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Common Bile Duct Strictures
JULY 1990, VOL. 52.
NO I
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Common Bile Duct Strictures DIAGNOSIS, MANAGEMENT, FOLLOW-UP Mary E. Front, RN; Stephen R. Wise, MD; Larry C . Carey, MD
T
raumatic strictures are the most common sequelae of injury to the bile ducts. Surgical injury, most commonly during cholecystectomy, is the major cause of benign bile duct stricture. The incidence of biliary tree injury is two injuries per 1,000 procedures for gallstones.' Less common causes of biliary damage that require reconstruction include blunt or penetrating trauma and inflammatory disease involving the extrahepatic biliary tree (ie, pancreatitis, peptic ulcer disease). The need for biliary tree reconstruction is a significant problem for the surgical team. Strictures, which range between 1 and 3 cm in length, usually are found at the junction of the cystic and common bile ducts. Biliary obstruction, as a result of untreated stricture, can lead to recurrent cholangitis and biliary cirrhosis with lifethreatening consequences.
A natomy/Physiolog;v
T
he right and left hepatic ducts drain bile from their respective lobes and converge outside the liver parenchyma to form the common hepatic duct (Fig 1). The gallbladder acts as a reservoir for concentrated bile. It holds between 50 and 75 mL of bile until it is stimulated to release bile into the intestines to aid with fat digestion. The gallbladder mucosa concentrates bile by absorbing water and electrolytes, thus leaving active bile salts. The gallbladder is connected to the common hepatic duct by the cystic duct, and their convergence forms the common bile duct. Because
variations in patients' anatomy of this portion of the biliary tree are common, surgery can be complex. The common bile duct is joined by the pancreatic duct at its entrance to the duodenum. The junction of these ducts is surrounded by a muscular sphincter, and the duct travels within the duodenal wall. This structure is referred to as the ampulla of Vater or the sphincter of Oddi.
Signs, Symptom, Diagnosis
B
ile duct injury can be diagnosed during surgery, in the immediate postoperative period, or at some delayed time. Postoperatively, patients with bile duct injury may have bilious drainage from the wound or drain site indicating a biliary cutaneous fistula. This fistula is caused by bile leakage from the liver surface, Mary E. (Betsy) Front, Rh? BSN, is the clinical coordinator and research nurse, Grant Medical Center, Columbus, Ohio. She received her bachelor of science degree in nursing from Wheeling (WVa) Jesuit College. Stephen R. Wise, MD, FRCS, is an assistant professor of surgery, University of Chicago Health Sciences Center. He received his medical degree from McGill University,Montreal. Larry C. Carey, MD, is the director of medical affairs, Grant Medical Center, Columbus, Ohio. He received his medical degree from Ohio State University College of Medicine, Columbus. 57
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right and left hepatic ducts
common hepatic duct
superior mesenteric
sphincter muscles
Fig 1. Illustration of gallbladder, pancreas, bile ducts, and duodenum. The shaded area represents the most common site for biliary strictures to occur.
unligated or injured bile ducts, or loss of bowel integrity. Bile also may drain intraabdominally causing distension or peritonitis. The first indication of a problem may be jaundice. In some patients, signs and symptoms of bile duct injury are delayed as the duct begins to form a stricture during postoperative healing. Patients may have right upper quadrant pain, nausea, vomiting due to distension of the blocked biliary tree, fever due to cholangitis, or diarrhea due to fat malabsorption. Patients appear jaundiced, and 58
their sclera, mucus membranes, and skin will become yellow. Patients’ stools may become pale (ie, acholic), and their urine may become frothy and cola-colored as bile metabolites are passed by kidneys. In the late stages of bile duct obstruction, pruritus may develop as irritating bile acids are deposited within the skin. Nurses must closely evaluate the postbiliary surgery patient for signs of jaundice, bilious drainage from wound and drain sites, or excessive abdominal pain, distension, and fever associated
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In completing the diagnostic workup, it is important that patients and their families understand which tests will be performed and why. with intraabdominal sepsis. Patients also should be educated in these manifestations; however, only a small percentage of all cholecystectomies are associated with postoperative stricture. It is the responsibility of the nurse in an outpatient setting to obtain a complete patient history. Special attention needs to be directed toward the signs and symptoms of abdominal pain, jaundice, fever, acholic stools, or dark urine. The nurse should record how long the symptoms have been present and the order of events that led to the current episode. A complete list of medications and allergies should be included in the history. Diagnostic studies to evaluate the problem may be done on an outpatient or inpatient basis, depending on the circumstances and when the diagnosis is established. Laboratory tests and radiologic procedures will be helpful in determining the extent of the problem. In completing the diagnostic workup, it is important that patients and their families understand which tests will be performed and why. It also is important that patients receive complete instructions on how to prepare for the examination. Blood tests. The simplest form of testing involves a blood test for evidence of hepatic dysfunction, infection, or pancreatitis. Alkaline phosphatase, an enzyme produced by the lining of the hepatic bile ducts, is hypersecreted when a biliary obstruction is present. When the alkaline phosphatase level is elevated out of proportion to other liver enzymes (eg, aspertate amino transferase [AST], alanine aminotransferase [ALT], gamma-glutamyl transferase [GGT], lactate dehydrogenase [LDH]), it is a reliable indicator in diagnosing bile duct obstruction as opposed to other hepatobiliary abnormalities. Serum bilirubin is elevated when the liver is unable to properly metabolize and excrete bile into the gut. An elevated white blood count implies the presence of infection within the biliary tree, and
