Patients with cholelithiasis, when complaints arise, seek medical help from a therapist, who conducts an examination and makes recommendations on the need for surgical treatment. After the operation, patients are also monitored by a therapist. Thus, despite the fact that the main method of treatment for cholecystolithiasis is surgical, patients are observed mainly by therapists, which leads to the need for them to have the necessary knowledge, including methods of surgical treatment of cholelithiasis.

The widespread use of laparoscopic technologies in the treatment of cholecystolithiasis and the good results of cholecystectomy in the immediate postoperative period may create the impression of the harmlessness of gallbladder removal and complete restoration of the gastrointestinal tract in the postoperative period.

Conducting laparoscopic cholecystectomy changes the patient's lifestyle and eating behavior after the operation. In the literature, one can find a sufficient number of publications on changes in the quality of life of patients after gallbladder removal by open and laparoscopic methods.

Considering the fact that surgical treatment is mainly performed on middle-aged and elderly patients, both doctors and patients do not always make a connection between the emerging disorders of the organs of the hepatopancreatoduodenal zone and intestine with cholecystectomy in the remote periods after the operation. In the early postoperative period, there is also often insufficient evidence of the occurrence of complications arising from this surgical intervention precisely because of cholecystectomy. All this has led to the use of a general term, "postcholecystectomy syndrome," which includes all changes after surgical removal of the gallbladder.

There is no single definition of the concept of “postcholecystectomy syndrome.” In the literature, this term is understood as a symptom complex of pathological changes identified after laparoscopic cholecystectomy, including functional disorders, painful manifestations, as well as cases of previously unidentified concomitant diseases and the development of residual and recurrent choledocholithiasis. One of the first in literature to raise the topic of “postcholecystectomy syndrome” was V.M. Sitenko and A.I. Nechai in the monograph “Postcholecystectomy syndrome and repeated operations on the biliary tract” in 1972 [1] and P. Malle-Gi et al. in the monograph “Syndrome after cholecystectomy,” translated from French in 1973 [2]. Over the past 50 years, with changes in the level of medicine (improving the quality of preoperative and intraoperative diagnostics and the introduction of new medical technologies), the structure of postcholecystectomy syndrome [3,4]. More often, the term “postcholecystectomy syndrome” (“true” postcholecystectomy syndrome) refers to disorders resulting from dysfunction of the sphincter of Oddi after surgical removal of the gallbladder, regardless of whether the operation was performed openly, laparoscopically, or through a mini-access. Postcholecystectomy syndrome can develop in patients immediately after surgery or a long time after it.

Dysfunction of the sphincter of Oddi develops as a result of increased pressure in the bile ducts after removal of the gallbladder for cholelithiasis, since the process of bile formation is constant, and there is no longer a reservoir for its accumulation. After removal of the gallbladder in the postoperative period, there is no simultaneous release

of accumulated bile, which is observed when the bladder is emptied after eating food, and an expansion of the common bile duct is also noted. Surgical treatment of cholelithiasis with preservation of the gallbladder can significantly reduce the incidence of “true” postcholecystectomy syndrome.

There are frequent cases of dysfunction of the sphincter of Oddi even in unoperated cholelithiasis (including cases of asymptomatic disease) due to the passage of small stones through the major duodenal papilla and its permanent injury. In the diagnosis of sphincter of Oddi dysfunction in gallstone disease, there are a number of difficulties in the clinical interpretation of symptoms, in the availability in everyday medical practice of diagnostic methods confirming the diagnosis of dysfunction, etc. [5]. Untimely recognition of sphincter of Oddi dysfunction in such patients leads to increased load on the sphincter apparatus of the major duodenal papilla after surgical treatment.

Gallstone disease plays a particularly important role in the development of chronic biliary pancreatitis due to the peculiarities of the anatomical structure of the biliary system and its close connection with the main pancreatic duct, which in some cases requires preoperative preparation in patients with cholecystolithiasis [6,7].

In terms of the number of surgical interventions, laparoscopic cholecystectomy consistently occupies one of the first places in modern surgery due to the widespread dissemination of laparoscopic technologies, relatively good immediate results of surgical treatment, the possibility of delayed operations, including cases of acute cholecystitis, as well as a small number of contraindications to this surgical treatment [8,9]. Dysfunction of the sphincter of Oddi in the long term after removal of the gallbladder leads to disruption of the balanced functioning of all organs of the hepatopancreatoduodenal zone and requires its timely preoperative drug correction, which in fact should be part of the preoperative preparation of the patient.

