be replaced in time when damaged; Preoperative preparation should be sufficient, enema should be done well to eliminate flatulence; It is safe to use low-voltage and high-frequency electrocoagulation at 200V, and ionization sparks should not be generated during cutting. For the injury of intestinal canal, the surgeon often failed to find it at that time, so the electrocoagulation instrument should always be placed in the monitoring screen during the operation; When using the electrocoagulation hook, the operator should keep the force upward (abdominal wall) to prevent the electrocoagulation hook from rebounding and burning the surrounding organs.

C.Calot triangle anatomy: mainly to prevent bile duct injury. Abnormal bile duct walking is very common, so be especially careful. During dissection, electrocoagulation should not be used to prevent damage to the common bile duct. It is best to dissect carefully only with electrocoagulation hooks or separation forceps. When Calot triangle adhesion is serious or congestion and edema are obvious, and the common bile duct is unclear, it should be wisely converted to open surgery.

D. Treatment of cystic duct: One of the causes of biliary fistula is improper treatment of cystic duct, too short or too thick cystic duct, and incomplete clamping of titanium clip, which often leads to difficulty in treatment of cystic duct. When encountering a short cystic duct, try to clamp the titanium clip on the side of the common bile duct, open the gallbladder side and suck out all the bile. Sufficient length should be left at the broken end of gallbladder to prevent the titanium clip from slipping. When you encounter a thick cystic duct, you should first ligate it with silk thread and then put on a titanium clip. At present, the existing large titanium clip has a better effect on the thicker cystic duct.

E. intraoperative cholangiography: there are many methods of cholangiography. The method of PLA General Hospital is to clamp the cystic duct on the gallbladder side first, and then make a small incision on the cystic duct. Clamp the cannula with a fixing clip, and inject contrast agent to take pictures. Laparoscopic monitoring was used during the operation. Now there are tweezers specially used for radiography, which are very convenient to use.

F. Take out the gallbladder: The abdominal muscles in the umbilical cannula hole are weak and easy to be separated by hemostatic forceps. When the gallstones are large, first lift the gallbladder neck away from the abdominal wall, open the gallbladder to suck out bile, and take the stones out of the gallbladder with lithotomy forceps. If the stone is large, it can be crushed in the gallbladder before being taken out. After taking it out, dry the blood and bile in the incision. Never pull it out forcibly when the incision is not big enough, so as to avoid the gallbladder rupture stones falling into the abdominal cavity. If stones fall into abdominal cavity, they should all be taken out, otherwise the residual stones will cause abdominal cavity infection and adhesion.

G. Laparoscopic cholecystectomy is a dangerous operation. The whole operation process should be recorded, so as to find out the reasons when there are surgical complications.

⑤ Main complications:

Bile duct injury: Bile duct injury is one of the most common and serious complications of laparoscopic cholecystectomy. The incidence of bile duct injury and bile leakage is about 65438 00%. We should pay enough attention to this. It is mainly due to unclear anatomy of Calot triangle, especially lack of vigilance against the variation of common bile duct or cystic duct. When the cystic duct was separated, the bile duct was accidentally damaged by heat, and there was no bile leakage during the operation. Postoperative necrosis and shedding of tissue in thermal injury area can also cause bile leakage. In addition, the gallbladder bed often has a large vagus bile duct, which can not be completely coagulated by electrocoagulation during operation, and can also form bile leakage. The main manifestations of bile duct injury are severe epigastric pain, high fever and jaundice. Those with typical manifestations are generally treated in time after operation; However, a few patients only showed abdominal distension, loss of appetite and progressive aggravation of low fever. Such patients should be closely observed, and it is reported that bile accumulation in abdominal cavity was found several months after operation. Judging whether there is bile leakage mainly depends on ultrasound or CT examination, and then the diagnosis is made by fine needle puncture or radionuclide cholangiography under the guidance of ultrasound or CT.

B. Vascular injury: One kind is that when making pneumoperitoneum and placing trocar, the tip of the needle injures the abdominal aorta, iliac artery or mesenteric blood vessels, which leads to massive bleeding, and reports of death caused by trocar puncture are common. Therefore, after successful pneumoperitoneum, laparoscopy should peep through the whole abdomen to prevent missing blood vessel injury; The other is that the anatomy of the hepatic portal is unclear or the gallbladder artery bleeding mistakenly clamps the right hepatic artery or the proper hepatic artery, and there are also reports that the portal vein is injured during dissection. 1 case of right liver necrosis caused by hepatic artery clamping error.