elevated amylase is suggestive of stricture involving the pancreatic duct as well. When the physician suspects an obstruction based on clinical impression and laboratory information, the patient is ready for a more direct examination of the biliary tract. Ultrasound. An ultrasound is a radiologic technique that records the reflection of sound waves directed at deep strictures of the body. This test may detect dilated bile ducts proximal to the point of stricture. The value of ultrasound is limited because partial obstructions may not lead to ductal dilation. A negative study, however, does not exclude a stricture. Patients who will undergo abdominal ultrasound are instructed to remain NPO after midnight, while a pelvic ultrasound only requires a full bladder. Endoscopic retrograde cholangiopancreatography (ERCP). During this procedure, patients are sedated and a flexible endoscope is passed through the esophagus and stomach into the duodenum. The surgeon or gastroenterologist cannulates the biliary tree, and under fluoroscopy, injects dye into the common bile and pancreatic ducts. The surgeon can visualize the location of the bile duct stricture, leak, or anastomotic abnormality. Biopsies of suspicious lesions may be taken. If the surgeon can visualize only the distal portion of the duct, further tests may be required. Patients are instructed to remain NPO after midnight before the exam and inform their physicians if severe pain or a fever above 101 O F (38 "C) occur after the procedure. There is a 1% to 5% complication rate with ERCP. Cholangitis and pancreatitis represent the majority of complications with ERCP.2 Percutaneous transhepatic cholangiogram (PTHC). Patients receive a local anesthetic, and the radiologist places a flexible catheter percutaneously through the liver and into the intrahe-
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Fig 2. Preoperative percutaneous transhepatic cholangiogram showing biliary stricture at the proximal common hepatic duct.
patic ducts. The radiologist injects dye, and under fluoroscopy, images the biliary tree (Fig 2). Even though PTHC is associated with a slightly higher risk than ERCP, the test is useful in visualizing proximal ducts that may not be seen on ERCP. The catheter may be left in the biliary tree to ensure preoperative drainage and act as a guide for dissection and postoperative decompression. Patients are instructed to remain NPO after midnight before the exam and report any severe abdominal pain or a temperature above 101 O F (38 "C)after the procedure. Another complication of PTHC is intraperitoneal hemorrhage. Patients, therefore, should be observed and vital signs monitored for several hours after the cholangiogram. The complication rate for PTHC is between 2%and 8%and may be higher in patients with biliary obstruction because of ensuing hepatic dysfunction.3 Cholescintigram. This noninvasive radioisotope examination allows the surgeon to visualize the liver, extrahepatic bile ducts, and gallbladder. An intravenous (IV) line is started, and the radioisotope is administered. The radioisotope is
absorbed by the liver, and images are taken every 15 minutes for one hour to observe the flow of isotope from the liver through the bile ducts, into the gallbladder, and into the small intestine. Patients are instructed to remain NPO after midnight before the exam. Although a cholescintigram does not provide as detailed an image as radiographic techniques, it is valuable in assessing hepatic function. Cholescintigrams can provide low-risk imaging in postoperative situations (eg, Roux en Y reconstruction) when the bile ducts can not be reached by ERCP.
Methodr of Treatrnenl f the 450,000 cholecystectomies performed in the United States annually, 1,500 bile duct injuries can be expected, and only 25% are recognized intraoperatively.4 If the injury is recognized intraoperatively, the surgeon may choose to bypass the defect or perform a direct repair. Regardless of the procedure, the role of anastomotic stenting is controversial. Partly 61
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It is important that the nurse try to speak to patients in a neutral, quiet environment, and to talk with them in terms that they will understand. transected ducts may be sutured together over a T-tube left in the duct to act as a stent. Completely transected ducts may be directly reconnected if they are not under tension. Stents are used to decrease fibrotic narrowing during early healing, provide a conduit for bile flow, and provide for adequate radiologic imaging of the biliary tree.’ In most significant injuries, treatment can be achieved by choledochoenteric anastomosis rather than direct repair. Injuries that are recognized in the immediate postoperative period do not need to be treated definitively at that time. Biliary-cutaneous fistulas should be studied radiographically. If the liver is drained completely without evidence of sepsis, fistulas may be treated conservatively. Some fistulas heal spontaneously and require no further care. If the fistula persists or a bile duct stricture forms during healing, patients may require further intervention. Patients who develop biliary ascites or peritonitis related to the leak must have bile diverted from the site of injury immediately and undergo definitive treatment after the inflamed biliary structures return to normal.