As stated above, it is extremely difficult to prove the connection between the disorders that arise in the gastrointestinal tract in the long term after gallbladder removal.

Organ-conserving operations for cholelithiasis, due to the preservation of the bile outflow mechanism, do not lead to an increase in the load on the sphincter of Oddi and can be considered as a method of preventing postcholecystectomy syndrome in the postoperative period.

An alternative to cholecystectomy is performing ideal cholecystolithotomy or laparoscopic cholecystolithotraction. This operation involves removing stones from the gallbladder cavity while preserving the bladder itself.

In the Republican Center for Functional Surgical Gastroenterology (Krasnodar, Russian Federation) in 2004-2006, endoscopic methods removal of stones from the gallbladder with the preservation of the bladder have been developed and implemented.

The technique of endoscopic organ-preserving surgery in the presence of stones in the gallbladder (laparoscopic cholecystolithoextraction) consisted of opening the lumen of the gallbladder using standard laparoscopic access, its revision using a choledochoscope, removing the stone, followed by suturing the cholecystostomy wound and preliminary double external drainage according to the method of Onopriev A.V. Based on the results of developments in 2007, 2 inventions were registered and 2 patents were received related to organ-preserving operations for gallstone disease.

The gallbladder cavity during surgery and in the early postoperative period was washed with a solution containing furacilin, chymotrypsin, and hydrocortisone. The need for lavage was due to the impact on such mechanisms of the development of cholecystolithiasis as inflammation (hydrocortisone 0.5%), infectious factors (furacillin 0.02%), and decreased protein concentration in bile (chymotrypsin 0.2%) [10].

For the endoscopic removal of stones from the gallbladder, a special device has been developed (Fig. 1), containing a tubular body with a handle and a tube placed inside it with an endoscope installed inside with petals on the working stone, which are installed with the ability to compress when entering the body. A tubular rod is placed inside the tube, with the ability to connect a suction system. The technical features of the invention make it possible to capture stones with petals under the control of an endoscope, crush large stones with rigid petals, and remove small stones using a suction system after removing the endoscope [11].

In the period from 2004 to 2008, under the leadership of Doctor of Medical Sciences Onopriev A.V. and Head of the Endoscopic Department Gabriel S.A., 12 surgical interventions were performed at the Republican Center for Functional Surgical Gastroenterology.

Figure 1: Device for Endoscopic Removal of Gallstones.

Designations:

1 – Handle on the rod,

2 – Handle on the tube,

3 – Handle on the body,

4 – Trocar,

5 – Tube,

6 – Hard petals,

7 – Body,

8 – Hole for installing an endoscope,

9 – Tubular rod,

10 – Connection point for the suction system.

In the study, all patients were female, aged from 19 to 57 years; the average age was 41.7 years. In patients undergoing surgical intervention, ultrasound examination revealed from 1 to 3 stones with a diameter of 8 to 20 mm. The average stone diameter was 13.9 mm.

Mandatory conditions for organ-preserving surgical intervention were

• Presence of preserved contractile function of the gallbladder,
• Absence of inflammation of the gallbladder wall,
• Average size of the stones, allowing them to be captured and removed from the cavity of the gallbladder while maintaining its anatomical integrity,
• No signs of sphincter of Oddi dysfunction,
• The patient does not have gastric and duodenal ulcers or visible pathology of the major duodenal papilla during endoscopic examination.
• No signs of the presence of stones in the biliary tract,
• Absence of previously established liver and pancreas disease,
• The patient’s desire to undergo organ-conserving surgery despite the risk of relapse.

Regarding concomitant somatic pathology, strict contraindications were general contraindications for any surgical intervention, use of anesthetics, intubation, etc. There were no contraindications for laparoscopic cholecystolithoextraction from pathology of other organs and systems. Nevertheless, we tried not to include patients with severe decompensated somatic pathology in the study.

The first control examination of the operated patients was scheduled from May 2009 to January 2011, at a time after surgery ranging from 8 months to 5 years and 4 months, respectively (an average of 2 years and 2 months). The earliest control examination of the patient (8 months) was caused by the appearance of pain in the epigastric region and an independent ultrasound examination gallbladder, the results of which revealed stones. Patient Sh. was the first to undergo laparoscopic cholecystolithectomy (in 2004); however, due to living in another city, she was unable to come for a control examination for a long time. As a result, she was seen 5 years and 4 months after the operation.

The patients were interviewed, examined objectively by physical examination methods, and underwent general clinical and biochemical blood tests, ultrasound examination of the abdominal organs, and endoscopic examination of the stomach and duodenum. There was no need for additional research methods in any of the examined patients.