C. Intestinal injury: Intestinal injury is mostly accidental injury caused by electrocoagulation, mainly because the electrocoagulation hook was not placed on the TV monitoring screen and was not found. Abdominal pain, abdominal distension and fever occurred after operation, causing severe peritonitis and high mortality.

D. Postoperative intra-abdominal bleeding: Postoperative intra-abdominal bleeding is also one of the serious complications of laparoscopic surgery, and the main injury sites are blood vessels near the gallbladder, such as hepatic artery, portal vein, and abdominal aorta or vena cava during periumbilical puncture. It is characterized by hemorrhagic shock, abdominal distension and peripheral circulation failure. Open surgery should be performed immediately to stop bleeding.

E. subcutaneous emphysema: the causes of subcutaneous emphysema: first, when making pneumoperitoneum, the pneumoperitoneum needle did not penetrate the abdominal wall and high-pressure carbon dioxide entered the skin; Second, because the skin incision is small, the trocar is tightly embedded, the peritoneal puncture hole is loose, and carbon dioxide gas leaks into the subcutaneous layer of the abdominal wall during the operation. Postoperative examination can find abdominal subcutaneous torsion pronunciation, generally without special treatment.

Others: such as incisional hernia, incision infection and abdominal abscess.

Second, other special therapies:

Non-surgical treatment of cholecystolithiasis includes litholysis, lithotripsy, extracorporeal shock wave lithotripsy and endoscopic lithotripsy. The first three species are non-invasive, and the last 1 species are invasive. Clinical practice shows that the lesions of gallstones are located in the gallbladder. Only the above-mentioned non-surgical treatment can temporarily remove stones for some patients, but it can not radically cure the gallbladder itself. Long-term recurrence of gallstones is inevitable, so we should be cautious in choosing non-surgical treatment for gallstones.

(1) Lithotripsy: At present, the main drugs for litholysis are chenodeoxycholic acid (chenodeoxycholic acid) and ursodeoxycholic acid (ursodeoxycholic acid). Chenodeoxycholic acid (CDCA) is extracted from bovine bile and its structure is the same as that of human liver. Oral capsule preparation, 250 ~ 1000 mg per day, the absorption rate is 80% ~ 90%. After absorption, it is transported to the liver, where it combines with glycine and taurine and is secreted into the biliary tract with bile. The mechanism of chenodeoxycholic acid can be summarized as follows: ① Restrict cholesterol biosynthesis by inhibiting HMG-CoA (coenzyme) in liver; ② Reduce the absorption of intestinal cholesterol; ③ Decrease the activity of 7α- hydroxylase, inhibit the biosynthesis of endogenous cholic acid, and reduce the entry of cholesterol into the exchange cholesterol pool; ④ chenodeoxycholic acid can increase low density lipoprotein in blood.

However, chenodeoxycholic acid's treatment also has side effects. The main side effects are: ① The elevation of serum transaminase is generally temporary, rarely exceeding twice the normal level; (2) Serum cholesterol continues to increase; ③ Diarrhea occurred in the high dose group. The dosage of chenodeoxycholic acid is 0/0 ~ 20 mg/d per kg body weight/kloc, so the bile of most patients is in a state of cholesterol unsaturation, and the ratio of bile acid to lecithin/cholesterol reaches about 20. Chenodeoxycholic acid's course of treatment is 6 months to 2 years, which is suitable for most small cholesterol stones with gallbladder contraction function, but the effect on large single stones is very poor. Most gallstones in China are mixed stones, and the effect of drug treatment is even worse. The biggest problem of chenodeoxycholic acid's treatment is the recurrence of gallstones after stopping the treatment. 25% ~ 50% of patients relapse, often after 3 months, and the annual recurrence rate is 10%.

Ursodeoxycholic acid is the 7-β isomer of chenodeoxycholic acid. Its effect is better than that of chenodeoxycholic acid, and there is no side effect of chenodeoxycholic acid. The mechanism of action is different. UDCA has no inhibitory effect on cholesterol biosynthesis and cholic acid biosynthesis, but it can increase the content of UDCA in bile. UDCA has fewer side effects, and the effect may be better. The dosage of UDCA is: 8 ~ 13 mg per kilogram of body weight per day, taken in three times.