Patient Teaching
P
atient education must include patients, family members, and significant others. Nurses should provide the patient with information regarding outpatient testing, preoperative teaching, postoperative information, and discharge instructions. It is important that the nurse try to speak to patients in a neutral, quiet environment, and to talk with them in terms that they will understand. Patients learn more if nurses attempt to lower their anxiety level. Preoperative teaching for patients who undergo biliary reconstruction is similar to that for other abdominal surgery patients. The nurse should include written instructions or illustrated pamphlets to support verbal instructions in preoper62
ative teaching. This allows patients to review the information and ask questions at their own pace. Preoperative teaching also should include where the family should wait during surgery, how long the surgery will take, and what to expect when family members see patients following surgery. Because this is an anxious time for patients and their families, nurses try to allay their fears and anxiety. Providing calm, reassuring, and honest answers is important.
Preoperative Care
W
hen the patient is admitted for surgery, the nurse performs a thorough history and physical and ensures that the patient’s informed consent forms are signed. The nurse will ensure that the patient is not wearing nail polish, dentures, or eyeglasses. An IV is set up and a complete blood count is drawn, urinalysis taken, and electrocardiogram and chest x-ray are completed. The anesthesiologist visits the patient the evening before surgery, or in the case of outpatient surgery, in the holding area before surgery. No routine preoperative medications are given for biliary surgery. Preoperative antibiotics (eg, second-generation cephalosporin) may be administered to prevent wound infection. The surgery is expected to last between one and two hours.
Intraoperative Care: Choledochoenteric Anastomosis
T
he OR team consists of a circulating nurse, scrub nurse, surgeon and his or her assistant, and the anesthesiology team. The circulating nurse ensures that the patient’s chart contains a signed informed consent form and that the patient has been properly prepared for surgery. The nurse speaks to the patient in a calm, reassuring manner.
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Fig 3. Postoperative cholangiogram of a choledochojejunostomy reconstruction. Note the biliary decompression into the Roux en Y loop of the small intestine (arrow).
The nurse brings the patient into the OR and places him or her in a supine position on the O R bed. Following induction of general anesthesia, the abdominal area is prepped with povidone-iodine and draped by the scrub nurse. The nurse inserts a Foley catheter, and the anesthesiologist inserts a nasogastric (NG) tube. A standard instrument tray for abdominal surgery is set up. A choledochoscope is included to enable the surgeon to check the biliary tree for any retained stones or abnormality proximal to the injury site. The surgeon makes an incision into the abdominal cavity in the right subcostal region. The incision may be extended over the midline to the left if additional exposure is needed. The duct with the stricture is dissected free of surrounding portal structures. The surgeon 64
continues to dissect toward the hilum of the liver until a region of bile duct with adequate lumen above the obstruction is found. This may require dissection into the liver tissue to find nondiseased bile ducts. The surgeon then performs an anastomosis between the mucosa of the unstrictured bile duct and the mucosa of the defunctioned duodenum or a defunctioned limb of the jejunum. The distal bile duct is oversewn (Fig 3). The nurse constantly checks the suction cannisters for blood loss. The scrub and circulating nurses record the sponge counts throughout the procedure. After the surgeon completes the anastomosis and tests it under pressure, he or she places a closed-system drain in the wound and closes the abdomen with absorbable sutures. After the nurses determine the final instrument, sharps, and sponge
A O R N JOURNAL
count, the surgical team transports the patient to the postanesthesia care unit (PACU).
Postoperative Care
T
he patient remains in the PACU for approximately one hour. The PACU nurse frequently checks the patient’s vital signs, blood loss, NG tube drainage, and the patient’s level of consciousness. The patient usually has an NG tube, Foley catheter, and one or more abdominal drains. Soft, closed drains that can be connected to suction are left to drain the site of the bile duct repair. These usually drain serosanguineous fluid unless a bile leak develops. In some cases, the surgeon leaves the “T” arm of a T-tube within the bile duct and brings it out through the skin. This tube is expected to drain pure bile. The PACU nurse records the output of all drains. When the patient’s vital signs are stable, he or she is returned to the medical/surgical unit. The patient usually remains in the hospital seven days postoperatively. The physician removes the NG tube on the second or third postoperative day, depending on the amount of drainage and when the patient’s bowel function returns. The Foley catheter is removed on the second day, and the abdominal drains are removed on the fifth day or when the patient’s output has decreased to 20 mL within a 24-hour period. After oral intake is well tolerated, IV fluids are discontinued. The nurse encourages the patient to walk and deep breathe as instructed. By the seventh postoperative day, the patient should be walking freely, tolerating a regular diet, and be ready for discharge.