According to the results of the first control examination, stones were identified in 3 patients. In the first case, 5 stones 3-7.5 mm in diameter; in the second, 2 stones 4.3 and 3.8 mm in diameter; and in the third case, 2 stones 12 and 11 mm. Hyperechoic suspension in different quantities was visualized in 4 patients. In 5 patients no signs of cholelithiasis were detected. All patients who did not have a relapse of the disease (9 people) were examined. There were no clinical or ultrasound signs to suspect postcholecystectomy syndrome.

Starting in 2011, due to the reorganization and subsequent liquidation of the Republican Center for Functional Surgical Gastroenterology, monitoring of patients was discontinued.

In 2023, we established contact with patients in whom, during the first control examination, a hyperechoic suspension was identified or there were no stones (second control examination, average time—15 years and 6 months after surgery). Of the 9 people, no stones were detected in 3 patients, laparoscopic cholecystectomy was performed in 3 patients (in 2013, 2021, and 2022), and the connection with 3 patients could not be established. Patients who did not have a relapse of the disease (3 people) were examined. No clinical or ultrasound signs of postcholecystectomy syndrome were detected in them.

In the study of patients with newly developed cholecystolithiasis who required reoperation (laparoscopic cholecystectomy), none of the above patients had any regrets about the experimental operation or negative feedback about this surgical intervention.

The development of postcholecystectomy syndrome is the main disadvantage of laparoscopic cholecystectomy due to disruption of the bile outflow mechanism after removal of the gallbladder. The basis of the so-called true postcholecystectomy syndrome is dysfunction of the sphincter of Oddi; in addition, the development of other diseases of the organs of the hepatopancreatoduodenal zone can also in one way or another be associated with impaired bile outflow. The exception is cases of previously undetected diseases, including residual choledocholithiasis, when the question arises about the advisability of surgical treatment. In all of the above cases, organ-preserving intervention may be an alternative to laparoscopic cholecystectomy.

The fact that patients with cholelithiasis are observed mainly by therapists, and the choice of surgical treatment method remains with the surgeon, may play an important role in the insufficient distribution of methods of organ-preserving operations for cholelithiasis.

In 9 out of 12 patients (75%) who underwent laparoscopic cholecystolithoextraction during the first control examination in the immediate postoperative period and 3 out of 12 patients (25%) during the second control examination in the long-term postoperative period, no relapse of the disease was detected and signs of postcholecystectomy syndrome.

These operated patients are not subject to the classification of cholelithiasis adopted by the Congress of the Scientific Society of Gastroenterologists of Russia in 2002, which distinguishes 4 stages of the disease:

Stage I – initial, or pre-stone:

1. Thick heterogeneous bile,
2. Formation of biliary sludge: with the presence of microlites, with the presence of putty-like bile, or a combination of putty-like bile with microliths.

Stage II – formation of gallstones.

Stage III – chronic recurrent calculous cholecystitis.

Stage IV – complications.

In this case, the pathology should be classified as the presence of “cholelithiasis without cholelithiasis, thick heterogeneous bile, and biliary sludge,” and such patients must be registered with a dispensary for this disease with a mandatory examination, including an ultrasound examination of the abdominal organs, at least once every 3-6 months. It is dispensary observation that is extremely necessary for this group of patients to prevent recurrence of cholecystolithiasis by prescribing timely litholytic and choleretic therapy at the acalculous stage of lithogenesis using modern technologies [12]. The opinion that the inevitability of reformation of stones casts doubt on the prevention of cholelithiasis as such. Considering that the average growth of stones is 3-5 mm per year, we consider examination of patients once every 3-6 months sufficient.

Of the 12 patients operated on by laparoscopic cholecystolithoextraction, in 9 of them (75%) we did not detect a relapse in the immediate postoperative period (on average 2 years and 2 months), and in at least 3 of them (25%) there was no recurrence of stone formation in the long-term period (on average after 15 years and 6 months) despite the lack of dynamic monitoring of patients. When examining all patients in whom no relapse of the disease was detected (9 people in the immediate postoperative period and 3 people in the late postoperative period), no clinical or ultrasound signs of postcholecystectomy syndrome were identified.

Thus, performing organ-preserving surgical interventions for cholelithiasis (laparoscopic cholecystolithoextraction) made it possible not only to preserve the gallbladder in at least 3 out of 12 patients (25%) for at least 15 years after surgery, despite the lack of follow-up for patients, but also to prevent postcholecystectomy syndrome in them. The data obtained from the study are not statistically reliable due to the small number of patients and can be confirmed or refuted in a larger targeted study.

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