The combined application of chenodeoxycholic acid (chenodeoxycholic acid) and ursodeoxycholic acid (ursodeoxycholic acid) in half amount can enhance the litholytic effect and reduce the side effects when each medicine is used alone.

To sum up, chenodeoxycholic acid and/or UDCA are only effective for cholesterol gallstones, and are only suitable for patients whose gallstones are less than 1cm in diameter, and the number can be single or multiple, and the gallstones are examined by X-ray and their gallbladder functions are good. Continuous medication is effective for six months to two years. Due to the long course of treatment, less than 10% can persist in treatment. High recurrence rate, side effects and high drug price limit its application. In recent years, it is often used in combination with shock wave lithotripsy and becomes an integral part of the systematic treatment of cholelithiasis.

(2) Extracorporeal shock wave lithotripsy (ESWL): China held the first national symposium on extracorporeal shock wave lithotripsy of biliary tract in June, and reported 6357 cases of ESWL. ESWL treatment of cholelithiasis has not been carried out for a long time at home and abroad, but it has a wide influence. At present, the third generation extracorporeal shock wave lithotripsy with high degree of automation has appeared. According to the different extracorporeal shock wave generators, it can be divided into three types: ① electro-hydraulic shock wave; (2) Electromagnetic shock wave, which uses the working principle of electromagnetic pulse generator to break stones; (3) piezoelectric shock wave, is the principle of using the piezoelectric effect of gravel.

According to the indications of the first national (199 1) biliary ESWL conference, gallstones are: ① symptomatic gallstones; ② Oral cholecystography confirmed normal gallbladder function; ③ gallbladder negative stones; ④ 5 ~ 25mm single stone or 5 ~ 15mm 2 ~ 5 stone.

Contraindications are: ① The gallbladder is not developed by oral cholecystography or the gallbladder position is too high or abnormal, which makes it difficult to locate stones; ② Positive stones; ③ gallbladder atrophy or gallbladder wall thickening more than 5mm; ④ Acute cholecystitis; ⑤ Coagulation mechanism disorder; ⑥ Patients with heart, lung, liver, kidney and duodenal ulcers, especially those with pacemakers, should not choose this therapy; ⑦ Pregnancy; (8) Crushing the stone for three times is still invalid.

Complications and prevention of ESWL: Common complications include biliary colic, which occurs in about13 patients; About 65438 0.4% patients have ecchymosis under the skin. About 65438 0.2% patients developed pancreatitis; In addition, there are fever, jaundice, arrhythmia, cholangitis, melena, hematuria, bloodshot phlegm, biliary bleeding and so on. In severe cases, shock will occur. In order to improve the safety of shock wave lithotripsy and prevent the occurrence of side effects, it is necessary to strictly control the case selection, continuously improve the overall performance of the lithotriptor and the quality of the staff, and form a treatment team with experienced surgeons to guide ESWL treatment.

The curative effect evaluation includes two parts: the largest fragment of gravel is less than 4mm, and all the gravel is discharged. Ultrasonic examination proved that there was no stone in gallbladder, and oral cholecystography proved that gallbladder function was normal and clinical symptoms disappeared completely.

In order to completely discharge the broken gallstone fragments, it is necessary to rely on: ① natural discharge of the fragments; ② Lithotripsy; ③ Lithotripsy treatment. The natural stone removal rate of cholecystolithiasis is less than 65438 0%. To improve the curative effect of ESWL depends largely on the progress of litholysis and lithotripsy.

(3) Lithotripsy: Based on the functions of some traditional Chinese medicines, such as increasing bile secretion, promoting gallbladder contraction and expanding Oddi sphincter, combined with modern medical knowledge, a calculus-removing therapy combining traditional Chinese and western medicine was formed. The main drugs of traditional Chinese medicine preparation for removing calculus are Lysimachia christinae and Herba Artemisiae Scopariae. Followed by rhubarb and mirabilite; Western medicine has magnesium sulfate, which can benefit gallbladder and reduce the tension of Oddi sphincter. The latter has the strongest effect after taking medicine for 40min. The dosage of magnesium sulfate is 33% solution 10 ~ 20 ml, taken orally three times a day. The effective therapy of traditional Chinese and western medicine is mainly in the common bile duct.