Postoperative Instructions
P
atients who receive informative postoperative teaching from nurses feel less threatened and anxious about their recovery. This enables them to have a more positive attitude and possibly quicker recovery. Discharge instructions should be reviewed verbally and supplemented with written instructions. Nurses should instruct patients to remain 66
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independent during their recovery, but to realize that activity must be alternated with rest. Patients are instructed not to lift anything heavier than 5 lbs for four weeks. Patients may resume walking, climbing stairs, and taking showers before discharge. Patients are instructed to wash sutures with soap and water unless the wound is open or packed. In this case, the packing regimen is individualized for the wound being treated. Patients should be able to tolerate a normal diet. Nurses schedule postoperative appointments with the surgeon in four weeks. It takes patients between four and six weeks to feel healthy and unrestricted. Postoperative complications may include bleeding from the wound or intraabdominally from impaired liver production of coagulation factors following prolonged duct obstruction, recurrent biliary obstruction, bile leakage, which may produce biliary cutaneous fistula or biliary ascites, or intraabdominal infection. The nurse must educate patients about possible signs of complications. These may include jaundice, dark urine, clay-colored stools, fever, abdominal pain, wound drainage, and abdominal distension.
Long-Term Follow-Up
A
t the post-discharge appointment, the surgeon evaluates the patient’s general health and wound healing. He or she will routinely obtain serum alkaline phosphatase and bilirubin levels to assess the success of the reconstruction. Alkaline phosphatase levels seem to be the most sensitive serologic marker for recurring obstruction. Following the initial postoperative appointment at four weeks, the surgeon sees the patient every three months for one year. Visits gradually taper to one per year. Although most patients do very well, a recurrent stricture may develop. Restricture may occur several years following repair, and therefore, the biliary reconstruction patient 0 should be considered a “patient for life.”
Suggested reading Blumgart, L H; Thompson, J N. “The management
of malignant strictures of the bile duct.” Current Problems in Surgery 24 (February 1987) 75-1 18. Hermann, R E. “Diagnosis and management of bile duct strictures.” American Journal of Surgery I30 (November 1975) 519-522. Pellegrini, C A; Thomas, M J; Way, L W. “Recurrent biliary stricture: Patterns of recurrence and outcome of surgical therapy.” American Journal of Surgery 147 (January 1984) 175-179. Pitt, H A, et al. “Factors influencing outcome in patients with postoperative biliary strictures.” American Journal of Surgery 144 (July 1982) 14-21. Way, L W, Bernhoft, R A; Thomas, M J. “Biliary stricture.” Surgical Clinics of North America 61 (August 1981) 963-971.
Top AIDS Physicians Succumb to Epidemic
Invalid Research Studies Found in Literature
The medical profession has lost many promising, young physicians to acquired immune deficiency syndrome (AIDS). Many of them were leaders in AIDS research and treatment, according to a report in the April 9, 1990, issue of Medical World News. One informal count by physicians’ groups in New York and California estimates the number of AIDS-related deaths of physicians at over 100. The Centers for Disease Control estimates the toll to be about 350. These losses have left a void of AIDS experts in many parts of the country. In many cities, finding a physician to care for HIV antibodypositive patients is becoming increasingly difficult. If a patient is insured, he or she can usually find a physician. But those with no insurance or who require home care are finding it nearly impossible to get private sector care. According to the report, few doctors have publicly acknowledged having an HIV-related illness. When physicians get sick, they are often embarrassed or feel they have failed. When the illness is related to AIDS, the stigma of being part of a despised minority can increase that feeling. These factors imply that the number of physician deaths from AIDS could be much higher than estimated.
Invalid research that was retracted after initial publication often continues to be used and cited in follow-up scientific studies, according to an article in the March 9, 1990, issue of the Journal of the American Medical Association (JAMA). In attempts at professional achievement, researchers produce a tremendous number of studies. This may decrease their attention to the detail and increase chances that journals will continue to receive manuscripts citing invalid information. Authors of the JAMA article targeted 82 studies published between 1973 and 1983 that were retracted as invalid. The 82 articles were cited at least 733 times to support later scientific concepts, an average of nine citations per invalid study. They were cited in well-known, influential journals; obscure, rarely cited journals; and everything in between. The authors state that typical scientists are vulnerable to reading articles with invalid supporting evidence. They conclude that there is no reliable source for or method of locating fraudulent or erroneous work. Most of the retracted studies were not indexed in the journals that originally published them.
Notes I . L H Blumgart, J N Thompson, “The management of benign strictures of the bile duct,” Current Problems in Surgery 24 (January 1987) 13. 2. J E Berk, ed, Gastroenterologv, fourth ed (Philadelphia: W B Saunders Co, 1985) 3570. 3. M V Sivak, ed, Gastroenterologic Endoscopy (Philadelphia: W B Saunders Co, 1987) 585. 4. J T Innes, J J Ferrara, L C Carey, “Biliary reconstruction without transanastomotic stent,” The American Surgeon 54 (January 1988) 29. 5. ibid.
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Common Bile Duct Strictures DIAGNOSIS, MANAGEMENT, FOLLOW-UP Mary E. Front, RN; Stephen R. Wise, MD; Larry C . Carey, MD
T
raumatic strictures are the most common sequelae of injury to the bile ducts. Surgical injury, most commonly during cholecystectomy, is the major cause of benign bile duct stricture. The incidence of biliary tree injury is two injuries per 1,000 procedures for gallstones.' Less common causes of biliary damage that require reconstruction include blunt or penetrating trauma and inflammatory disease involving the extrahepatic biliary tree (ie, pancreatitis, peptic ulcer disease). The need for biliary tree reconstruction is a significant problem for the surgical team. Strictures, which range between 1 and 3 cm in length, usually are found at the junction of the cystic and common bile ducts. Biliary obstruction, as a result of untreated stricture, can lead to recurrent cholangitis and biliary cirrhosis with lifethreatening consequences.
A natomy/Physiolog;v
T
he right and left hepatic ducts drain bile from their respective lobes and converge outside the liver parenchyma to form the common hepatic duct (Fig 1). The gallbladder acts as a reservoir for concentrated bile. It holds between 50 and 75 mL of bile until it is stimulated to release bile into the intestines to aid with fat digestion. The gallbladder mucosa concentrates bile by absorbing water and electrolytes, thus leaving active bile salts. The gallbladder is connected to the common hepatic duct by the cystic duct, and their convergence forms the common bile duct. Because
variations in patients' anatomy of this portion of the biliary tree are common, surgery can be complex. The common bile duct is joined by the pancreatic duct at its entrance to the duodenum. The junction of these ducts is surrounded by a muscular sphincter, and the duct travels within the duodenal wall. This structure is referred to as the ampulla of Vater or the sphincter of Oddi.
Signs, Symptom, Diagnosis
B
ile duct injury can be diagnosed during surgery, in the immediate postoperative period, or at some delayed time. Postoperatively, patients with bile duct injury may have bilious drainage from the wound or drain site indicating a biliary cutaneous fistula. This fistula is caused by bile leakage from the liver surface, Mary E. (Betsy) Front, Rh? BSN, is the clinical coordinator and research nurse, Grant Medical Center, Columbus, Ohio. She received her bachelor of science degree in nursing from Wheeling (WVa) Jesuit College. Stephen R. Wise, MD, FRCS, is an assistant professor of surgery, University of Chicago Health Sciences Center. He received his medical degree from McGill University,Montreal. Larry C. Carey, MD, is the director of medical affairs, Grant Medical Center, Columbus, Ohio. He received his medical degree from Ohio State University College of Medicine, Columbus. 57
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right and left hepatic ducts
common hepatic duct
superior mesenteric
sphincter muscles
Fig 1. Illustration of gallbladder, pancreas, bile ducts, and duodenum. The shaded area represents the most common site for biliary strictures to occur.
unligated or injured bile ducts, or loss of bowel integrity. Bile also may drain intraabdominally causing distension or peritonitis. The first indication of a problem may be jaundice. In some patients, signs and symptoms of bile duct injury are delayed as the duct begins to form a stricture during postoperative healing. Patients may have right upper quadrant pain, nausea, vomiting due to distension of the blocked biliary tree, fever due to cholangitis, or diarrhea due to fat malabsorption. Patients appear jaundiced, and 58
their sclera, mucus membranes, and skin will become yellow. Patients’ stools may become pale (ie, acholic), and their urine may become frothy and cola-colored as bile metabolites are passed by kidneys. In the late stages of bile duct obstruction, pruritus may develop as irritating bile acids are deposited within the skin. Nurses must closely evaluate the postbiliary surgery patient for signs of jaundice, bilious drainage from wound and drain sites, or excessive abdominal pain, distension, and fever associated
JULY 1990, VOL. 52, NO I
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In completing the diagnostic workup, it is important that patients and their families understand which tests will be performed and why. with intraabdominal sepsis. Patients also should be educated in these manifestations; however, only a small percentage of all cholecystectomies are associated with postoperative stricture. It is the responsibility of the nurse in an outpatient setting to obtain a complete patient history. Special attention needs to be directed toward the signs and symptoms of abdominal pain, jaundice, fever, acholic stools, or dark urine. The nurse should record how long the symptoms have been present and the order of events that led to the current episode. A complete list of medications and allergies should be included in the history. Diagnostic studies to evaluate the problem may be done on an outpatient or inpatient basis, depending on the circumstances and when the diagnosis is established. Laboratory tests and radiologic procedures will be helpful in determining the extent of the problem. In completing the diagnostic workup, it is important that patients and their families understand which tests will be performed and why. It also is important that patients receive complete instructions on how to prepare for the examination. Blood tests. The simplest form of testing involves a blood test for evidence of hepatic dysfunction, infection, or pancreatitis. Alkaline phosphatase, an enzyme produced by the lining of the hepatic bile ducts, is hypersecreted when a biliary obstruction is present. When the alkaline phosphatase level is elevated out of proportion to other liver enzymes (eg, aspertate amino transferase [AST], alanine aminotransferase [ALT], gamma-glutamyl transferase [GGT], lactate dehydrogenase [LDH]), it is a reliable indicator in diagnosing bile duct obstruction as opposed to other hepatobiliary abnormalities. Serum bilirubin is elevated when the liver is unable to properly metabolize and excrete bile into the gut. An elevated white blood count implies the presence of infection within the biliary tree, and