(4) Contact litholysis: Thistle first used percutaneous gallbladder puncture and inserted tube, and injected methyl butyl ether (MTBE) for contact litholysis. MTBE can quickly and effectively dissolve cholesterol stones, and its boiling point is 55.2℃, which is higher than that of ether. It will not volatilize immediately after entering the human body, and cholesterol stones can be dissolved after contacting for about 24 hours.

The application conditions require less gallstones, transparent X-ray, good gallbladder function and no acute inflammation. Pay attention to pumping as much bile as possible before injection, and the specific gravity of MTBE is 0.74. If bile exists, it will be stratified, which will affect the stone dissolving effect. MTBE liquid medicine should be changed regularly to ensure that effective liquid medicine is in contact with gallstones. According to the literature, the side effects of this drug in contact with dissolved stone include: ① burning pain in the upper abdomen; ② Causes enteritis and hemolysis, which mostly occurs when the liquid medicine is perfused too fast; ③ Localized hepatic parenchymal necrosis and hemorrhagic pneumonia. Animal experiments show that MTBE has strong hemolysis and acute inflammatory reaction of gallbladder mucosa. Therefore, it is dangerous to dissolve stones with MTBE, so we must be very careful. MTBE cannot be used for bile duct litholysis. Up to now, dozens of drugs for dissolving cholesterol gallstones have been reported, and the drugs discussed more are: compound monoglyceride octanoate, compound orange oil mixture and so on.

Gallstone prescription

1. Grind 30g of Endothelium Corneum Gigeriae Galli, 30g of Lygodium japonicum, and 0/0g of Radix et Rhizoma Rhei into fine powder, and mix with ginger and licorice soup, each time10g.

2. Sunflower leaves 30g, Endothelium Corneum Gigeriae Galli 15g, and Kochia scoparia 15g. Decoct with water. I do it once a day and twice a day.

3. Semen Sinapis Albae 30g, Endothelium Corneum Gigeriae Galli 30g, Semen Plantaginis10g. Apply * * * medicine to the ground powder, 3g each time, twice a day.

4. 30 grams of Sophora japonica bark, 30 grams of mung beans and 3 grams of licorice. Decoct with water. Daily 1 dose, taken twice.

5. Lysimachia christinae100g, Lygodium japonicum 30g, talc 12.

6. 50 grams of Lysimachia christinae, 0/5g of Bupleurum chinense/kloc, 0/0g of rhubarb, 0/0g of mirabilite/kloc (washed) and 0/0g of rhizoma corydalis/kloc. * * * Decoct into decoction, and take it in the morning and evening 1 time. Is suitable for patients with cholecystolithiasis, hepatolithiasis and choledocholithiasis.

7. Flos Lonicerae 25g, Herba Taraxaci 25g, Herba Lysimachiae Christinae 25g, Radix Bupleuri 20g, Pericarpium Citri Reticulatae Viride 20g, Pericarpium Citri Tangerinae 20g, Herba Dendrobii 20g, Radix Paeoniae Alba15g, Fructus Forsythiae15g, Scutellariae Radix10g, Rhizoma Sparganii10g. Decoct with water, daily 1 dose, twice a day. It is suitable for stagnation of qi in liver and gallbladder and accumulation of damp heat, and has the effect of soothing the liver and detoxifying fossils.

8. Xiaoshi powder: Yujin powder 0.6g, Alum powder 0.45g, Glauber's salt powder 1 g, talcum powder10.8g, and licorice root tip 0.3g.. The above is the daily dose, which is swallowed twice. Suitable for patients with qi stagnation.

9. Lidan Pill: Herba Artemisiae Scopariae 12g, Radix Gentianae, Radix Curcumae, Radix Aucklandiae and Fructus Aurantii 9g each, * * * ground into fine powder, added with 500g of pig bile liquid and sheep bile juice (the bile liquid is boiled to half a catty first), mixed with the medicinal powder, and added with appropriate amount of honey to make pills. Each pill weighs 9g, and each pill is taken 1 in the morning and evening.

10, Rhizoma Polygoni Cuspidati 30g, Herba Lysimachiae Christinae, Herba Artemisiae Scopariae 30g, Radix Cyathulae, Lygodium japonicum 30g, Radix et Rhizoma Rhei15g, Endothelium Corneum Gigeriae Galli15g, Radix Bupleuri and Radix Curcumae 9g each. Decoct that above raw materials into extract, adde white sugar essence and granulated sugar, stirring uniformly, baking and granulate. 20g each time, three times a day, with boiled water after meals, 2 weeks for 1 course of treatment.