elevated amylase is suggestive of stricture involving the pancreatic duct as well. When the physician suspects an obstruction based on clinical impression and laboratory information, the patient is ready for a more direct examination of the biliary tract. Ultrasound. An ultrasound is a radiologic technique that records the reflection of sound waves directed at deep strictures of the body. This test may detect dilated bile ducts proximal to the point of stricture. The value of ultrasound is limited because partial obstructions may not lead to ductal dilation. A negative study, however, does not exclude a stricture. Patients who will undergo abdominal ultrasound are instructed to remain NPO after midnight, while a pelvic ultrasound only requires a full bladder. Endoscopic retrograde cholangiopancreatography (ERCP). During this procedure, patients are sedated and a flexible endoscope is passed through the esophagus and stomach into the duodenum. The surgeon or gastroenterologist cannulates the biliary tree, and under fluoroscopy, injects dye into the common bile and pancreatic ducts. The surgeon can visualize the location of the bile duct stricture, leak, or anastomotic abnormality. Biopsies of suspicious lesions may be taken. If the surgeon can visualize only the distal portion of the duct, further tests may be required. Patients are instructed to remain NPO after midnight before the exam and inform their physicians if severe pain or a fever above 101 O F (38 "C) occur after the procedure. There is a 1% to 5% complication rate with ERCP. Cholangitis and pancreatitis represent the majority of complications with ERCP.2 Percutaneous transhepatic cholangiogram (PTHC). Patients receive a local anesthetic, and the radiologist places a flexible catheter percutaneously through the liver and into the intrahe-
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Fig 2. Preoperative percutaneous transhepatic cholangiogram showing biliary stricture at the proximal common hepatic duct.
patic ducts. The radiologist injects dye, and under fluoroscopy, images the biliary tree (Fig 2). Even though PTHC is associated with a slightly higher risk than ERCP, the test is useful in visualizing proximal ducts that may not be seen on ERCP. The catheter may be left in the biliary tree to ensure preoperative drainage and act as a guide for dissection and postoperative decompression. Patients are instructed to remain NPO after midnight before the exam and report any severe abdominal pain or a temperature above 101 O F (38 "C)after the procedure. Another complication of PTHC is intraperitoneal hemorrhage. Patients, therefore, should be observed and vital signs monitored for several hours after the cholangiogram. The complication rate for PTHC is between 2%and 8%and may be higher in patients with biliary obstruction because of ensuing hepatic dysfunction.3 Cholescintigram. This noninvasive radioisotope examination allows the surgeon to visualize the liver, extrahepatic bile ducts, and gallbladder. An intravenous (IV) line is started, and the radioisotope is administered. The radioisotope is
absorbed by the liver, and images are taken every 15 minutes for one hour to observe the flow of isotope from the liver through the bile ducts, into the gallbladder, and into the small intestine. Patients are instructed to remain NPO after midnight before the exam. Although a cholescintigram does not provide as detailed an image as radiographic techniques, it is valuable in assessing hepatic function. Cholescintigrams can provide low-risk imaging in postoperative situations (eg, Roux en Y reconstruction) when the bile ducts can not be reached by ERCP.
Methodr of Treatrnenl f the 450,000 cholecystectomies performed in the United States annually, 1,500 bile duct injuries can be expected, and only 25% are recognized intraoperatively.4 If the injury is recognized intraoperatively, the surgeon may choose to bypass the defect or perform a direct repair. Regardless of the procedure, the role of anastomotic stenting is controversial. Partly 61
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It is important that the nurse try to speak to patients in a neutral, quiet environment, and to talk with them in terms that they will understand. transected ducts may be sutured together over a T-tube left in the duct to act as a stent. Completely transected ducts may be directly reconnected if they are not under tension. Stents are used to decrease fibrotic narrowing during early healing, provide a conduit for bile flow, and provide for adequate radiologic imaging of the biliary tree.’ In most significant injuries, treatment can be achieved by choledochoenteric anastomosis rather than direct repair. Injuries that are recognized in the immediate postoperative period do not need to be treated definitively at that time. Biliary-cutaneous fistulas should be studied radiographically. If the liver is drained completely without evidence of sepsis, fistulas may be treated conservatively. Some fistulas heal spontaneously and require no further care. If the fistula persists or a bile duct stricture forms during healing, patients may require further intervention. Patients who develop biliary ascites or peritonitis related to the leak must have bile diverted from the site of injury immediately and undergo definitive treatment after the inflamed biliary structures return to normal.
Patient Teaching
P
atient education must include patients, family members, and significant others. Nurses should provide the patient with information regarding outpatient testing, preoperative teaching, postoperative information, and discharge instructions. It is important that the nurse try to speak to patients in a neutral, quiet environment, and to talk with them in terms that they will understand. Patients learn more if nurses attempt to lower their anxiety level. Preoperative teaching for patients who undergo biliary reconstruction is similar to that for other abdominal surgery patients. The nurse should include written instructions or illustrated pamphlets to support verbal instructions in preoper62
ative teaching. This allows patients to review the information and ask questions at their own pace. Preoperative teaching also should include where the family should wait during surgery, how long the surgery will take, and what to expect when family members see patients following surgery. Because this is an anxious time for patients and their families, nurses try to allay their fears and anxiety. Providing calm, reassuring, and honest answers is important.
Preoperative Care
W
hen the patient is admitted for surgery, the nurse performs a thorough history and physical and ensures that the patient’s informed consent forms are signed. The nurse will ensure that the patient is not wearing nail polish, dentures, or eyeglasses. An IV is set up and a complete blood count is drawn, urinalysis taken, and electrocardiogram and chest x-ray are completed. The anesthesiologist visits the patient the evening before surgery, or in the case of outpatient surgery, in the holding area before surgery. No routine preoperative medications are given for biliary surgery. Preoperative antibiotics (eg, second-generation cephalosporin) may be administered to prevent wound infection. The surgery is expected to last between one and two hours.
Intraoperative Care: Choledochoenteric Anastomosis
T
he OR team consists of a circulating nurse, scrub nurse, surgeon and his or her assistant, and the anesthesiology team. The circulating nurse ensures that the patient’s chart contains a signed informed consent form and that the patient has been properly prepared for surgery. The nurse speaks to the patient in a calm, reassuring manner.
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Fig 3. Postoperative cholangiogram of a choledochojejunostomy reconstruction. Note the biliary decompression into the Roux en Y loop of the small intestine (arrow).
The nurse brings the patient into the OR and places him or her in a supine position on the O R bed. Following induction of general anesthesia, the abdominal area is prepped with povidone-iodine and draped by the scrub nurse. The nurse inserts a Foley catheter, and the anesthesiologist inserts a nasogastric (NG) tube. A standard instrument tray for abdominal surgery is set up. A choledochoscope is included to enable the surgeon to check the biliary tree for any retained stones or abnormality proximal to the injury site. The surgeon makes an incision into the abdominal cavity in the right subcostal region. The incision may be extended over the midline to the left if additional exposure is needed. The duct with the stricture is dissected free of surrounding portal structures. The surgeon 64
continues to dissect toward the hilum of the liver until a region of bile duct with adequate lumen above the obstruction is found. This may require dissection into the liver tissue to find nondiseased bile ducts. The surgeon then performs an anastomosis between the mucosa of the unstrictured bile duct and the mucosa of the defunctioned duodenum or a defunctioned limb of the jejunum. The distal bile duct is oversewn (Fig 3). The nurse constantly checks the suction cannisters for blood loss. The scrub and circulating nurses record the sponge counts throughout the procedure. After the surgeon completes the anastomosis and tests it under pressure, he or she places a closed-system drain in the wound and closes the abdomen with absorbable sutures. After the nurses determine the final instrument, sharps, and sponge
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count, the surgical team transports the patient to the postanesthesia care unit (PACU).
Postoperative Care
T
he patient remains in the PACU for approximately one hour. The PACU nurse frequently checks the patient’s vital signs, blood loss, NG tube drainage, and the patient’s level of consciousness. The patient usually has an NG tube, Foley catheter, and one or more abdominal drains. Soft, closed drains that can be connected to suction are left to drain the site of the bile duct repair. These usually drain serosanguineous fluid unless a bile leak develops. In some cases, the surgeon leaves the “T” arm of a T-tube within the bile duct and brings it out through the skin. This tube is expected to drain pure bile. The PACU nurse records the output of all drains. When the patient’s vital signs are stable, he or she is returned to the medical/surgical unit. The patient usually remains in the hospital seven days postoperatively. The physician removes the NG tube on the second or third postoperative day, depending on the amount of drainage and when the patient’s bowel function returns. The Foley catheter is removed on the second day, and the abdominal drains are removed on the fifth day or when the patient’s output has decreased to 20 mL within a 24-hour period. After oral intake is well tolerated, IV fluids are discontinued. The nurse encourages the patient to walk and deep breathe as instructed. By the seventh postoperative day, the patient should be walking freely, tolerating a regular diet, and be ready for discharge.
Postoperative Instructions
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atients who receive informative postoperative teaching from nurses feel less threatened and anxious about their recovery. This enables them to have a more positive attitude and possibly quicker recovery. Discharge instructions should be reviewed verbally and supplemented with written instructions. Nurses should instruct patients to remain 66
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independent during their recovery, but to realize that activity must be alternated with rest. Patients are instructed not to lift anything heavier than 5 lbs for four weeks. Patients may resume walking, climbing stairs, and taking showers before discharge. Patients are instructed to wash sutures with soap and water unless the wound is open or packed. In this case, the packing regimen is individualized for the wound being treated. Patients should be able to tolerate a normal diet. Nurses schedule postoperative appointments with the surgeon in four weeks. It takes patients between four and six weeks to feel healthy and unrestricted. Postoperative complications may include bleeding from the wound or intraabdominally from impaired liver production of coagulation factors following prolonged duct obstruction, recurrent biliary obstruction, bile leakage, which may produce biliary cutaneous fistula or biliary ascites, or intraabdominal infection. The nurse must educate patients about possible signs of complications. These may include jaundice, dark urine, clay-colored stools, fever, abdominal pain, wound drainage, and abdominal distension.
Long-Term Follow-Up
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t the post-discharge appointment, the surgeon evaluates the patient’s general health and wound healing. He or she will routinely obtain serum alkaline phosphatase and bilirubin levels to assess the success of the reconstruction. Alkaline phosphatase levels seem to be the most sensitive serologic marker for recurring obstruction. Following the initial postoperative appointment at four weeks, the surgeon sees the patient every three months for one year. Visits gradually taper to one per year. Although most patients do very well, a recurrent stricture may develop. Restricture may occur several years following repair, and therefore, the biliary reconstruction patient 0 should be considered a “patient for life.”
Suggested reading Blumgart, L H; Thompson, J N. “The management
of malignant strictures of the bile duct.” Current Problems in Surgery 24 (February 1987) 75-1 18. Hermann, R E. “Diagnosis and management of bile duct strictures.” American Journal of Surgery I30 (November 1975) 519-522. Pellegrini, C A; Thomas, M J; Way, L W. “Recurrent biliary stricture: Patterns of recurrence and outcome of surgical therapy.” American Journal of Surgery 147 (January 1984) 175-179. Pitt, H A, et al. “Factors influencing outcome in patients with postoperative biliary strictures.” American Journal of Surgery 144 (July 1982) 14-21. Way, L W, Bernhoft, R A; Thomas, M J. “Biliary stricture.” Surgical Clinics of North America 61 (August 1981) 963-971.
Top AIDS Physicians Succumb to Epidemic
Invalid Research Studies Found in Literature
The medical profession has lost many promising, young physicians to acquired immune deficiency syndrome (AIDS). Many of them were leaders in AIDS research and treatment, according to a report in the April 9, 1990, issue of Medical World News. One informal count by physicians’ groups in New York and California estimates the number of AIDS-related deaths of physicians at over 100. The Centers for Disease Control estimates the toll to be about 350. These losses have left a void of AIDS experts in many parts of the country. In many cities, finding a physician to care for HIV antibodypositive patients is becoming increasingly difficult. If a patient is insured, he or she can usually find a physician. But those with no insurance or who require home care are finding it nearly impossible to get private sector care. According to the report, few doctors have publicly acknowledged having an HIV-related illness. When physicians get sick, they are often embarrassed or feel they have failed. When the illness is related to AIDS, the stigma of being part of a despised minority can increase that feeling. These factors imply that the number of physician deaths from AIDS could be much higher than estimated.
Invalid research that was retracted after initial publication often continues to be used and cited in follow-up scientific studies, according to an article in the March 9, 1990, issue of the Journal of the American Medical Association (JAMA). In attempts at professional achievement, researchers produce a tremendous number of studies. This may decrease their attention to the detail and increase chances that journals will continue to receive manuscripts citing invalid information. Authors of the JAMA article targeted 82 studies published between 1973 and 1983 that were retracted as invalid. The 82 articles were cited at least 733 times to support later scientific concepts, an average of nine citations per invalid study. They were cited in well-known, influential journals; obscure, rarely cited journals; and everything in between. The authors state that typical scientists are vulnerable to reading articles with invalid supporting evidence. They conclude that there is no reliable source for or method of locating fraudulent or erroneous work. Most of the retracted studies were not indexed in the journals that originally published them.
Notes I . L H Blumgart, J N Thompson, “The management of benign strictures of the bile duct,” Current Problems in Surgery 24 (January 1987) 13. 2. J E Berk, ed, Gastroenterologv, fourth ed (Philadelphia: W B Saunders Co, 1985) 3570. 3. M V Sivak, ed, Gastroenterologic Endoscopy (Philadelphia: W B Saunders Co, 1987) 585. 4. J T Innes, J J Ferrara, L C Carey, “Biliary reconstruction without transanastomotic stent,” The American Surgeon 54 (January 1988) 29. 5. ibid.
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